Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-08-26

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 note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.


Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://medpol.providers.amerigroup.com/green-provider/medical-policies-and-clinical-guidelines.

 

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

  • *CG-MED-89 - Home Parenteral Nutrition
    • Outlines the medically necessary and not medically necessary criteria for initial and continuing use of home parenteral nutrition
  • *CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
    • Added the use of a magnetically controlled wireless capsule as not medically necessary
  • *CG-SURG-59 - Vena Cava Filters
    • Removed major trauma indication from medically necessary statement
    • Added “severe trauma without documented venous thromboembolism” and “cancer and recurrent venous thromboembolism, despite anticoagulation treatment” to not medically necessary statement
  • *MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
    • Added electrical impedance spectroscopy for the evaluation of skin lesions as investigational and not medically necessary
  • *TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
    • Added noninvasive tests for detection of heart transplant rejection as investigational and not medically necessary including, but not limited to, AlloSure Heart, AlloSeq cell-free DNA, MMDx Heart, and myTAIHeart
  • CG-DME-49 - Standing Frames
    • A new Clinical Guideline was created from the content contained in DME.00034. There are no changes to the guideline content and the publish date is July 7, 2021
  • CG-SURG-111 - Open Sacroiliac Joint Fusion
    • A new Clinical Guideline was created from the content contained in SURG.00127. There are no changes to the guideline content and the publish date is July 30, 2021

 

Medical Policies
On May 13, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Blue Cross NC. These guidelines take effect November 23, 2021.

Publish Date Medical Policy #   New or Revised
7/7/2021 ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin Revised
7/1/2021 *MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography) Revised
5/20/2021 OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis Revised
7/7/2021 SURG.00095 Viscocanalostomy and Canaloplasty Revised
5/20/2021 SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring Revised
5/20/2021 SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy Revised
7/7/2021 SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) Revised
7/7/2021 *TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection Revised
5/20/2021 TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors Revised

Clinical UM Guidelines
On May 13, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Blue Cross NC. These guidelines were adopted by the medical operations committee for our members on May 27, 2021. These guidelines take effect November 23, 2021.

Publish Date Clinical UM Guideline # Clinical UM Guideline Title New or Revised
7/7/2021 *CG-MED-89 Home Parenteral Nutrition New 
7/7/2021 CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting Revised
7/7/2021 CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Revised
7/7/2021 CG-GENE-13 Genetic Testing for Inherited Diseases Revised
7/7/2021 *CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule Revised
5/27/2021 CG-SURG-01 Colonoscopy Revised
7/7/2021 CG-SURG-12 Penile Prosthesis Implantation Revised
7/7/2021 CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Revised
5/20/2021 CG-SURG-27 Gender Affirming Surgery Revised
7/7/2021 *CG-SURG-59 Vena Cava Filters Revised

 

https://www.bluecrossnc.com/providers/blue-medicare-providers/healthy-blue-medicare 
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BNCCARE-0183-21 August 2021 519318MUPENMUB