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Medical Policy Revision: Non-Invasive Home Positive Pressure Ventilation in Adults

Effective June 27, 2019, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims based on revisions to our medical policy, Non-Invasive Home Positive Pressure Ventilation in Adults.

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


Regardless of the submitted diagnosis code(s), claims submitted for services provided on and after June 27, 2019 will be processed as noted below.

  • Information will be requested to help us determine the medical appropriateness of the services represented by HCPCS code E0465 on claims for services provided to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) and Medicare Advantage (MA) plans.

    Following our review of medical record information, the services represented by E0465 may be denied as not medically necessary.

  • Information will be requested to help us determine the medical appropriateness of the services represented by HCPCS code E0467 submitted on claims for services provided to patients enrolled in Horizon BCBSNJ MA plans.

    Following our review of medical record information, the services represented by E0467 may be denied as not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member based on a national coverage determination or local coverage determination.

  • The services represented by HCPCS code E0467 included on claims for services provided to patients enrolled in Horizon BCBSNJ commercial or ASO plans will be denied as an experimental/investigational, non-covered service.

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 June 27, 2019.

¹The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA 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.

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

Published on: March 28, 2019, 09:39 a.m. ET
Last updated on: March 28, 2019, 09:58 a.m. ET