Posted in BCBS (Various States), Training, Updates

BCBS Federal Plan: DEXA Policy 06/01/2021

This is a the most current reimbursement/medical policy that becomes effective as of 06/01/2021

According to BCBS Federal Plan the initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.


Picture via Verywell Health.

Both men and women with the following conditions may have an indication for BMD:

  • Women age 65 and older, independent of other risk factors;
  • Men age 70 and older, independent of other risk factors;
  • Younger postmenopausal women with an elevated risk factor assessment; (see policy guidelines)
  • Men age 50 to 70 with an elevated risk factor assessment; (see policy guidelines)
  • Adults with a pathologic condition associated with low bone mass or increased bone loss;
  • Adults taking a medication associated with increased bone loss.

Picture via Scientific Publishing

Patients who have previously tested negative should not be tested again in the intervals no more than 3 to 5 years; the interval depends on an updated patient fracture risk assessment


Patients who fall in the following categories qualify for a repeat BMD for interval not more frequent than every 1-2 years:

  • Individuals with a baseline evaluation of osteopenia (BMD T- score -1.0 to -2.5)
  • Adults with a pathologic condition associated with low bone mass or increased bone loss;
  • Adults taking a medication associated with increased bone loss.

Patients who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy, BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years.


Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.


NON COVERED SERVICES:

BMD measurement using ultrasound densitometry is considered not medically necessary.

BMD measurement using quantitative computed tomography is considered investigational.


IF you would like to read the entire policy you can find it on fepblue.org Hope you found the outline of this policy helpful.


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Posted in BCBS Empire NY, Updates

Empire BCBS (NY) and SOMOS IPA Utilization Management

Reminder that effective 10/01/2020- SOMOS IPA will assume the administrative functions for several Empire HealthPlus Plans:

Medicaid Managed Care (MMC)

Health and Recovery Plan (HARP)

Child Health Plus (CHPlus)

Essential Plan programs

SAMPLE EMPIRE SOMOS IPA CARDS:

FRONT OF THE CARD
BACK OF THE CARD

Contacting SOMOS for patient Eligibility, benefits and authorizations: OON and IN providers

Credentialing process:
• SOMOS IPA providers: SOMOS will handle all credentialing for its participating providers. This
includes the submission of any demographic changes or terminations.
• Non-SOMOS IPA providers: Providers who are not contracted with the IPA must continue to follow the Empire processes.

For more information please click here.

Posted in BCBS Empire NY, Updates

Empire BCBS (NY) Voluntary Cancer Care Quality Program (changes 07/01/2021)

According to Empire BCBS NY: in order to align the program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Empire BCBS is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program. 

Starting 07/01/2021, authorization process for on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy, will be adjusted to reflect specific regiments and enhanced reimbursements, for the medical oncologists.

Which regiments are affected?

Only select oral and hormonal agents for which a monthly in-office visit may not be required.

For the complete list please click here.

Which Authorizations will be affected?

This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates. 

Which HCPCS codes will be affected?

Billable S-codes for treatment planning and care coordination management for cancer.

How will be the payment affected for the billable S-codes?

The optional enhanced reimbursement award will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353)

AIM/Empire will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support. 

If you have any questions, please Contact your Empire network representative or your oncology provider engagement liaison for more information.

Click here for the full updated Cancer Treatment Planning and Care Coordination policy (Commercial Plans)