Material Adverse Change (MAC)

 

These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy 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 empireblue.com.

 

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

 

To view medical policies and utilization management 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

 

Revised Medical Policy Effective 11-18-2021

(The following policy was revised to expand medical necessity indications or criteria.)

  • GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling


Archived Medical Policies Effective 11-18-2021

(The following policies have been archived.)

  • MED.00095 Anterior Segment Optical Coherence Tomography
  • MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
  • OR-PR.00004 Partial-Hand Myoelectric Prosthesis [Content moved to CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices]

 

Revised Medical Policy Effective 12-29-2021

(The following policy was revised to expand medical necessity indications or criteria.)

  • SURG.00037 Treatment of Varicose Veins (Lower Extremities)

 

Archived Medical Policies Effective 12-29-2021

(The following policies have been archived.)

  • GENE.00036 Genetic Testing for Hereditary Pancreatitis [Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
  • GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing [Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
  • MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium [Content moved to TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products]

 

Revised Medical Policies Effective 12-29-2021

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

  • ADMIN.00001 Medical Policy Formation
  • DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
  • GENE.00016 Gene Expression Profiling for Colorectal Cancer
  • GENE.00025 Proteogenomic Testing for the Evaluation of Malignancies
  • GENE.00037 Genetic Testing for Macular Degeneration
  • GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
  • GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
  • GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • LAB.00024 Immune Cell Function Assay
  • LAB.00026 Systems Pathology Testing for Prostate Cancer
  • LAB.00034 Serological Antibody Testing For Helicobacter Pylori
  • LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
  • MED.00002 Selected Sleep Testing Services
  • MED.00065 Hepatic Activation Therapy
  • MED.00091 Rhinophototherapy
  • MED.00092 Automated Nerve Conduction Testing
  • MED.00097 Neural Therapy
  • MED.00110 Silver-based Products for Wound and Soft Tissue Applications [Moved content addressing autologous skin-, blood- or bone marrow-derived products for wound and soft tissue applications to TRANS.00035 Other Stem Cell Therapy. Moved content addressing bioengineered autologous skin-derived products (for example, SkinTE, MyOwn Skin) to SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue.]
  • MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • MED.00116 Near-Infrared Spectroscopy Scanning for Brain Hematoma Screening
  • MED.00121 Implantable Interstitial Glucose Sensors
  • MED.00122 Wilderness Programs
  • MED.00128 Insulin Potentiation Therapy
  • MED.00129 Gene Therapy for Spinal Muscular Atrophy
  • MED.00130 Surface Electromyography Devices for Seizure Monitoring
  • MED.00131 Electronic Home Visual Field Monitoring
  • RAD.00036 MRI of the Breast
  • RAD.00053 Cervical and Thoracic Discography
  • RAD.00065 Radiostereometric Analysis (RSA)
  • REHAB.00003 Hippotherapy
  • SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting [Incorporated position statement addressing bioengineered autologous skin-derived products from MED.00110 Silver-based Products for Wound and Soft Tissue Applications into this document.]
  • SURG.00019 Transmyocardial Revascularization
  • SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
  • SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis
  • SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • SURG.00073 Epiduroscopy
  • SURG.00079 Nasal Valve Suspension
  • SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
  • SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain
  • SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma
  • SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
  • SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
  • SURG.00130 Annulus Closure After Discectomy
  • SURG.00138 Laser Treatment of Onychomycosis
  • SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
  • SURG.00146 Extracorporeal Carbon Dioxide Removal
  • SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • THER-RAD.00008 Neutron Beam Radiotherapy
  • TRANS.00008 Liver Transplantation
  • TRANS.00009 Lung and Lobar Transplantation
  • TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
  • TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
  • TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
  • TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
  • TRANS.00026 Heart/Lung Transplantation
  • TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00033 Heart Transplantation
  • TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
  • TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products [Moved “Autologous Skin, Blood or Bone Marrow derived Products for Wound and Soft Tissue Applications” content from MED.00110 Silver-based Products for Wound and Soft Tissue Applications to this document. Moved content from MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium to this document.]

 

Revised Medical Policies Effective 12-29-2021

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

  • GENE.00023 Gene Expression Profiling of Melanomas
  • LAB.00031 Advanced Lipoprotein Testing
  • MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
  • MED.00102 Ultrafiltration in Decompensated Heart Failure
  • MED.00111 Intracardiac Ischemia Monitoring
  • MED.00112 Autonomic Testing
  • SURG.00007 Vagus Nerve Stimulation
  • SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
  • SURG.00045 Extracorporeal Shock Wave Therapy
  • SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
  • SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00121 Transcatheter Heart Valve Procedures
  • SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

New Medical Policies Effective 04-01-2022

(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.00044 Wheelchair Mounted Robotic Arm Attachment
  • MED.00138 Wearable Devices for Stress Relief and Management

 

Revised Medical Policy Effective 04-01-2022

(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.)

  • MED.00099 Navigational Bronchoscopy


Revised Medical Policies Effective 04-02-2022

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

  • SURG.00010 Treatments for Urinary Incontinence
  • SURG.00097 Scoliosis Surgery

Clinical Guideline Updates

 

Revised Clinical Guideline Effective 11-18-2021

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices [Moved content addressing partial-hand prosthesis from OR-PR.00004 Partial-Hand Myoelectric Prosthesis to this document.]

 

Unadopted Clinical Guidelines Effective 12-01-2021

(The criteria in the following guidelines will no longer be applied.)

  • CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs–Ultra Lightweight
  • CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
  • CG-SURG-12 Penile Prosthesis Implantation
  • CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
  • CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
  • CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

 

Revised Clinical Guideline Effective 12-29-2021

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-DME-06 Compression Devices for Lymphedema

 

Revised Clinical Guidelines Effective 12-29-2021

(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-ANC-04 Ambulance Services: Air and Water
  • CG-ANC-07 Inpatient Interfacility Transfers
  • CG-BEH-14 Intensive In-Home Behavioral Health Services
  • CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
  • CG-DME-31 Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
  • CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
  • CG-GENE-13 Genetic Testing for Inherited Diseases [Moved content of GENE.00036 Genetic Testing for Hereditary Pancreatitis and GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing to this document.]
  • CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
  • CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
  • CG-GENE-18 Genetic Testing for TP53 Mutations
  • CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
  • CG-LAB-13 Skin Nerve Fiber Density Testing
  • CG-MED-19 Custodial Care
  • CG-MED-23 Home Health
  • CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
  • CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
  • CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
  • CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-72 Endothelial Keratoplasty
  • CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
  • CG-SURG-77 Refractive Surgery
  • CG-SURG-92 Paraesophageal Hernia Repair
  • CG-SURG-94 Keratoprosthesis
  • CG-SURG-96 Intraocular Telescope
  • CG-SURG-105 Corneal Collagen Cross-Linking
  • CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
  • CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)

 

Revised Clinical Guidelines Effective 12-29-2021

(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)

  • 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-22 Gene Expression Profiling for Managing Breast Cancer Treatment
  • CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
  • CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
  • CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

 

Archived Clinical Guidelines Effective 12-29-2021

(The following guidelines have been archived.)

  • CG-MED-77 SPECT/CT Fusion Imaging
  • CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Unadopted Clinical Guidelines Effective 01-01-2022

(The criteria in the following guidelines will no longer be applied.)

  • CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
  • CG-SURG-77 Refractive Surgery
  • CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)

 

Revised Clinical Guideline Effective 04-01-2022

(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-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

 

1511-0122-PN-NY



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