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Medical Policy Implementation: Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer

Effective August 31, 2021, Horizon BCBSNJ will change the way we consider certain professional claims based on the implementation of our medical policy, Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer.

Access our Medical Policy Manual to review this medical policy content.

                                                                                                                                                               

These medical policy guidelines will apply to claims submitted for services provided on and after August 31, 2021 to patients enrolled plans/products that do not participate in our Molecular and Genomic Testing Program administered by eviCore healthcare, including members enrolled in State Health Benefits Program/School Employees’ Health Benefit Program (SHBP/SEHBP) plans, other Administrative Services Only (ASO) employer group plans, and Horizon BCBSNJ Medicare Advantage (MA) plans (including Braven Health℠ plans).

Claims submitted for services provided on and after August 31, 2021 to patients enrolled in SHBP/SEHBP, ASO and MA plans will be processed as follows.

  • Based on the submitted diagnosis code(s), the services represented by CPT® codes 0155U, 0177U, 88360, 88361 may be denied as experimental/investigational, non-covered services.

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 0155U, 0177U, 81191, 81192, 81193, 81194, 88360, 88361.

    Following our review of medical record information, these services may be denied as experimental/investigational services or as not medically necessary.
  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 0037U, 0211U, 86152, 86153.

    Following our review of medical record information, services provided to members enrolled in commercial or ASO plans may be denied as experimental/investigational services or as not medically necessary.

    Following our review of medical record information, services provided to members enrolled in MA plans may be denied as “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.”

Claims submitted for services provided on and after August 31, 2021 to patients enrolled in SHBP/SEHBP and ASO plans will be processed as follows.

  • Based on the submitted diagnosis code(s), the services represented by CPT code 81309 may be denied as experimental/investigational, non-covered services.

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 81309.

    Following our review of medical record information, these services may be denied as not medically necessary.
  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 0048U, 81301, 81445,81455.

    Following our review of medical record information, services may be denied as experimental/investigational services or as not medically necessary.

Claims submitted for services provided on and after August 31, 2021 to patients enrolled in MA will be processed as follows.

  • Based on the submitted diagnosis code(s), the services represented by CPT code 0048U may be denied as “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.”

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 0048U.

    Following our review of medical record information, these services may be denied as “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.”

  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 81455.

    Following our review of medical record information, these services may be denied as “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.”

Access the guidelines that apply to members enrolled in plans that participate in our Molecular and Genomic Testing Program administered by eviCore healthcare.

CPT® is a registered mark of the American Medical Association.

The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: May 31, 2021, 06:59 a.m. ET
Last updated on: June 7, 2021, 10:22 a.m. ET