Loading...Loading...In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and reimbursement policies, Clinical Position Statements and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies. Monthly change summaries are added to our website within 10 business days of our newsletter publication.
Review other monthly changes for 2022.
Effective November 1, 2022, the following codes were added to our pre-authorization lists:
Commercial
Surgical Site of Service - Hospital Outpatient (#UM19)
- 43235, 43237-43239, 43242, 43245-, 43251, 43254, 45378-45381, 45384-45386, 45390, 45398
Uniform Medical Plan
Hypoglossal Nerve Stimulation (#SUR215)
- C1767
Medicare Advantage
- Surgical Site of Service – Hospital Outpatient (#M-UM19)
- 43235, 43237-43239, 43242, 43245-43251, 43254, 45378-45381, 45384-45386, 45390, 45398
Transcatheter Heart Valve Procedures (Surgery #221)
- 0484T
Please review our pre-authorization lists for all updates and pre-authorize services accordingly. You can submit standard medical pre-authorizations through Availity Essentials. Learn more about electric authorizations.
Medical policy updates
We provided 90-day notice in the August 2022 issue of The Bulletin about the following medical policies, which are effective November 1, 2022:
- Hypoglossal Nerve Stimulation (#SUR215)
Surgical Site of Service – Hospital Outpatient (#UM19 and #M-UM19)
Reimbursement policy updates
We provided 90-day notice in the August 2022 issue of The Bulletin about changes to the Drugs, Immunizations/Vaccines, Radiopharmaceuticals, and Skin Substitutes Reimbursed Under Medical Coverage (Medicine #104) commercial and Medicare Advantage reimbursement policies, which are effective November 1, 2022.
Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our website.
Revised medication policies effective November 1, 2022
Immune Globulin Replacement Therapy, dru020
Read the August 2022 issue of our newsletter for details.
Effective November 1, 2022, select gastrointestinal procedures (e.g., colonoscopy, endoscopy) performed at a hospital outpatient surgical site will require pre-authorization for the site of service.
Under our new commercial and Medicare Advantage Surgical Site of Service – Hospital Outpatient (#UM19) medical policies, we will require pre-authorization for the following codes when performed at a hospital outpatient place of service:
- Colonoscopy: CPT 45378-45381, 45384-45386, 45390 and 45398
Endoscopy: CPT 43235-43239, 43242, 43245-43251 and 43254
These services will not require pre-authorization when performed at an ambulatory surgical center (ASC) or physician office.
We consider an individual’s health status, facility and geographic availability, specialty requirements, physician privileges and other factors when determining the appropriate site of service.
Note: Some services require pre-authorization regardless of the site of service.
These policies apply to our commercial and Medicare Advantage lines of business. They were announced in the August 1, 2022, issue of The Bulletin.
Effective November 1, 2022, HCPCS C9098, J0895, J1952 and J9223 will require pre-authorization for CHG Healthcare Services (group #70000004), IEC Group (group #70000000) and Alsco Inc. (group #70000002) members.
View the complete list of specialty medications that require pre-authorization for these members.
For dates of service beginning November 1, 2022, we will apply medically unlikely edits (MUEs) to freestanding ambulatory surgical center (ASC) claims for commercial and BCBS FEP members. When billed units of a procedure/item exceed the practitioner MUE value, we will allow units up to the maximum limit and deny excess units. For additional information about MUEs, see our Maximum Daily Units (Administrative #120) reimbursement policy.