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New Capital BlueCross Policies

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From time to time, Capital BlueCross (CBC) introduces new policies or revises existing policies that guide how benefits and services are administered. When this happens, Human Resources (HR) includes that new information in the Flexible Benefits Guide which is added to our website during Open Enrollment. This guide remains on the website throughout the plan year.

This year, the revised policies include the addition of a number of procedures and treatments to the list of those requiring preauthorization for CBC’s Comprehensive Major Medical (CMM) and Preferred Provider Organization (PPO) plans. These services already required preauthorization under the Keystone Health Maintenance Organization (HMO) plan.

The new preauthorization list for the CMM and PPO plans is included on page 35 of the Flexible Benefits Guide. While the entire list of services and procedures are worth your time to review, we wanted to share several key revisions.

Prior Authorization Required for Sleep Studies

Capital BlueCross now requires prior authorization before the initiation of all sleep studies, including home and facility sleep studies, for all of its insurance plans.
It is the ordering physician’s responsibility to obtain prior authorization. Providers rendering the service should verify that the ordering physician has done so prior to scheduling the sleep study. Failure to do so may result in nonpayment of the claim.

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

Capital BlueCross developed a new policy titled Cryosurgical Ablation of Primary or Metastatic Liver Tumors, effective September 1, 2011. This information was formerly in the policy titled Radiofrequency Ablation or Cryoablation of Liver Tumors.

When the original policy was developed, the procedure was considered medically necessary. However, the procedure is now considered investigational, since further research has shown that this procedure has not been found to be beneficial, and the health outcomes have not improved for patients with unresectable liver cancer.

Cryosurgery has numerous risk factors associated with the procedure. Published outcomes are inconclusive, and recent literature does not provide any new information. Interest appears to focus on radiofrequency procedures.


For Further Reading

You can access the full text of your medical plan’s Certificate of Coverage via the Employee tab of the Lehigh Portal. These documents provide the most detailed explanation of each of Lehigh’s four plans.

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Spotlight is published monthly by Human Resources. Please address any comments to Hillary Kwiatek, Spotlight Editor, Human Resources, 428 Brodhead Avenue, send email to hik210@lehigh.edu, or call extension 85165.

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