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Medical Policy Revision: Photodynamic Therapy for Choroidal Neovascularization

Effective February 4, 2019, Horizon Blue Cross Blue Shield of New Jersey will change the way we process certain claims based on revisions to our medical policy, Photodynamic Therapy for Choroidal Neovascularization.

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


Claims submitted for services provided on and after February 4, 2019 to patients enrolled in Horizon BCBSNJ Commercial, Administrative Services Only (ASO) and/or Medicare Advantage (MA) plans will be processed as noted below.

  • Medical record information may be requested to help us determine the medical appropriateness of services represented by CPT® codes 67221, +67225 and/or HCPCS code J3396 included on claims submitted for Horizon BCBSNJ MA members.
  • CPT codes 67221, +67225 and/or HCPCS code J3396 included on claims submitted for Horizon BCBSNJ MA members may be denied as not medically necessary services.
  • Medical record information may be requested to help us determine the medical appropriateness of services represented by CPT code +67225 included on claims submitted for Horizon BCBSNJ Commercial and ASO members.
  • CPT code 67221, +67225 and/or HCPCS code J3396 included on claims submitted for Horizon BCBSNJ Commercial and ASO members may be denied as experimental/investigative, noncovered services.

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 4, 2019.

¹ The 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, NCDs and 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 5, 2018, 12:22 p.m. ET
Last updated on: November 11, 2018, 23:38 p.m. ET