Category: Medicaid

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit https://www11.empireblue.com/ny_search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • *GENE.00023 — Gene Expression Profiling of Melanomas
    • o Expanded Scope to include testing for the diagnosis of melanoma
    • o Updated INV&NMN statement to include suspicion of melanoma
  • *GENE.00046 — Prothrombin G20210A (Factor II) Mutation Testing
    • o Revised title
    • o Expanded scope and position statement to include all prothrombin (factor II) variations
  • *MED.00110 — Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
    • o Revised title
    • o Added new INV&NMN statements addressing Autologous adipose-derived regenerative cell therapy and use of autologous protein solution
  • *SURG.00052 — Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
    • o Revised title
    • o Combined the three INV&NMN statements into a single statement
    • o Added Intraosseous basivertebral nerve ablation to the INV&NMN statement
  • *TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
    • o Revised title
    • o Expanded Position Statement to include non-hematopoietic adult stem cell therapy
  • *CG-ANC-07 — Inpatient Interfacility Transfers
    • Added NMN statements regarding admission and subsequent care at the receiving facility
  • *CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities
    • Revised title
    • Expanded Scope
    • Revised MN statement to include upper extremities
  • The following AIM Specialty Health® updates were approved:
    • o *Spine Surgery
    • o *Radiation Oncology-Brachytherapy Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines
    • o Sleep Disorder Management Diagnostic & Treatment Guidelines
    • o Advanced Imaging
      • Imaging of the Heart: Cardiac CT for Quantitative Evaluation of Coronary Calcification
      • *Imaging of the Abdomen and Pelvis
    • MCG Customization for Repair of Pelvic Organ Prolapse (W0163) — Updated Coding Section

 

Medical Policies

On August 22, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

 

Publish date

Medical Policy number

Medical Policy title

New or revised

9/25/2019

MED.00130

Surface Electromyography Devices for Seizure Monitoring

New

8/29/2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

8/29/2019

DRUG.00082

Daratumumab (DARZALEX®)

Revised

9/25/2019

GENE.00010

Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

9/25/2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

9/25/2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

8/29/2019

OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

8/29/2019

RAD.00023

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

9/25/2019

SURG.00129

Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Revised

7/30/2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

Revised

Clinical UM Guidelines

On August 22, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for Empire members on September 26, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

8/29/2019

CG-DME-47

Noninvasive Home Ventilator Therapy for Respiratory Failure

New

9/25/2019

CG-MED-84

Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

New

9/25/2019

CG-SURG-103

Male Circumcision

New

11/20/2019

CG-GENE-12

PIK3CA Mutation Testing

New

9/25/2019

CG-GENE-02

Analysis of RAS Status Previous title: Analysis of KRAS Status

Revised

11/20/2019

CG-MED-39

Bone Mineral Density Testing Measurement Previous title: Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Revised

9/25/2019

CG-MED-68

Therapeutic Apheresis

Revised

9/25/2019

CG-REHAB-08

Private Duty Nursing in the Home Setting

Revised

9/25/2019

CG-SURG-52

Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

Revised

9/25/2019

CG-SURG-63

Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

Revised

11/20/2019

CG-SURG-78

Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies Previous Title: Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

Revised

9/25/2019

CG-SURG-79

Implantable Infusion Pumps

Revised

9/25/2019

CG-SURG-83

Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Revised

 

NYE-NU-0177-19 November 2019



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January 2020 Empire Provider News