Medical Policy Update: Pharmacogenetic Testing for Pain Management

Effective August 29, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on the inclusion of Horizon BCBSNJ Medicare Advantage (MA) plans within the scope of our medical policy Pharmacogenetic Testing for Pain Management.

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

Claims submitted for services provided on and after August 29, 2019 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) 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® code 81227. Following our review of medical record information, these services may be denied as experimental/investigational, noncovered services.

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 August 29, 2019.

CPT® is a registered mark of the American Medical Association.

¹ 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.