Medical Policy Revision: Intravenous Anesthetics for the Management of Chronic Pain and Depression
Effective February 25, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims related to the administration of intravenous anesthetics based on the guidelines of our revised medical policy, Intravenous Anesthetics for the Management of Chronic Pain and Depression.
HCPCS code J2001 submitted on claims for dates of service February 25, 2015 and after will be denied as an investigational service when submitted with any of the major depressive disorder diagnosis codes listed below.
ICD-9 diagnosis codes: 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35 or 296.36
ICD-10 diagnosis codes: F32.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F33.40, F33.9, F33.0, F33.1, F33.2, F33.3, F33.41 or F33.42
Claims submitted with HCPCS code J3490 for dates of service February 25, 2015 and after will pend while information required for us 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 February 25, 2015.