Billing chart: Blues highlight medical, benefit policy changes

77061, 77062, 77063, G0279**

** Covered by Medicare

Basic benefit and medical policy

Digital breast tomosynthesis

Digital breast tomosynthesis (3-D mammography) may be considered established as a screening or diagnostic modality in the assessment and management of breast cancer for individuals meeting criteria, effective March 1, 2018.

Diagnostic procedure codes are subject to cost-sharing requirements.

Inclusions:
Digital breast tomosynthesis may be considered established for screening for any of the following:

• Digital breast tomosynthesis is used in combination with digital screening mammography in high risk individuals.
• A qualified health care provider (ordering provider or radiologist) determines that digital breast tomosynthesis should be the primary mammographic study.

Digital breast tomosynthesis may be considered established for screening or diagnostic purposes when:

• Digital mammography alone is inadequate or insufficient, in the judgment of the radiologist reviewer, to support clinical decision-making.

Exclusions:

• Those not meeting the above criteria.

94772, 94774, 94775, 94777, A4556, A4557, E0619

Non-covered:

Basic benefit and medical policy

Home cardiorespiratory monitoring for pediatric patients

The safety and effectiveness of home cardiorespiratory monitoring have been established. It may be considered a useful monitoring tool for patients meeting selection criteria. 

The inclusionary and exclusionary guidelines have been updated, effective Feb. 1, 2018. At this time, procedure code E0618 will no longer be covered unless Medicare is the primary insurer.

Note: The monitor with a recording feature will remain a benefit.

Inclusions:
Home cardiorespiratory monitoring when initiated in infants younger than 12 months of age (see policy guidelines below for more about age limits) in any of the following situations:

• Those who have experienced a brief resolved unexplained event (previously known as apparent life-threatening event) and aren’t considered lower risk following clinical evaluation
• Those with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise
• Those with neurologic or metabolic disorders affecting respiratory control, including central apnea and apnea of prematurity
• Those with chronic lung disease (e.g., bronchopulmonary dysplasia; see policy guidelines below).      

Home cardiorespiratory monitoring in children over 12 months of age in any of the following situations:

• Those with home noninvasive ventilator use
• Those home invasive ventilator use
• Those with chronic lung disease
• Those with cyanotic heart disease

Exclusions:

• Home cardiorespiratory monitoring in infants with any siblings with a history of sudden infant death syndrome, but without at least one of the indications listed above
• Home cardiorespiratory monitoring in all other conditions, including, but not limited to, the diagnosis of obstructive sleep apnea
• Apnea monitors without an event recorder

Policy guidelines
Home cardiorespiratory monitoring is intended, in part, to alert caregivers to the need for intervention at the time of an event in patients with apnea and isn’t appropriate for diagnosis of sleep-disordered breathing (central or obstructive).

This policy doesn’t address the use of an unattended (unsupervised) home sleep study for the diagnosis and management of obstructive sleep apnea. If obstructive sleep apnea is a consideration, refer to the medical policy titled “Sleep Disorders – Diagnosis and Medical Management.”

This policy applies only to the use of U.S. Food and Drug Administration approved home monitoring systems. A variety of commercially available baby monitoring devices are marketed to parents for monitoring infants’ sleep, breathing and behavior. Although some of the devices include pulse oximetry, they aren’t sold as medical devices and are therefore not cleared for marketing by FDA.

2016 Clinical Practice Guidelines from the American Academy of Pediatrics (Tieder et al., 2016) defined brief resolved unexplained event (formerly apparent life-threatening event) as: An event occurring in an infant younger than 1 year when the observer reports a sudden, brief and now resolved episode of ≥1 of the following:

1. cyanosis or pallor
2. absent, decreased or irregular breathing
3. marked change in tone (hyper- or hypotonia)
4. altered level of responsiveness

The diagnosis of bronchopulmonary dysplasia is dependent on gestational age and is based on the 2001 consensus definition from the U.S. National Institute of Child Health and Human Development (Jobe et al., 2001).

As suggested in a policy statement from the American Academy of Pediatrics, the physician should establish a review of the problem, a plan of care and a specific plan for periodic review and termination. Clear documentation of the reasons for continuing monitoring is necessary should monitoring beyond 43 weeks of postmenstrual age be recommended. Home cardiorespiratory monitoring for apnea is generally not considered appropriate for pediatric patients older than 1 year of age. There may be a subset of young children who require cardiorespiratory monitoring beyond 1 year of age, such as certain patients with home noninvasive or invasive ventilator use or chronic lung disease.

Home monitors should be equipped with an event recorder.

General Motors

Effective April 1, 2018, General Motors will allow payment for mental health and substance abuse claims associated with emergency room visit or service codes.

These codes include *99281, *99282, *99283, *99284 and *99285. If the claim meets the medical emergency criteria, services will pay according to the appropriate emergency room benefit guidelines. This applies to outpatient services only.

Inpatient mental health and substance abuse claims for these groups will be handled by Beacon Health.

Group numbers: 83640, 83650, 83200