Material Adverse Change (MAC)

 

These updates list the new and/or revised Empire BlueCross BlueShield (Empire) Medical Policies and Clinical Guidelines. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

 

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and Clinical Guidelines (and Medical Policy takes precedence over Clinical Guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire. Please include this update with your provider manual for future reference.

 

Please note that Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s Medical Policies and Clinical Guidelines can be found at https://www.empireblue.com.

 

Note: These updates may not apply to all ASO Accounts as some accounts may have nonstandard benefits that apply.

 

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP®]), please visit www.fepblue.org > Policies & Guidelines.

 

Medical Policy updates


Archived medical policy effective May 19, 2022

The following policy has been archived:

  • SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent

 

Archived medical policy effective June 29, 2022

The following policy has been archived and its content has been transitioned to an existing Clinical UM Guideline:

  • MED.00121 Implantable Interstitial Glucose Sensors [Note: Content transitioned to
    CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps.

Revised medical policies effective June 29, 2022

The following policies were updated with new CPT®/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:

  • GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
  • GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
  • GENE.00056 Gene Expression Profiling for Bladder Cancer
  • LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

Revised medical policies effective June 29, 2022

The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

  • DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
  • MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
  • SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

 

Archived medical policies effective July 6, 2022

The following policies have been archived:

  • DME.00024 Transtympanic Micropressure
  • SURG.00137 Focused Microwave Thermotherapy for Breast Cancer

 

Archived medical policy effective July 6, 2022

The following policy has been archived and its content has been transitioned to a new Clinical UM Guideline:

  • MED.00127 Chelation Therapy [Note: Content transitioned to new clinical UM guideline CG-MED-90 Chelation Therapy.]

 

Revised medical policies effective July 6, 2022

The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

  • ADMIN.00002 Preventive Health Guidelines
  • ADMIN.00004 Medical Necessity Criteria
  • ADMIN.00005 Investigational Criteria
  • ADMIN.00007 Immunizations
  • ANC.00006 Biomagnetic Therapy
  • ANC.00007 Cosmetic and Reconstructive Services: Skin Related
  • ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
  • DME.00012 Intrapulmonary Percussive Ventilation Devices
  • DME.00030 Altered Auditory Feedback Devices for Fluency Disorders
  • DME.00037 Cooling Devices and Combined Cooling/Heating Devices
  • DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
  • GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens
  • GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
  • GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
  • LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
  • LAB.00029 Rupture of Membranes Testing in Pregnancy
  • LAB.00031 Advanced Lipoprotein Testing
  • LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
  • LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
  • LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline
  • MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
  • MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
  • MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
  • MED.00098 Hyperoxemic Reperfusion Therapy
  • MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
  • MED.00133 Ingestion Event Monitors
  • MED.00137 Eye Movement Analysis Using Non-Spatial Calibration for the Diagnosis of Concussion
  • OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
  • OR-PR.00005 Upper Extremity Myoelectric Orthoses
  • OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
  • RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
  • RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
  • SURG.00005 Partial Left Ventriculectomy
  • SURG.00007 Vagus Nerve Stimulation
  • SURG.00037 Treatment of Varicose Veins (Lower Extremities)
  • SURG.00045 Extracorporeal Shock Wave Therapy
  • SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • SURG.00071 Percutaneous and Endoscopic Spinal Surgery
  • SURG.00076 Nerve Graft after Prostatectomy
  • SURG.00084 Implantable Middle Ear Hearing Aids
  • SURG.00095 Viscocanalostomy and Canaloplasty
  • SURG.00105 Bicompartmental Knee Arthroplasty
  • SURG.00111 Axial Lumbar Interbody Fusion
  • SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
  • SURG.00118 Bronchial Thermoplasty
  • SURG.00120 Internal Rib Fixation Systems
  • SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
  • SURG.00126 Irreversible Electroporation
  • SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • SURG.00134 Interspinous Process Fixation Devices
  • SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
  • SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
  • SURG.00147 Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
  • SURG.00155 Cryoneurolysis
  • THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
  • TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

 

Revised medical policy effective July 9, 2022

The following policy was revised to expand medical necessity indications or criteria:

  • SURG.00097 Scoliosis Surgery

 

Archived medical policy effective September 12, 2022

The following policy has been archived and has been replaced by AIM guidelines:

  • DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea)

 

New medical policies effective November 1, 2022

The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

  • DME.00047 Rehabilitative Devices with Remote Monitoring
  • DME.00048 Virtual Reality-Assisted Therapy Systems
  • GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer
  • MED.00139 Electrical Impedance Scanning for Cancer Detection
  • TRANS.00039 Portable Normothermic Organ Perfusion System

 

Revised medical policy effective November 1, 2022

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

  • GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma

 

New medical policies effective November 5, 2022

The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

  • DME.00046 Intermittent Abdominal Pressure Ventilation Devices
  • LAB.00048 Pain Management Biomarker Analysis

 

Revised medical policy effective November 12, 2022

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

  • LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests


Clinical Guideline updates

Revised clinical guideline effective June 29, 2022

The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates:

  • CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management

 

Revised clinical guideline effective July 6, 2022

The following adopted guideline was revised to expand medical necessity indications or criteria:

  • CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

 

Revised clinical guidelines effective July 6, 2022

The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria:

  • CG-DME-45 Ultrasound Bone Growth Stimulation
  • CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
  • CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
  • CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
  • CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
  • CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
  • CG-MED-89 Home Parenteral Nutrition
  • CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • CG-SURG-27 Gender Affirming Surgery
  • CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
  • CG-SURG-50 Assistant Surgeons
  • CG-SURG-71 Reduction Mammaplasty
  • CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
  • CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
  • CG-SURG-85 Hip Resurfacing
  • CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus
  • CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised clinical guideline effective November 12, 2022

The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary:

  • CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield.


NYBCBS-CM-003512-22



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