Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com NCDs and LCDs to Be Implemented Claims submitted for services provided on and after April 9, 2018 to Horizon BCBSNJ MA members will be processed following the guidelines set forth in the NCDs, LCDs and/or their supporting articles listed below. The LCDs below are organized by LCD ID. LCD Title Assays for Vitamins and Metabolic Function Surgery: Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control Allergy Testing Intensity Modulated Radiation Therapy (IMRT) BRCA1 and BRCA2 Genetic Testing Reflectance Confocal Microscopy Electroretinography (ERG) LCD ID L34914 L35011 L36241 L36711 L36715 L37375 L37371 The NCDs below are organized into separate tables by NCD Section. NCDs within each table are organized by. NCD Section 10: Anesthesia and Pain Management Autogenous Epidural Blood Graft 10.5 Anesthesia in Cardiac Pacemaker Surgery 10.6 NCD Section 20: Cardiovascular System Vertebral Artery Surgery 20.1 Cardiac Rehabilitation Programs for Chronic Heart Failure 20.10.1 Intraoperative Ventricular Mapping 20.11 Diagnostic Endocardial Electrical Stimulation Pacing 20.12 HIS Bundle Study 20.13 Cardiac Output Monitoring by Thoracic Electrical Bio-impedance (TEB) 20.16 Ambulatory Blood Pressure Monitoring 20.19 External Counterpulsation ECP Therapy for Severe Angina 20.2 Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery 20.2 Chelation Therapy for Treatment of Atherosclerosis 20.21 EthylenediamineTetraAcetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis 20.22 Fabric Wrapping of Abdominal Aneurysms 20.23 Partial Ventriculectomy 20.26 Cardiointegram CIG as an Alternative to Stress Test or Thallium Stress Test 20.27 Hyperbaric Oxygen Therapy 20.29 CMC0011500 An Independent Licensee of the Blue Cross and Blue Shield Association.
NCD Section 20: Cardiovascular System (continued) Microvolt TWave Alternans (MTWA) 20.3 Intensive Cardiac Rehabilitation (ICR) Programs 20.31 Transcatheter Aortic Valve Replacement (TAVR) 20.32 The Pritikin Program 20.31.1 Ornish Program for Reversing Heart Disease 20.31.2 Intensive Cardiac Rehabilitation Program Benson-Henry Institute Cardiac Wellness Program 20.31.3 Transcatheter Mitral Valve Repair (TMVR) 20.33 Percutaneous Left Atrial Appendage Closure (LAAC) 20.34 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns 20.5 Transmyocardial Revascularization (TMR) 20.6 Percutaneous Transluminal Angioplasty (PTA) 20.7 Artificial Hearts and Related Devices 20.9 NCD section 30: Complementary and Alternative Medicine Laetrile and Related Substances 30.7 Cellular Therapy 30.8 NCD section 40: Endocrine System and Metabolism Outpatient Intravenous Insulin Treatment 40.7 NCD section 70: Evaluation & Management of Patients - office/hospital/home Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility 70.2 NCD Section 80: Eye PhacoEmulsification Procedure Cataract Extraction 80.1 Vitrectomy 80.11 Hydrophilic Contact Lenses 80.4 Intraocular Photography 80.6 Refractive Keratoplasty 80.7 NCD section 90: Genetics Pharmacogenomic Testing for Warfarin Response 90.1 NCD section 100: Gastrointestinal System Surgery for Diabetes 100.14 24-Hour Ambulatory Esophageal ph Monitoring 100.3 Gastric Freezing 100.6
NCD Section 110: Hematology/Immunology/Oncology Challenge Ingestion Food Testing 110.12 Apheresis Therapeutic Pheresis 110.14 Stem Cell Transplantation Formerly 110.8 110.23 Extracorporeal Photopheresis 110.4 NCD Section 130: Mental Health Hemodialysis for Treatment of Schizophrenia 130.8 NCD section 140: Miscellaneous Surgical Procedures Abortion 140.1 Plastic Surgery to Correct Moon Face 140.4 NCD section 150: Musculoskeletal System Lumbar Artificial Disc Replacement LADR 150.1 Manipulation 150.1 Thermal Intradiscal Procedures (TIPs) 150.11 Collagen Meniscus Implant 150.12 Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee 150.9 NCD section 160: Nervous System Induced Lesions of Nerve Tracts 160.1 Invasive Intracranial Pressure Monitoring 160.14 Electrotherapy for Treatment of Facial Nerve Paralysis Bell s Palsy 160.15 Sensory Nerve Conduction Threshold Tests (sncts) 160.23 Deep Brain Stimulation for Essential Tremor and Parkinson s Disease 160.24 Stereotaxic Depth Electrode Implantation 160.5 Electrical Nerve Stimulators 160.7 NCD Section 190: Pathology and Laboratory Histocompatibility Testing 190.1 Diagnostic Pap Smears 190.2 Sweat Test 190.5 Hair Analysis 190.6 Lymphocyte Mitogen Response Assays 190.8 NCD section 210: Pathology and Laboratory Prostate Cancer Screening Tests 210.1 Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs 210.1 Intensive Behavioral Therapy for Cardiovascular Disease 210.11 Intensive Behavioral Therapy for Obesity 210.12
NCD section 210: Pathology and Laboratory (continued) Screening for Hepatitis C Virus (HCV) in Adults 210.13 Lung Cancer Screening with Low Dose Computed Tomography (LDCT) 210.14 Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer 210.2 Screening for Cervical Cancer With Human Papillomavirus (HPV) Testing 210.2.1 Counseling to Prevent Tobacco Use 210.4.1 Screening for Hepatitis B Virus (HBV) Infection 210.6 Screening for the Human Immunodeficiency Virus HIV Infection 210.7 Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse 210.8 Screening for Depression in Adults 210.9 NCD section 220: Radiology Thermography 220.11 Percutaneous Image Guided Breast Biopsy 220.13 NCD section 230: Renal and Genitourinary System - ERSD Services Treatment of Kidney Stones 230.1 Dimethyl Sulfoxide (DMSO) 230.12 Ultrafiltration Monitor 230.14 Sacral Nerve Stimulation For Urinary Incontinence 230.18 Uroflowmetric Evaluations 230.2 Sterilization 230.3 Cryosurgery of Prostate 230.9 NCD section 240: Respiratory System Lung Volume Reduction Surgery Reduction Pneumoplasty 240.1 Heat Treatment including the use of Diathermy and Ultrasound for Pulmonary Conditions 240.3 Sleep Testing for Obstructive Sleep Apnea (OSA) 240.4 NCD section 250: Skin Treatment of Psoriasis 250.1 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) 250.5 NCD section 260: Transplantation - Solid Organ Transplants Adult Liver Transplantation 260.1 Heartsbreath Test for Heart Transplant Rejection 260.1 Pediatric Liver Transplantation 260.2 Pancreas Transplants 260.3 Islet Cell Transplantation in the Context of a Clinical Trial 260.3.1 Intestinal and MultiVisceral Transplantation 260.5 Dental Examination Prior to Kidney Transplantation 260.6
NCD section 260: Transplantation - Solid Organ Transplants (continued) Lymphocyte Immune Globulin AntiThymocyte Globulin Equine 260.7 Heart Transplants 260.9 NCD section 270: Wound Treatment Electrical Stimulation ES and Electromagnetic Therapy for the Treatment of Wounds 270.1 Blood Derived Products for Chronic Non-Healing Wounds 270.3 NCD section 300: Diagnostic Tests Not Otherwise Classified Obsolete or Unreliable diagnostic tests 300.1