Focal Treatments for Prostate Cancer
Effective 1 de abril de 2023, High-Intensity Focused Ultrasound will be changed to not covered for Medicare Advantage Plans. Please refer to the policy for additional details here.
Genetic Testing Services
Effective 1 de abril de 2023, CPT codes 81254 and 81341 will be reviewed against the criteria in this policy in lieu of the criteria via the web-based tool. Please refer to the policy for additional details here.
Gene Expression Profiling for Cutaneous Melanoma
Effective 1 de abril de 2023, CPT code 81529 will require prior authorization for Medicare Advantage plans. Additionally, the medical necessity criteria for CPT code 0090U for Medicare Advantage plans will be updated. There will be no change to coverage for commercial products. Please refer to the policy for additional details here.
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Effective 1 de abril de 2023, the medical necessity criteria for CPT codes 0005U, 81313 and 81551 for Medicare Advantage plans will be updated. There will be no change to coverage for commercial products. Additionally, CPT codes 0021U, 0113U and 0228U will be changed to “Not Covered for Medicare Advantage Plans." There will be no change to coverage for commercial products. Please refer to the policy for additional details here.
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Effective 1 de abril de 2023, commercial product coverage for CPT codes 0022U, 0037U, 0048U, 0111U, 0172U and 0239U will be changed from “Not Medically Necessary" to “Needs Prior Authorization" following the medical criteria outlined in the policy. Additionally, medical criteria will be updated for CPT code 0242U for both Medicare Advantage plans and commercial products. Please refer to the policy for additional details here.
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Effective 1 de abril de 2023, there will be changes to the medical criteria for the Breast Cancer Index, MammaPrint and MammaPrint NGS tests. The DCISionRT®, CPT code 0295U, will be added to this policy and is not covered for Medicare Advantage plans and is not medically necessary for commercial products. Please refer to the policy for additional details here.
Proprietary Laboratory Analyses (PLA)
Effective 1 de abril de 2023, the DCISionRT® test, CPT code 0295U, which has required prior authorization for Medicare Advantage plans, will not be covered for Medicare Advantage plans based on the policy. Please refer to the policy for additional details here.
Prior Authorization with Web-Based Tool for Durable Medical Equipment (DME)
Effective 1 de abril de 2023, HCPCS code L5982 will be removed from prior authorization for Medicare Advantage plans and commercial products. Please refer to the policy for additional details here.
Termination of Pregnancy
This policy was updated with minor editorial changes. Inclusive language was added as well as BCBSRI’s statement following the Dobbs vs. Jackson Supreme court decision. Please refer to the policy for additional details here.
Foot Care and Nail Debridement
This policy was updated to add diagnosis E51.11 and E75.244 effective 1 de enero de 2023. Please refer to the policy for additional details here.
Provider Reimbursement for Care Plan Management
This policy is being archived effective due to codes that are no longer advertised by BCBSRI.
Physical and Occupational Therapy
This policy was updated clarifying that members need an order from a qualified healthcare professional to receive PT/OT services and non-physician providers (NPPs) can provide PT services with the correct license. Please refer to the policy for additional details here.
Outpatient Observation Services
This policy was updated to remove correct coding guidelines. Please refer to the policy for additional details here.
Unlisted Procedures
This policy was updated to reflect slight changes to what is needed when submitting unlisted codes for review. Forms within policy can now be filled in electronically. Please refer to the policy for additional details here.
Preventive Services for Commercial Members
This policy was updated to reflect that coverage for contraceptive counseling and fertility apps should be provided as a preventive service with no cost share. Please refer to the policy for additional details here.
Prolonged Physician Services
This policy was updated to remove the medical record requirement previously used to process claims for prolonged services. We also removed correct coding guidance from the policy. Deleted CPT codes were removed, and new CPT codes for 2023; 99418, G0316, G0317, and G0318 have been added to the policy. Please refer to the policy for additional details here.
Immunizations Adult and Pediatric
This policy was updated to add the RSV vaccine to the non-covered section of policy due to waiting for FDA approval. We also removed CPT 90671 pneumococcal 15-valent from this section as it has received FDA approval (20 de julio22). Please refer to the policy for additional details here.
Non-Reimbursable Health Service Codes
This policy was updated to add new CPT and HCPCs codes effective 1 de enero de 2023. Please refer to the policy for additional details here.
COVID-19 Monoclonal Antibody Treatment and Antiviral IV
This policy was updated to edit the list of specific monoclonal antibody treatments, with end dates for coverage according to the FDA dates. Please refer to the policy for additional details here.
COVID-19 Vaccinations
This policy was updated with two updates:
- We updated FDA approval dates for 0164A and 91316. Codes 91317 and 0173A, Pfizer vaccine children 6 months to 4 years bivalent third dose, were added.
- This policy was also updated to include information on the Novavax COVID-19 Vaccine (Novavax, Inc.) ADMINISTRATION – Booster (effective 10/19/2022) and Moderna’s booster dose-specific COVID-19 vaccine product for adult patients aged 6 months to 5 years Booster (pending EUA approval). Approval updates made to codes 91315, 0154A, 91314, and 0144A.
Please refer to the policy for additional details here.
Prior Authorization of Spinal Procedures
As a reminder, this policy is applicable to Medicare Advantage plans only. Please note in the final version of the policy, HCPCS codes E0748 and E0749 will no longer be included in this spinal procedure authorization vendor policy. HCPCS code E0748 will continue to require prior authorization via the web-based tool. This information may be found in the Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME) policy. HCPCS code E0749 will remain to be a covered service with no prior authorization required. Information regarding HCPCS code E0749 may be found in the Electrical Bone Growth Stimulation of the Appendicular Skeleton - Implantable and Semi-Implantable policy.
Effective 1 de abril de 2023, CPT codes 0775T and 22860 will require prior authorization for Medicare Advantage Plans via the Spine Procedures vendor.
Please refer to the policy for additional details here.
2023 Pediatric Dental Services - Essential Health Benefit
New CDT codes were updated effective 1 de enero de 2023. Those codes include D0372, D0373 and D0374 under the Diagnostic Services category; D6105 and D6197 under the Implant Services category; and D7509 under the Oral Surgery category. The following CDT codes encompass updated descriptions effective 1 de enero de 2023: D0210, D4266, D4267, D4355, D2391 – D2394, D7251, D7509 and D9110. Please refer to the policy for additional details here.