Medical Policy Revision: Prescription Digital Therapeutics for Substance Use Disorder
Effective September 14, 2021, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Prescription Digital Therapeutics for Substance Use Disorder.
Based on this policy revision, claims submitted for services provided on and after September 14, 2021 to patients enrolled in Horizon BCBSNJ commercial plans and Administrative Services Only (ASO) employer group will be processed as follows.
- Regardless of the submitted diagnosis code(s), the services represented by CPT® codes 99453, 99457, 99458 will be denied as experimental/investigational non-covered services.
Based on this policy revision, claims submitted for services provided on and after September 14, 2021 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans (including Braven Health℠ plans) will be processed as follows.
- Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 99453, 99457, 99458.
Following our review of medical record information, these services may be denied as not medically necessary.
CPT® is a registered mark of the American Medical Association.
The 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.