BCBSM/BCN Dual Header The Record Header Logo

The Record - Insurance Card with the BCBSM/BCN Cross and Shield logo that reads, Blue Cross Blue Shield, Blue Care Network of Michigan. Tagline: Confidence comes with every card. Image of Note boards with paper that has the letters RX on it accompanied by a stethoscope

Forward to a friend  |  Subscribe  |  The Record Archive  |  Contacts  |  bcbsm.com  |  Print this article
January 2018

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

  • Log in to web-DENIS.
  • Click on BCBSM Provider Publications & Resources.
  • Click on Benefit Policy for a Code.
  • Click on Topic.
  • Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
  • Enter the procedure code.
  • Click on Finish.
  • Click on Search.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
NEW PAYABLE PROCEDURES

0402T

Payable diagnoses:
H18.601- H18.609, H18.611- H18.619,
H18.621- H18.629, H18.711- H18.719

Basic benefit and medical policy

Corneal collagen cross-linking

The application of riboflavin with ultraviolet light for the treatment of keratoconus, also called corneal cross-linking, is considered established for patients meeting specific selection criteria, effective Nov. 1, 2017.

Inclusions:
Corneal collagen cross-linking using riboflavin and ultraviolet A may be considered medically necessary when all of the following conditions have been met:

  • Treatment of progressive keratoconus or corneal estasia after refractive surgery
  • Patients have failed conservative treatment (e.g., spectacle correction, rigid contact lens)

Exclusions:
Corneal collagen cross-linking using riboflavin and ultraviolet A is considered experimental for all other indications.
UPDATES TO PAYABLE PROCEDURES

73501, 73502, 73503

Basic benefit and medical policy

PPO Radiology Management Program

Effective Jan. 1, 2016, the following provider specialties are payable for procedure codes 73501, 73502 and 73503 under the PPO Radiology Management Program:

  • 01 General Practice
  • 03 Allergy
  • 08 Family Practice
  • 10 Gastroenterology
  • 11 Internal Medicine
  • 20 Orthopedic Surgery
  • 24 Plastic Surgery
  • 25 Physical Medicine and Rehabilitation
  • 76 Preventive Medicine
  • AD Rheumatology
  • AF Infectious Disease
  • UC Urgent Care Provider
  • WC Family Practice-Sports Medicine
  • WJ Pediatric Sports and Fitness Medicine

J3490

Basic benefit and medical policy

Baxdela covered for FDA-approved indications

Effective Oct. 20, 2017, Baxdela (Delafloxacin) is covered for the following Food and Drug Administration-approved indications:

Baxdela is indicated in adults for the treatment of acute bacterial skin and skin structure infections caused by susceptible isolates of the following:

  • Gram-positive organisms:
    • Staphylococcus aureus, including methicillin-resistant (MRSA) and methicillinsusceptible (MSSA) isolates
    • Staphylococcus haemolyticus
    • Staphylococcus lugdunensis
    • Streptococcus agalactiae
    • Streptococcus anginosus Group, including Streptococcus anginosus, Streptococcus intermedius and Streptococcus constellatus
    • Streptococcus pyogenes
    • Enterococcus faecalis
  • Gram-negative organisms:
    • Escherichia coli
    • Enterobacter cloacae
    • Klebsiella pneumoniae
    • Pseudomonas aeruginosa

J3490

Basic benefit and medical policy

Zilretta payable for FDA-approved indications

Zilretta (triamcinolone acetonide) is payable for FDA-approved indications, effective Oct. 9, 2017. Report Zilretta (triamcinolone acetonide) with procedure code J3490 and national drug code number 70801-0003-01.
POLICY CLARIFICATIONS

90875, 90876, 90901

Basic benefit and medical policy

Neurofeedback training treatment option

Neurofeedback training as an alternative therapy for individuals with attention deficit/hyperactivity disorder has been established. It may be a useful treatment option when indicated.

Neurofeedback training for other disorders, such as autism spectrum disorder, substance abuse, epilepsy, anxiety, depression and insomnia, is experimental. There is a lack of evidence in the peer reviewed published medical literature on the clinical utility and effectiveness of neurofeedback for these conditions.

The policy updates are effective Jan. 1, 2018.

Inclusions:

  • The patient has a DSM-5 diagnosis of ADHD rendered within the last 12 months before initiation of neurofeedback therapy that is confirmed by a practitioner independent of the neurofeedback provider, using evidenced-based tools/scales to support the diagnosis and assessment. Traditionally, a definitive diagnosis of ADHD is rendered by a mental health professional. However, an independent diagnosis may also be rendered by clinicians in other specialties, including primary care practitioners as long as their medical records fully support the diagnosis and that the diagnosis was made using a validated, standardized tool such as the Vanderbilt or the Connors or similar established tool in conjunction with a DSM-5 (or most currently published edition) based interview.
  • Traditionally, patients receive between 20 to 40 sessions of neurofeedback training. The medical record should support the clinical need for additional sessions over 40, and should demonstrate ongoing benefit and progress to goals.

Exclusions:
Neurofeedback training/therapy for all other diagnoses, including, but not limited to, other mental health disorders.

J3490, J3590

Basic benefit and medical policy

Criteria for Kymriah

Kymriah is considered established when criteria are met, effective Dec. 1, 2017.

Criteria

  1. Coverage of the requested drug is provided when all the below criteria are met:
    1. Age 3-25 at time of initial request
    2. Diagnosis of pediatric and young adult with B-cell precursor acute lymphoblastic leukemia, or ALL, that is refractory or in second or later relapse
      1. Previous trial and failure of at least two cycles of one standard chemotherapy regimen and one cycle of tyrosine kinase inhibitors, or TKI, therapy, unless it’s contraindicated or not tolerated
      2. For patients with Philadelphia (Ph) chromosome positive (Ph+) ALL must provide documentation of previous trial and failure of at least two lines of TKI therapy unless TKI therapy is contraindicated or not tolerated
      3. Ineligible for allogeneic stem cell transplant, or SCT
      4. Any bone marrow relapse after allogenic SCT
    3. Documentation of CD 19 tumor expression
  2. Quantity Limitations, Authorization Period and Renewal Criteria
    1. Quantity limits align with FDA recommended dosing
    2. Initial authorization period: One dose per lifetime
    3. Renewal criteria: N/A
    4. Renewal authorization period: No renewal allowed
  3. Kymriah is considered investigational when used for all other conditions, including, but not limited to:
    1. Refractory aggressive non-Hodgkin lymphoma
    2. Relapsed/refractory mantle cell lymphoma
    3. Multiple myeloma
    4. Chronic lymphocytic leukemia
    5. Small lymphocytic lymphoma
EXPERIMENTAL PROCEDURES

0443T

Basic benefit and medical policy

Spectral analysis of prostate tissue

Spectral analysis of prostate tissue by fluorescence spectroscopy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

This policy is effective Jan. 1, 2018.
GROUP BENEFIT CHANGES

Aptiv (formerly Delphi)

Aptiv, group number 71759, will join Blue Cross, effective Jan. 1, 2018.

Group number: 71759
Alpha prefix: DED

Plans offered:
CDH – HDHP HSA
Medical, hearing and prescription drugs

Delphi Powertrain Technologies General Partnership

Delphi Powertrain Technologies General Partnership, group number 71758, will join Blue Cross, effective Jan. 1, 2018.

Group number: 71758
Alpha prefix: DPO

Plans offered:
CDH – HDHP HSA
Medical, hearing and prescription drugs

Mary Free Bed

Effective Jan. 1, 2018, Mary Free Bed, group number 71771, will be offering a PPO and a PPO with an HSA benefit package to its active enrollees. There are no retirees for this account. Prescription drugs are covered through Express Scripts.

Group number: 71771
Alpha prefix:  JXP-PPO

Tecumseh Products

Tecumseh Products, group number 72696, is adding a plan.

Group number: 72696
Alpha prefix: PPO TPM

Plans offered:
1 PPO basic value, medical/surgical
1 prescription drug

Tower International

Effective Jan. 1, 2018, Tower International, group number 71379, is updating its Reference Based Benefits feature (called the Fair Price Program) to include additional outpatient services and imaging.
 
Group number: 71379
Alpha prefix: TOV

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.