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Medical Policy Revision: Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

Effective December 3, 2018, we will change the way we process claims for certain services provided to patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage (MA) plans based on revisions to our medical policy, Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer.

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


Claims submitted for services provided on and after December 3, 2018 to members enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

  • Medical record information may be requested to help us determine the medical appropriateness of the services represented by CPT® codes 81551 and/or 0053U.

    Following our review of medical record information, these services may be denied as not medically necessary.

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 December 3, 2018.

¹ The policy content of Horizon BCBSNJ medical policies that apply to services provided to Horizon BCBSNJ MA members may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). Horizon BCBSNJ follows Centers for Medicare & Medicaid Services (CMS) guidelines, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) in our processing of claims for services provided to Horizon BCBSNJ MA members. For those services where no LCD or NCD exists, claims for services provided to MA members will be processed based on our policy guidelines.

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

Published on: November 1, 2018, 12:32 PM ET
Last updated on: November 1, 2018, 13:53 PM ET