Advanced Imaging Medical Policies to be Implemented

Horizon Blue Cross Blue Shield of New Jersey recently reviewed over 70 current medical policies on advanced imaging and associated procedures, including, but not limited to, CT, MRI, PET and nuclear medicine studies and has consolidated this policy content into 23 new medical policies, including a set of policies dedicated specifically to pediatric patients.

Effective July 18, 2016, Horizon BCBSNJ is changing the way we consider certain advanced imaging services and associated procedures based on the guidelines of the new medical policies noted here.

Effective July 18, 2016, the existing medical policies noted here will be terminated. The guidelines included within the new medical policies being implemented will replace the guidelines of the existing medical policies being terminated.

We strongly encourage you to access our Medical Policy Manual to review these policies online.

The new policies are based on the patient’s presenting complaint or known disease process, an approach similar to the way treating health care practitioners use the patient’s chief complaint or known disease to help direct his or her examinations, testing and treatment. In the majority of cases, the application of these condition-based criteria and outcome is the same. In other cases, they may lead to more focused advanced imaging decisions in clinical scenarios that lead to more desirable outcomes.

Our new policies include:

• Recommendations regarding clinical evaluations and treatments which may be appropriate before advanced imaging is considered;
• The specific imaging procedures which are most appropriate to meet the patient’s diagnostic needs; and
• Circumstances in which imaging may not be appropriate.

Consistent with our previous advanced imaging policies, these new policies have been developed using evidence-based sources such as medical society appropriate utilization criteria (i.e., American College of Radiology (ACR), the National Comprehensive Cancer Network and the American College of Cardiology) as well as peer-reviewed medical literature and advice from panels of subject matter experts.

Beginning for services provided on and after July 18, 2016 to members enrolled in Horizon BCBSNJ health insurance plans/products for whom advanced imaging services are managed by eviCore healthcare, and based on the guidelines of our new medical policies, the criteria that eviCore uses to determine medical appropriateness of services that require Prior Authorization or Medical Necessity Determination may change. This change may result in certain advanced imaging services being determined to be not medically necessary on and after July 18, 2016 where similar services were determined to be medically appropriate prior to July 18, 2016.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after July 18, 2016.

Horizon BCBSNJ contracts with eviCore healthcare, a nationally recognized, management services company, to manage nonemergency radiology services, Advanced Imaging Services (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), cardiac imaging services, radiation therapy and pain management services provided to members enrolled in many of the plans we offer. More information about Horizon BCBSNJ programs managed by eviCore healthcare is available online.