Wiki New BCBS Policy 115 for transthoracic echocardiograms

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amcghee

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Has anyone been experiencing denials from BCBS for 93306, TC? On 10/01/24, they implemented a new medical necessity policy and all of our claims are being denied no matter what diagnosis we submit. I called BCBS and they do not have a list of covered, medically necessary codes. You basically need to read the policy and medical verbage and choose a code. I'm wondering if it's an internal problem with BCBS?
 
I have not had this specific problem, but in general my office has an insane amount of problems with BCBS (our local plan anyway) not following their own policies or denying for seemingly no reason. Good luck 😅
 
First what state is the BCBS. I see a policy 115 for BCBS Massachusetts, that policy does contain medically necessary ICD-10 codes and it also states when the procedure is deemed medically necessary and has a link to medically necessary codes-- A56781 Billing and coding Transthoracic Echocardiography (TTE) diagnosis codes. It is not deemed medically necessary for routine screening.
 
Yes, we are getting denials for not being medically necessary. We have been on the phone with BCBS with a response of the diagnosis being non covered, yet the diagnosis is on the list as covered. We are looking more into this. Has anyone gotten a direct answer on this yet? thanks!
 
I believe this is an internal problem with BCBS of MA. I have initiated a case with a BCBS supervisor as well as Beth Israel Deaconess who manages our contracts.
BCBS implemented Policy 115 in October 2024 in which they added a few medically necessary diagnoses for echocardiograms. It seems as if somehow they deleted all of the previous covered diagnoses from their list.
 
On their policy it reads "In addition to the covered diagnosis codes in Billing and Coding Article A56781, the following ICD diagnosis codes are considered medically necessary for commercial products when submitted with the CPT/HCPCS codes above if medical necessity criteria are met" so to me they are following the ICD10 codes listed under that Medicare article where all the ICD10 codes they are denying as a C050/LCD are covered. So I don't understand the denials.
 
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