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Medical Policy Update: Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions

Effective December 1, 2018, claims for services provided to patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage (MA) plans will also be processed per our medical policy, Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions. (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 for services provided on and after December 1, 2018 to members enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

  • HCPCS codes A4639 and/or E0221 will be denied, regardless of the submitted diagnosis code(s), as experimental/investigational, noncovered services.

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.

Published on: October 31, 2018, 13:29 p.m. ET
Last updated on: October 31, 2018, 13:29 p.m. ET