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Medical Policy Implementation: Radiation Treatment with Azedra (Iobenguane I-131)

Effective August 22, 2019, Horizon BCBSNJ will change the way we consider certain professional and facility claims based on the implementation of our medical policy Radiation Treatment with Azedra (Iobenguane I-131).

Access our Medical Policy Manual to review this medical policy content.¹


Based on this policy implementation, facility claims submitted for services provided on and after August 22, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) and Medicare Advantage (MA) plans will be processed as noted below.

For patients age 12 years and older, based on the submitted diagnosis code(s):

  • The services represented by HCPCS codes C9407 or C9408 may be denied as experimental/investigational, non-covered services, or
  • Information may be requested to help us determine the medical appropriateness of the services represented by HCPCS codes C9407 or C9408. Following our review of medical record information, these codes may be denied as experimental/investigational, non-covered services.

For patients under age 12 years, regardless of the submitted diagnosis code(s):

  • The services represented by HCPCS codes C9407 or C9408 will be denied as experimental/investigational, non-covered services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after August 22, 2019.

¹The 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 22, 2019, 14:17 p.m. ET
Last updated on: May 22, 2019, 14:18 p.m. ET