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Medical Policy Update: Aqueous Shunts and Stents for Glaucoma

Effective January 4, 2020, we will change the way we consider certain services provided to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans based on an update to our medical policy, Aqueous Shunts and Stents for Glaucoma.

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


Claims submitted for services provided on and after January 4, 2020 to patients enrolled in Horizon BCBSNJ MA plans will be processed as follows.

  • Regardless of the submitted diagnosis codes, the services represented by CPT® codes 0253T, 0376T, 0450T, or E0474 will 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.

  • Based on the submitted diagnosis code(s), the services represented by CPT codes 0191T or 0449T 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.

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 0191T or 0449T. Following our review of medical record information, these services 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.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after January 4, 2020.

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.

CPT® is a registered mark of the American Medical Association

 

Published on: December 4, 2019, 10:35 a.m. ET
Last updated on: December 4, 2019, 10:50 a.m. ET