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.

 

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 March 22, 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

3/29/2018

MED.00120

Voretigene neparvovec-rzyl (Luxturna™)

New

4/25/2018

SURG.00151

Balloon Dilation of Eustachian Tube

New

4/25/2018

DME.00009

Vacuum-Assisted Wound Therapy in the Outpatient Setting

Revised

3/29/2018

GENE.00028

Genetic Testing for Colorectal Cancer Susceptibility

Revised

4/25/2018

RAD.00029

CT Colonography (Virtual Colonoscopy) for Colorectal Cancer

Revised

4/25/2018

SURG.00033

Cardioverter Defibrillators

Revised

4/25/2018

SURG.00098

Mechanical Embolectomy for Treatment of Acute Stroke

Revised

4/25/2018

SURG.00121

Transcatheter Heart Valve Procedures

Revised

 

Clinical UM Guidelines

On March 22, 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 April 19, 2018.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/28/2018

CG-BEH-15

Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

New

6/22/2018

CG-DRUG-89

Implantable and Extended-Release Buprenorphine-Containing Products

New

6/28/2018

CG-DRUG-90

Intravitreal Treatment for Retinal Vascular Conditions

New

6/28/2018

CG-DRUG-91

Intravitreal Corticosteroid Implants

New

6/28/2018

CG-DRUG-92

Alpha-1 Proteinase Inhibitor Therapy

New

6/28/2018

CG-DRUG-93

Sarilumab (Kevzara®)

New

6/28/2018

CG-LAB-13

Skin Nerve Fiber Density Testing

New

6/28/2018

CG-MED-69

Inhaled Nitric Oxide

New

6/28/2018

CG-MED-70

Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

New

6/28/2018

CG-SURG-73

Balloon Sinus Ostial Dilation

New

6/28/2018

CG-SURG-74

Total Ankle Replacement

New

6/28/2018

CG-SURG-75

Transanal Endoscopic Microsurgical Excision of Rectal Lesions

New

6/28/2018

CG-THER-RAD-07

Intravascular Brachytherapy (Coronary and Noncoronary)

New

4/25/2018

CG-SURG-31

Treatment of Keloids and Scar Revision

Revised

4/25/2018

CG-SURG-49

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

Revised



Featured In:
October 2018 Empire Provider Newsletter