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Medical Policy Revision: Adult Cardiac Imaging

Effective April 1, 2021, Horizon BCBSNJ will change the way we consider certain professional claims based on a revision to our medical policy, Adult Cardiac Imaging.

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

Claims submitted for Computed Tomography (CT) for Coronary Calcium Scoring for the purpose of coronary artery disease screening provided on and after April 1, 2021 will be processed as noted below.

  • We will continue to request information to help us determine the medical appropriateness of the services represented by CPT® code 75571.

    If the information received indicates that services were performed for coronary artery disease screening in an asymptomatic member, the services represented by CPT code 75571 will be denied as not medically necessary.

This revision impacts all Horizon BCBSNJ members (except as noted below), including those members enrolled in plans that participate in our Cardiology Imaging Program managed by eviCore. You may access eviCore’s clinical guidelines for to review the criteria applicable to members enrolled in plans participating in this program.

This policy revision will not impact claims submitted for services provided to patients enrolled in the following programs/plans/products:

  • BlueCard® (please contact the member’s local BCBS Plan regarding requirements)
  • Federal Employee Program® (FEP®)

The content of Horizon BCBSNJ medical policies that apply to members enrolled in Medicare Advantage 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.

eviCore healthcare is an independent company that supports Horizon BCBSNJ in the provision of Prior Authorization and/or Medical Necessity Review (PA/MND) of certain nonemergency radiology services. eviCore Healthcare is not affiliated with Horizon BCBSNJ or the Blue Cross Blue Shield Association. eviCore healthcare is a registered trademark of eviCore healthcare.

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

Published on: December 31, 2020, 00:50 a.m. ET
Last updated on: May 6, 2021, 03:20 a.m. ET