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Medical Policy Update: Laboratory Tests for Heart Transplant Rejection

Effective December 1, 2018, we will change the way we process claims for certain services provided to patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage (MA) plans based on revisions to our medical policy, Laboratory Tests for Heart Transplant Rejection. (This policy has previously only applied to patients enrolled in Horizon BCBSNJ Commercial and Administrative Services Only plans).

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


Claims submitted for services provided on and after December 1, 2018 to members enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

  • CPT® code 0085T will be denied, regardless of the submitted diagnosis code(s), as not medically necessary.
  • CPT code 0055U will be denied, regardless of the submitted diagnosis code(s), as an experimental/investigational, noncovered service.
  • CPT code 81595 may be denied, based on the submitted diagnosis code(s), as an experimental/investigational, noncovered 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 December 1, 2018.

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, National Coverage Determinations (NCDs) and Local Coverage Determinations (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: October 31, 2018, 12:50 p.m. ET
Last updated on: October 31, 2018, 13:15 p.m. ET