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Medical Policy Implementation: Extracorporeal Membrane Oxygenation for Adult Conditions

Effective July 22, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for extracorporeal membrane oxygenation.

Based on the guidelines of our medical policy, Extracorporeal Membrane Oxygenation for Adult Conditions, claims for dates of service on and after July 22, 2015 that include CPT® codes 33946, 33947, 33948, 33949, 33952, 33954, 33956, 33958, 33962, 33964, 33966, 33984, 33986, 33987, 33988 or 33989 will be processed as indicated below.

For patients age 18 years and older:

  • Claims for dates of service on and after July 22, 2015 that include the CPT codes listed above AND one or more of the diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.
  • The CPT codes listed above when submitted on claims for dates of service on and after July 22, 2015 that include a diagnosis code other than one of those listed below will be denied as not medically necessary.

ICD-9 diagnosis codes: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92, 422.0, 422.90, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.43, 428.9, 518.0, 518.81, 518.82, 518.84, 674.50, 674.51, 674.52, 674.53, 674.54, 799.1, 996.83

ICD-10 diagnosis codes: I21.09, I21.01, I21.02, I22.0, I21.19, I22.1, I21.11, I21.29, I22.8, I21.4, I22.2, I21.21, I21.3, I22.9, I41, I40.9, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9, I50.1, I50.20, J98.11, J98.19, J96.00, J96.01, J96.02, J96.90, J96.91, J96.92, J80, J98.4, J96.20, J96.21, J96.22, O90.3, R09.2, T86.20, T86.21, T86.22, T86.23, T86.290, T86.298, T86.30, T86.31, T86.32, T86.33, T86.39

For patients under age 18 years:

  • The CPT codes listed above when submitted on claims for dates of service on and after July 22, 2015 that include any appropriate diagnosis code will be considered for reimbursement based on that patient’s eligibility and benefits.

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 for dates of service on and after July 22, 2015.

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

Published on: April 22, 2015, 10:00 a.m. ET
Last updated on: November 24, 2020, 23:37 p.m. ET