Material Adverse Change (MAC)

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guidelines 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. Include this update with your provider manual for future reference.

 

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

 

Note: These updates may not apply to all administrative services only (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 policies effective April 1, 2023

The following policies have been archived:

  • 00033 Genetic Testing for Inherited Peripheral Neuropathies (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases)
  • 00037 Genetic Testing for Macular Degeneration (Note: Content merged into GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling and CG-GENE-13 Genetic Testing for Inherited Diseases.)
  • 00038 Genetic Testing for Statin-Induced Myopathy (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases.)
  • 00039 Genetic Testing for Frontotemporal Dementia (FTD) (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases)

 

Revised medical policy effective April 1, 2023

This 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:

  • 00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling (Note: Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document.)

 

Clinical Guidelines updates

Archived clinical guidelines effective April 1, 2023

The following clinical guidelines have been archived:

  • CG-GENE-07 BCR-ABL Mutation Analysis (Note: Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.)
  • CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility (Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.)
  • CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases and GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling.)

 

Revised clinical guidelines effective April 1, 2023

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

  • CG-GENE-13 Genetic Testing for Inherited Diseases (Note: Moved content from CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions, GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies, GENE.00037 Genetic Testing for Macular Degeneration (partial content), GENE.00038 Genetic Testing for Statin-induced Myopathy, and GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD) into this document.)
  • CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management (Note: Moved content from CG-GENE-07 BCR-ABL Mutation Analysis and CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility into this document.)

NYBCBS-CM-014475-22



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January 2023 Newsletter