As a result of coding updates in the claims system, the claim system edits for the policies and clinical guidelines listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination.
Effective August 1, 2019, we will be implementing coding updates in the claims system for the following policies listed below which may result in investigational/not medically necessary determinations for certain services.
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00023 - Gene Expression Profiling of Melanomas
Effective August 1, 2019, we will be implementing coding updates in the claims system for the following clinical guidelines listed below which may result in not medically necessary determinations for certain services.
- CG-GENE-07 - BCR-ABL Mutation Analysis
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome
May 2019 Empire Provider Newsletter