All PlansCoverageMedium impact
Amniotic Membrane Grafting/Transplantation (AMG/AMT) for Ophthalmologic Conditions - (Effective Date - 2026-12-15) 9.01.20
Excellus BlueCross BlueShield·Ophthalmology·Eyes (Ophthalmology)
Effective date
Dec 15, 2026
We identified it
Sep 16, 2026
Summary
Excellus BlueCross BlueShield has released a new policy (effective December 15, 2026) establishing coverage criteria for amniotic membrane grafting/transplantation (AMG/AMT) in ophthalmology. The policy covers 14 specific ophthalmic indications when FDA-cleared products are used per labeling, but excludes mild-to-moderate dry eye and considers all other uses investigational. Billing teams must verify FDA product clearance, document the specific qualifying indication, and ensure prior authorization compliance before claim submission.
Action Required
By December 15, 2026: Billing and clinical teams must (1) implement prior authorization verification process for all AMG/AMT claims to confirm use of FDA-cleared products and compliance with the 14 covered indications; (2) update encounter forms and documentation templates to capture the specific ophthalmic indication being treated (band keratopathy, corneal ulcer, neurotrophic keratitis, etc.); (3) audit provider documentation to ensure it references the applicable indication from the policy's covered list; (4) train billing staff to deny claims for mild-to-moderate dry eye (DEWS 1-2) or investigational indications not listed in Section I.C; (5) establish process to verify that amniotic membrane products used are FDA-cleared as tissue products for ocular use. Failure to obtain prior authorization or use non-FDA-cleared products will result in claim denials. For unspecified diagnosis codes, require detailed clinical documentation clearly describing the specific indication before processing claims.