The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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.

 

Note:

  • Effective November 1, 2018, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Advanced Imaging Guidelines will be used for clinical reviews.
  • When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

 

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

 

To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

 

Medical Policies

On July 26, 2018, 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

8/29/2018

DRUG.00096

Ibalizumab-uiyk (Trogarzo™)

New

8/29/2018

GENE.00049

Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)

New

8/29/2018

ADMIN.00007

Immunizations

Revised

8/29/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

8/29/2018

DRUG.00050

Eculizumab (Soliris®)

Revised

8/2/2018

DRUG.00067

Ramucirumab (Cyramza®)

Revised

8/2/2018

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

8/29/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

8/29/2018

DRUG.00088

Atezolizumab (Tecentriq®)

Revised

8/29/2018

DRUG.00098

Lutetium Lu 177 dotatate (Lutathera®)

Revised

8/29/2018

GENE.00006

Epidermal Growth Factor Receptor (EGFR) Testing

Revised

8/2/2018

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

8/29/2018

GENE.00025

Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

Revised

8/29/2018

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

8/2/2018

MED.00124

Tisagenlecleucel (Kymriah®)

Revised

8/2/2018

SURG.00023

Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

8/2/2018

SURG.00032

Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention                                                                                                                            

Revised

 

Clinical UM Guidelines

On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or Revised

9/20/2018

CG-DME-45

Ultrasound Bone Growth Stimulation

New

9/20/2018

CG-DRUG-103

Botulinum Toxin

New

9/20/2018

CG-DRUG-104

Omalizumab (Xolair®)

New

9/20/2018

CG-DRUG-105

Abatacept (Orencia®)

New

9/20/2018

CG-DRUG-106

Brentuximab Vedotin (Adcetris®)

New

9/20/2018

CG-DRUG-107

Pharmacotherapy for Hereditary Angioedema

New

9/20/2018

CG-DRUG-108

Enteral Carbidopa and Levodopa Intestinal Gel Suspension

New

9/20/2018

CG-DRUG-109

Asfotase Alfa (Strensiq™)

New

9/20/2018

CG-DRUG-110

Naltrexone Implantable Pellets

New

9/20/2018

CG-DRUG-111

Sebelipase alfa (KANUMA™)

New

9/20/2018

CG-DRUG-112

Abaloparatide (Tymlos™) Injection

New

9/20/2018

CG-MED-73

Hyperbaric Oxygen Therapy (Systemic/Topical)

New

9/20/2018

CG-MED-74

Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

New

9/20/2018

CG-MED-75

Medical and Other Non-Behavioral Health-Related Treatments for Autism Spectrum Disorders and Rett Syndrome

New

9/20/2018

CG-MED-76

Magnetic Source Imaging and Magnetoencephalography

New

9/20/2018

CG-MED-77

SPECT/CT Fusion Imaging

New

9/20/2018

CG-REHAB-11

Cognitive Rehabilitation

New

9/20/2018

CG-SURG-81

Cochlear Implants and Auditory Brainstem Implants

New

9/20/2018

CG-SURG-82

Bone-Anchored and Bone Conduction Hearing Aids

New

10/31/2018

CG-SURG-83

Bariatric Surgery and Other Treatments for Clinically Severe Obesity

New

9/20/2018

CG-SURG-84

Mandibular/Maxillary (Orthognathic) Surgery

New

10/31/2018

CG-SURG-85

Hip Resurfacing

New

10/31/2018

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

New

9/20/2018

CG-SURG-87

Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

New

9/20/2018

CG-SURG-88

Mastectomy for Gynecomastia

New

9/20/2018

CG-SURG-89

Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

New

8/29/2018

CG-ADMIN-02

Clinically Equivalent Cost Effective Services — Targeted Immune Modulators

Revised

8/29/2018

CG-DRUG-09

Immune Globulin (Ig) Therapy

Revised

8/29/2018

CG-DRUG-65

Tumor Necrosis Factor Antagonists

Revised

8/29/2018

CG-DRUG-68

Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

Revised

8/29/2018

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

Revised

8/29/2018

CG-DRUG-81

Tocilizumab (Actemra®)

Revised

8/29/2018

CG-GENE-03

BRAF Mutation Analysis

Revised

8/29/2018

CG-MED-35

Retinal Telescreening Systems

Revised

8/29/2018

CG-MED-71

Wound Care in the Home Setting

Revised

8/2/2018

CG-SURG-24

Functional Endoscopic Sinus Surgery (FESS)

Revised

8/29/2018

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Revised

8/2/2018

CG-SURG-73

Balloon Sinus Ostial Dilation

Revised

 



Featured In:
December 2018 Empire Provider Newsletter