Medical Policy Implementation: Artificial Pancreas Device Systems
Effective July 22, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for artificial pancreas device systems.
Based on the guidelines of our medical policy, Artificial Pancreas Device System, HCPCS codes S1034, S1035, S1036 or S1037 on claims submitted on and after July 22, 2015 will be processed as follows:
- For patients age 16 years and older, claims submitted on and after July 22, 2015 that include HCPCS codes S1034, S1035, S1036 or S1037 and one or more of the diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.
ICD-9 diagnosis codes: 250.01, 250.03, 250.11, 250.13, 250.21, 250.23, 250.31, 250.33, 250.41, 250.43, 250.51, 250.53, 250.61, 250.63, 250.71, 250.81, 250.83, 250.91, 250.93, V58.67
ICD-10 diagnosis codes: E10.9, E10.65, E10.69, E10.11, E10.641, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.610, E10.51, E10.52, E10.59, E10.8, Z79.4
- For patients age 16 years and older, HCPCS codes S1034, S1035, S1036 or S1037 submitted on claims on and after July 22, 2015 that include a diagnosis code other than those listed above will be denied as experimental/investigational devices.
- For patients under age 16 years, HCPCS codes S1034, S1035, S1036 or S1037 submitted on claims on and after July 22, 2015 will be denied as experimental/investigational devices regardless of the submitted diagnosis.
Review this revised policy in our online Medical Policy Manual.
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 on and after July 22, 2015.