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Fighting Fraud, Waste and Abuse: Amniotic Membrane and Amniotic Fluid Products

Posted December 9, 2020

The Blue Cross and Blue Shield of Illinois (BCBSIL) Special Investigations Department (SID) has become aware of several instances involving experimental, investigational and/or unproven applications of human amniotic membrane products.

SID would like to remind independently contracted providers that the BCBSIL Medical Policy for amniotic membrane and amniotic fluid (SUR704.011) includes specific requirements for the use of human amniotic membrane products such as PalinGen®, AmnioBand® Membrane, Biovance®, EpiCord®, Epifix®, Grafix™, to be considered medically necessary.

If you are aware of an instance of potential fraud, we encourage you to file a report online or call BCBSIL at 877-272-9741 to make a report. All online reports and calls are confidential, and you may remain anonymous. To view the medical policy for amniotic membrane and amniotic fluid, and access the most up-to-date BCBSIL Medical Policy information, refer to the Medical Policy section of our Provider website.

HMO reminder: Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual section.

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The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.