Medical Policies and Clinical Utilization Management Guidelines Update (Healthy Blue + Medicare HMO D-SNP)

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 providers in 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-22 — Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Bacterial Vaginosis:
  • Outlines the medically necessary and not medically necessary criteria for the use of nucleic acid amplification tests using algorithmic assays to detect bacterial vaginosis.
• CG-MED-91 — Remote Therapeutic and Physiologic Monitoring Services:
  • Outlines the medically necessary and not medically necessary criteria for remote therapeutic and physiologic monitoring services.
• CG-SURG-114 — Ophthalmic use of Nd: YAG Laser for Posterior Capsulotomy:
  • Outlines the medically necessary and not medically necessary criteria for ophthalmic use of Nd: YAG laser for posterior capsulotomy.
• DME.00049 — External Upper Limb Stimulation for the Treatment of Tremors:
  • Wrist-worn external upper limb tremor stimulator is considered investigational and not medically necessary for all indications, including but not limited to the treatment of essential tremor of the hands.
• DME.00050 — Remote Devices for Intermittent Monitoring of Intraocular Pressure:
  • The use of remote devices for intermittent monitoring of IOP is considered investigational and not medically necessary for all indications.
• LAB.00049 — Artificial Intelligence-Based Software for Prostate Cancer Detection:
  • Use of artificial intelligence-based software for prostate cancer detection is considered investigational and not medically necessary for all indications.
• MED.00140 — Gene Therapy for Beta Thalassemia:
  • Outlines the medically necessary and investigational and not medically necessary criteria for a one-time infusion of betibeglogene autotemcel for individuals with beta thalassemia.
• MED.00141 — High-volume Colonic Irrigation:
  • High-volume colonic irrigation is considered investigational and not medically necessary for all indications.
• MED.00142 — Gene Therapy for Cerebral Adrenoleukodystrophy:
  • Outlines the medically necessary and investigational and not medically necessary criteria for infusion of elivaldogene autotemcel.
• TRANS.00040 — Hand Transplantation:
  • Hand transplantation is considered investigational and not medically necessary.
• CG-DME-13 — Lower Limb Prosthesis:
  • Added new not medically necessary statements addressing prosthetics utilized primarily for leisure or sporting activities.
• CG-GENE-11 — Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status:
  • Added thiopurine methyltransferase (TPMT) to scope of document and Clinical Indications Medically Necessary section.
• DME.00044 — Robotic Arm Assistive Devices; previously titled: Wheelchair Mounted Robotic Arm:
  • Revised title.
  • Rescoped the Position Statement to also address robotic feeding assistive device.
• SURG.00079 — Nasal Valve Repair; previously titled: Nasal Valve Suspension:
  • Revised title.
  • Revised the Position Statement.
  • Expanded scope of document to address an absorbable nasal implant and low-dose radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction.
  • Content related to the absorbable nasal implant (Latera) moved from CG-SURG-87 to this document.
• CG-GENE-13 — Genetic Testing for Inherited Diseases:
  • Interim update to add genes PIK3CA and CDKL5 to the table of genes in the Discussion section; added existing CPT code 81309 and genes to tier 2 codes 81405, 81406 (medically necessary criteria)

AIM Specialty Health® (AIM)* updates
Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health Clinical Appropriateness Guidelines for medical necessity review for Blue Cross NC. Note, the Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Cardiology:
  • Diagnostic coronary angiography
  • Advanced imaging of the heart
  • Musculoskeletal guidelines:
  • Interventional pain management
• Radiology guidelines:
  • Chest imaging
  • Oncologic imaging
  • Brain imaging
  • Head and neck imaging
  • Abdominal and pelvic imaging
• Rehabilitative services:
  • Occupational therapy
  • Physical therapy
  • Speech therapy
• Radiation oncology:
  • SURG.00143 is transitioning to AIM Perirectal Hydrogel Spacers Guidelines
  • Radiation therapy
  • Proton beam therapy

MCG Care Guidelines 26th Edition updates
Effective May 1, 2023, we will implement the MCG Care Guidelines Content Patch 26.1 Updates for the following modules: General Recovery Care (GRG), Inpatient & Surgical Care (ISC), and Behavioral Health Care (BHG). The below information highlights the changes:

• Blue Cross NC customizations to MCG Care Guidelines 26th Edition: 
  • MCG 26th Edition Content Patch 26.1 Updates with an implementation date of May 1, 2023, for the following:
    • Updated hemodynamic instability definition:
      • Hemodynamic instability definition pop-up box update for multiple guidelines.
      • Hemodynamic instability definition inline update for the following General Recovery Care (GRG) guidelines:
        • CG-GAC General Admission Criteria
        • CG-PAC Pediatric General Admission Criteria
        • W0074 Medical Oncology GRG
        • PG-MDX Multiple Illness GRG
      • Revised threshold lactate levels for the following Inpatient & Surgical Care (ISC) guidelines:
        • M-575 Ventricular Arrhythmias
        • CCC-005 Arrhythmia: Common Complications and Conditions
        • CCC-019 Hemodynamic Instability: Common Complications and Conditions
      • MCG Content Patch 26.1 Update with additional customization to clarify theta burst stimulation for the following Behavioral Health Care (BHG) guideline:
        • W0174 Transcranial Magnetic Stimulation:
          • Added theta burst stimulation is considered not medically necessary for all indications.

If you have questions, contact the provider service number on the back of the member's ID card.

Clinical UM Guidelines
On August 11, 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 September 22, 2022. These guidelines take effect May 1, 2023.

Note: 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.

NCBCBS-CR-013821-22-CPN12607 December 2022