Medical Policy Revision: Intravenous Anesthetics for the Management of Chronic Pain
Effective November 11, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the use of intravenous medications for chronic pain management.
Based on the guidelines of our revised medical policy, Intravenous Anesthetics for the Management of Chronic Pain:
- HCPCS code J2001 submitted on claims for services provided on and after November 11, 2015 that include one of the following additional diagnosis codes will be denied as an investigational service.
ICD-9 diagnosis codes: 339.12, 339.41, 339.42, 346.70, 346.71, 346.72, 346.73
ICD-10 diagnosis codes: G44.221, G44.229, G44.51, G44.52, G43.709, G43.719, G43.701, G43.711
- Claims submitted for services provided on and after November 11, 2015 that include HCPCS code J3490 – regardless of diagnosis – will pend while information required to determine medical necessity is requested and reviewed.
Review this revised policy in our online Medical Policy Manual.
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 November 11, 2015.