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Revisions to Pain Management Related Medical Policies

Beginning November 1, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider requests for Prior Authorization & Medical Necessity Determination (PA/MND) of certain pain management services and, subsequently, related claims submitted for musculoskeletal pain management services and associated procedures that are provided on and after November 1, 2016 based on the guidelines of the following revised medical policies:

  • Epidural Steroid Injections
  • Facet Joint Injections
  • Implantable Intrathecal Drug Delivery Systems
  • Radiofrequency Joint Ablation/Denervation
  • Regional Sympathetic Blocks
  • Sacroiliac Joint Injections
  • Spinal Cord and Implantable Peripheral Nerve Stimulators
  • Trigger Point Injections

We strongly encourage you to access our Medical Policy Manual to review these policies.

We review our medical policies annually. Revisions to our policies are based on major national and international association and society guidelines and criteria, peer-reviewed literature, major treatises, and input from practicing academic and community-based physicians (sources are documented within each policy).

Based on the guidelines of the revised medical policies noted above, the criteria used to determine medical appropriateness of services that require Prior Authorization & Medical Necessity Determination (PA/MND) may change. This will impact members enrolled in Horizon BCBSNJ health insurance plans/products for whom pain management services are managed by eviCore healthcare for services provided on and after November 1, 2016. This change may result in certain pain management services being determined to be not medically necessary on and after November 1, 2016 where similar services were determined to be medically appropriate prior to November 1, 2016.

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 1, 2016.

Horizon BCBSNJ contracts with eviCore healthcare, a nationally recognized, management services company, to manage nonemergency radiology services, Advanced Imaging Services (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), cardiac imaging services, radiation therapy and pain management services provided to members enrolled in many of the plans we offer. Learn more about the Horizon BCBSNJ programs managed by eviCore healthcare.

Published on: August 2, 2016, 06:40 a.m. ET
Last updated on: November 25, 2020, 00:32 a.m. ET