Medical Policy Update: Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

Effective February 8, 2018, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for pneumatic compression pumps provided to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans.

We encourage you to access our Medical Policy Manual to review the guidelines of our medical policy, Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, which identify when these services are considered medically necessary. Beginning February 8, 2018 the guidelines of this policy will also apply to patients enrolled in Horizon BCBSNJ MA plans.

Based on the guidelines of our medical policy, Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers AND the submitted diagnosis code(s), claims for services provided on and after February 8, 2018 to patients enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

• Claims that include HCPCS codes E0650, E0655, E0660, E0665, E0666, E0651, E0667, E0668, E0669, E0652, E0671, E0672, E0673, E0656, E0657 and/or E0670 may pend while information required to help us determine if the service in question is considered medically necessary is requested and reviewed.

• HCPCS codes E0650, E0655, E0660, E0665, E0666, E0651, E0667, E0668, E0669, E0652, E0671, E0672, E0673, E0656, E0657 and/or E0670 may be denied as services “not related” to the submitted diagnosis code(s).

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 February 8, 2018.

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