Medical Policies and Clinical Utilization Management Guidelines Update

Please note, this communication applies to Healthy Blue + Medicare^℠ (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 note:  The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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-full-list.

Notes/Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *CG-LAB-15 – Red Blood Cell Folic Acid Testing

  • RBC folic acid testing is considered not medically necessary in all cases

• *CG-LAB-16 – Serum Amylase Testing

  • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions

• *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules

  • Added the Afirma Xpression Atlas as not medically necessary

• SURG.00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

  • A new Medical Policy was created from content contained in DME.00011
  • There are no changes to the policy content.
  • Publish date is December 16, 2020.

• CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing

  • A new Clinical Guideline was created from content contained in GENE.00026
  • There are no changes to the guideline content.
  • Publish date is December 16, 2020.

Medical Policies

On November 5, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Blue Cross NC. These guidelines take effect June 8, 2021.

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Blue Cross NC. These guidelines adopted by the medical operations committee for Blue Cross NC members on November 19, 2020. These guidelines take effect June 8, 2021.