Medical Policy Update: Arthroscopy for Treatment of Knee Derangement

Effective November 12, 2020, Horizon BCBSNJ will change the way we consider certain professional claims for knee arthroscopy services.

Access our Medical Policy Manual to review our medical policy Arthroscopy for Treatment of Knee Derangement¹.

Claims submitted for services provided on and after November 12, 2020 to patients enrolled in plans that DO NOT participate in our Surgical and Implantable Device Management Program² will be processed as follows.

• Based on the submitted diagnosis code(s), the services represented by CPT® codes 29880 and/or 29881 included on claims for services provided to patients age 50 years and older may be denied by experimental/investigational, non-covered services.


• 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 29880 and/or 29881 included on claims for services provided to patients age 50 years and older.
  
  Following our review of medical record information, these services may be denied as not medically necessary.

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 November 12, 2020.

¹The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ Medicare Advantage (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.

²Horizon BCBSNJ contracts with TurningPoint Healthcare Solutions, LLC (TurningPoint) to conduct Prior Authorization and Medical Necessity Determination reviews of certain orthopedic surgical services for members enrolled in fully insured plans and the SHBP/SEHBP plans as part of our Surgical and Implantable Device Management Program.

Visit HorizonBlue.com/turningpoint for instructions on accessing the policy criteria and guidelines that TurningPoint will follow as they conduct Prior Authorization/Medical Necessity determination (PA/MND) reviews as part of the Program.

TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain orthopedic and cardiac services for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association. CPT® is a registered mark of the American Medical Association.