Medical Policy Revision: Amniotic Membrane and Amniotic Fluid Injections

Effective February 1, 2019, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims based on the revised guidelines of our medical policy, Amniotic Membrane and Amniotic Fluid Injections.

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

Based on the guidelines of our revised medical policy, Amniotic Membrane and Amniotic Fluid Injections, claims for services provided on and after February 1, 2019 to patients enrolled in Horizon BCBSNJ Commercial and Administrative Services Only (ASO) plans will be processed as follows.

• HCPCS codes Q4140, Q4150 and/or Q4159 will be denied, regardless of the submitted diagnosis code(s), as experimental/investigational, non-covered services.

• Medical record information may be requested to help us determine the medical appropriateness of the skin substitute represented by the submission of HCPCS code Q4100 on claims.

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 on and after February 1, 2019.