Healthy Blue + MedicareSM (HMO D-SNP) - November 2021 Medical Policies and Utilization Management Guidelines Update

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

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.

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

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

• *CG-LAB-19 — Laboratory Evaluation of Vitamin B12
  • Outlines the medically necessary and not medically necessary criteria for the use of vitamin B12 blood test.
• *DME.00044 — Wheelchair Mounted Robotic Arm
  • The use of a wheelchair mounted robotic arm is considered investigational and not medically necessary for all uses.
• *MED.00138 — Wearable Devices for Stress Relief and Management
  • Wearable devices for management, monitoring or prevention of stress and stress-related conditions are considered investigational and not medically necessary for all indications.
• *CG-MED-53 — Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing
  • Removed criteria addressing chronically immunosuppressed individuals.
• *CG-MED-81 — Ultrasound Ablation for Oncologic Indications
  • Added not medically necessary statement for TULSA
• *CG-SURG-78 — Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
  • Revised the clinical indications to add a not medically necessary statement for histotripsy.
• *MED.00099 — Navigational Bronchoscopy
  • Removed the word electromagnetic in the position statement.
• *SURG.00010 — Treatments for Urinary Incontinence
  • Added new criterion to investigational and not medically necessary statement on endovaginal cryogen-cooled, monopolar radiofrequency remodeling.
  • Added as treatments for urinary incontinence to investigational and not medically necessary statement and removed wording on urinary incontinence.
• *SURG.00097 — Scoliosis Surgery
  • Added minimally invasive deformity correction system to the Scope and Position Statement

Effective May 18, 2022, Blue Cross NC will begin using the AIM Specialty Health®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Healthy Blue + Medicare Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Advanced Imaging Clinical Appropriateness Guideline:
  • Imaging of the brain
  • Imaging of the head and neck
  • Imaging of the heart
  • Imaging of the chest
  • Imaging of the abdomen and pelvis
  • Oncologic imaging
• Musculoskeletal Interventional Pain Management Clinical Appropriateness Guideline
• Cardiology Clinical Appropriateness Guidelines:
  • Diagnostic coronary angiography
  • Percutaneous coronary intervention
• Radiation Oncology Clinical Appropriateness Guideline

Medical Policies
On November 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Blue Cross NC. These guidelines take effect May 18, 2022.

Clinical UM Guidelines
On November 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Blue Cross NC. These guidelines were adopted by the medical operations committee for Healthy Blue + Medicare members on December 16, 2021. These guidelines take effect
May 18, 2022.

Note: AIM Speciality Health is an independent company providing some utilization review services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.

For more information, visit Healthy Blue + Medicare

BNCCARE-0258-22 February 2022