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.

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-LAB-20 — Thyroid Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
  • Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
  • Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
  • The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
    • Endometrial receptivity analysis
    • Sperm-capacitation test
    • Sperm deoxyribonucleic acid (DNA) fragmentation test
    • Sperm penetration assay
    • Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
  • Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
  • Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
  • Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
  • Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
  • Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
  • The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
  • Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

Medical Policies
On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Blue Cross NC. These guidelines take effect November 1, 2022.

Clinical UM Guidelines
On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Blue Cross NC. These guidelines adopted by the medical operations committee for Healthy Blue + Medicare members on March 24, 2022. These guidelines take effect November 1, 2022.

AIM Specialty 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-0696-22 August 2022