New Policy and PPA Requirement for Electromagnetic Navigation
Effective September 15, 2017, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) revised its Corporate Medical Policy for Electromagnetic Navigation Bronchoscopy (ENB) to consider benefits’ coverage for this service, which was previously considered investigational. Coverage for ENB services provided on and after September 15, 2017, will be considered, based upon review of each member’s individual eligibility and benefits for the ENB service, as well as the medical necessity supported by clinical criteria, as outlined in the ENB medical policy.
Additionally, effective January 1, 2018, ENB will be added to the Blue Cross NC Prior Plan Approval (PPA) code list. ENB will require advanced authorization by Blue Cross NC, prior to providing the service. (For dates spanning September 15 through December 31, 2017, PPA will not be required.)
Under the newly revised policy, ENB will be considered medically necessary for any of the following conditions:
- A suspicious pulmonary nodule that is deemed inaccessible by standard bronchoscopic methods, or when standard methods have failed
- A highly suspicious solitary pulmonary nodule in a patient who poses an unacceptable risk (e.g., bullous lung disease, diffuse emphysema) for a more invasive diagnostic procedure
- An identified lung lesion(s) and a co-existing cancer in a patient for whom further determination of the lung lesion will impact staging of the primary tumor, and thus impact the treatment plan
- Placement of fiducial markers in patients who are not candidates for surgical intervention and who have elected to undergo radiation therapy
Blue Cross NC requires the submission of records documenting a patient’s medical necessity for receiving the ENB service. When billing claims for ENB (Current Procedural Terminology - 31627), it’s very important to always proactively send medical records supporting the use of ENB. Without medical records, claims will be denied. Therefore, any relevant documentation should be submitted to Blue Cross NC at the same time the patient’s claim for payment is submitted. Please include the following:
- Nursing notes
- Office notes
- Medication records
- Operative reports
- History and physical reports
- Pathology reports
- Radiology reports
The following link provides information about how to submit proactive medical records: https://www.bcbsnc.com/content/providers/medical-records/index.htm.
The revised ENB policy applies for all Blue Cross NC members enrolled in insured and administered products, and members of the North Carolina State Employees’ and Teachers’ Health Plan. Always verify a member’s actual individual eligibility and benefits for a particular service in advance of providing services, as these can vary. Not included under this policy are members of Blue Cross NC’s Medicare Advantage products, members of the Federal Employees Program, and BlueCard members from other Blue Cross and or Blue Shield Plans. However, similar policies may apply and should be reviewed when applicable, in advance of providing the service.