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Medical Policy Implementation: Solesta (dextranomer and sodium hyaluronate gel for submucosal injection)

Effective October 17, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the use of Solesta®.

Our medical policy, Solesta (dextranomer and sodium hyaluronate gel for submucosal injection), identifies the situations and other criteria that must be met for us to consider the use of Solesta medically necessary.

We encourage you to review this policy in our Medical Policy Manual.

Based on the guidelines of our new medical policy, Solesta (dextranomer and sodium hyaluronate gel for submucosal injection):

  • Claims that include HCPCS code L8605 for services provided on and after October 17, 2016 to members 18 years of age and older may pend (depending on the submitted diagnosis code[s]) while we request and review information to help us determine if this service is considered medically necessary or investigational.
  • HCPCS code L8605 included on claims for services provided on and after October 17, 2016 to members younger than 18 years of age will be denied as an investigational service regardless of the submitted diagnosis code(s).
  • Claims that include CPT® code 0377T for services provided on and after October 17, 2016 to members enrolled in all plans except Horizon BCBSNJ Medicare Advantage plans may pend (depending on the submitted diagnosis code[s]) while we request and review information to help us determine if this service is considered medically necessary or investigational.
  • CPT code 0377T included on claims for services provided on and after ctober 17, 2016 to members enrolled in Horizon BCBSNJ Medicare Advantage plans will be denied as not medically necessary regardless of the submitted diagnosis code(s).

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 October 17, 2016.

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

This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross and Blue Shield Association.

Published on: July 18, 2016, 09:14 a.m. ET
Last updated on: November 25, 2020, 00:29 a.m. ET