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Monthly Changes

Our at-a-glance summary of monthly changes to our policies, pre-authorization requirements, Administrative Manual and other programs or initiatives that impact your office are published:

  • Monthly in our bulletin
  • Bi-monthly in our newsletter
  • On this page within two weeks of our newsletter publication

Subscribe to receive newsletters and bulletins via email. View the changes listed by effective date below:

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July, 2019

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies. 

eviCore simplifiers neurology pre-authorization 

eviCore healthcare (eviCore) is simplifying the medical necessity review process for physical and occupational therapy providers who submit pre-authorization requests for neurological conditions under our Physical Medicine program. The new process, called corePath, will replace the current pre-authorization process on July 1, 2019.

Physical and occupational therapists began using corePath to request pre-authorization for other services in 2018.

The corePath process:

  • Allows for real-time approval of the initial request
  • Includes specific questions for common neurological diagnoses
  • Eases administrative burden by reducing the quantity of clinical information required for pre-authorization; additionally, questions are limited to those that are meaningful for the member's condition

Read the June 2019 issue of our newsletter for details.

Medical Policy update

We publish updates to medical policies, dental policies and Clinical Position Statements in our monthly publication The Bulletin.

We provided 90-day notice in the April and May 2019 issues of The Bulletin about the following medical policies:

  • Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders (Behavioral Health #18), effective July 1, 2019
  • Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (Transplant #45.24), effective July 1, 2019
  • Hematopoietic Cell Transplantation for Hodgkin Lymphoma (Transplant #45.30), effective July 1, 2019
  • Rhinoplasty (Surgery #12.28), effective August 1, 2019 You can read issues of The Bulletin or subscribe to receive an email notification when issues are published on our website.

The Medical Policy Manual includes a list of recent updates and archived policies. All policies and Clinical Position Statements are available on our website.

Pre-authorization updates

The following codes were added to our pre-authorization lists effective July 1, 2019

Commercial

  • Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders
    • CPT 0362T, 0373T, 97151-97158
  • eviCore healthcare: speech and occupational therapy
    • HCPCS G0515
  • Phrenic Nerve Stimulation for Central Sleep Apnea (Surgery #212)
    • HCPCS C1823

UMP

  • ABA therapy
    • 97151 (pre-authorization is not required for initial assessments but is required for reassessments)
  • Phrenic Nerve Stimulation for Central Sleep Apnea (Surgery #212)
    • HCPCS C1823

Medicare

  • eviCore: speech and occupational therapy
    • G0515
  • Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing (Medicare Genetic Testing #64)
    • HCPCS 0086U, 0090U, 0097U, 0101U
  • Phrenic Nerve Stimulation for Central Sleep Apnea (Medicare Surgery #212)
    • HCPCS C1823

Please review our complete pre-authorization lists for all updates and pre-authorize services accordingly.

ABA services will require pre-authorization

Starting July 1, 2019, pre-authorization will be required for applied behavioral analysis (ABA) services. This change will apply to all lines of business, including BCBS FEP members.

We are making this change to:

  • Standardize pre-authorization requirements across lines of business
  • Continue to advocate for quality of care for our members with autism spectrum disorder
  • Support our members with ongoing care needs and providers through case management

View our Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders (Behavioral Health #18) medical policy.

Reimbursement policy updates

We review our reimbursement policies on an annual basis. Included below are updates to existing policies that will be added to our Reimbursement Policy Manual.

To see how a claim will pay, access the Clear Claim Connection tool on the Availity Portal.

Updated policy effective July 1, 2019:

  • Implants, Implant Components, Medical and Surgical Supplies for All Surgical Procedures (Administrative #125)

Medication policy updates

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.

New medication policies effective July 1, 2019:

  • Daurismo, glasdegib, dru585
  • Elzonris, tagraxofusp-erzs, dru589
  • Firdapse, amifampridine, dru588
  • Gamifant, emapalumab-lzsg, dru590
  • Lorbrena, lorlatinib, dru582
  • Vitrakvi, larotrectinib, dru583
  • Xospata, gilteritinib, dru586

Revised medication policies effective July 1, 2019:

  • Avanafil-containing medications, dru277
  • Avastin, bevacizumab, Mvasi, bevacizumab-awwb, dru215
  • Cabozantinib-containing medications, dru290
  • Complement Inhibitors, dru385
  • High-cost medications for chronic constipation, dru519
  • Inlyta, axitinib, dru273
  • Keytruda, pembrolizumab, dru367
  • Lenvima, lenvatinib, dru398
  • Nexavar, sorafenib, dru134
  • Praluent, alirocumab, dru406
  • Promacta, eltrombopag, dru180
  • Repatha, evolocumab, dru407
  • Site of Care Review, dru408
  • Tadalafil-containing medications, dru096
  • Tecentriq, atezolizumab, dru463
  • Vardenafil-containing medications, dru096
  • Votrient, pazopanib, dru199
  • Zykadia, ceritinib, dru354

Archived medication policies effective July 1, 2019:

  • High-Cost Oral Antidepressant Medications, dru352
  • High-Cost Oral Antipsychotics, dru425
  • Sildenafil-containing medications, dru461
  • Tadalafil-containing medications, dru184

Read more about these changes in the June 1, 2019, issue of our newsletter.

Livongo Diabetes Management available to more members

We are committed to ensuring that our members who are living with diabetes receive the best care, treatment and information about how to manage their chronic condition. We offer several diabetes prevention and management programs to our members, including Retrofit, Omada, Regence Diabetes management programs and Livongo.

The Livongo Diabetes Management program is for members with type 1 or type 2 diabetes who do not have a current cancer diagnosis. The program includes free strips and lancets—plus a new free blood glucose meter, better diabetes monitoring and answers to questions 24/7.

Effective July 1, 2019, Livongo Diabetes Management will be made available to the following members:

  • Salt Lake City Community College (group #10003141)
  • University of Utah (group #10002211)
  • Utah Valley University (group #10042213)

The program is also available to the following members:

  • BCBS FEP (in Oregon and Utah)
  • Cambia Health Solutions (group #60018408)
  • Northwest Pipe members (group #10018651)
  • O.C. Tanner (group #60026177)
  • Medicare Advantage 

Read more about this change in the June 1, 2019, issue of our newsletter. More information about our diabetes prevention and management programs, including eligibility criteria, is available on our website