Billing chart: Blues highlight medical, benefit policy changes

81257, 81258, 81259, 81269

Basic benefit and medical policy

Genetic testing for alpha thalassemia

The safety and effectiveness of genetic testing for α-thalassemia for specified populations has been established. It may be considered a useful therapeutic option for patients who meet specific selection criteria, effective July 1, 2018.

Payment policy
Requires documentation for individual consideration.

Inclusions:
Preconception (carrier) testing for α-thalassemia in prospective parents may be considered established when the following are met:

• Based on biochemical testing, one or both parents have evidence of one of the following:
• A-thalassemia, including α-thalassemia minor or hemoglobin H disease (α-thalassemia intermedia)
• A-thalassemia major

Exclusions:

• Genetic testing to confirm a diagnosis of α-thalassemia
• Genetic testing of patients with hemoglobin H disease (alpha-thalassemia intermedia) to determine prognosis
• Genetic testing in other clinical situations

See policy guidelines below for more information.

Biochemical testing to determine whether α-thalassemia is present should be the first step in evaluating the presence of the condition. Biochemical testing consists of complete blood count, or CBC, microscopic examination of the peripheral blood smear, and hemoglobin electrophoresis. In silent carriers and in α-thalassemia trait, the hemoglobin electrophoresis will most likely be normal. However, there should be evidence of possible α-thalassemia minor on the CBC and peripheral smear.

The probability of a pregnancy with hemoglobin Bart’s (α-thalassemia major) is dependent on the specific genotype found in each parent. Table PG1 summarizes the risk according to each category of α-thalassemia.

This policy doesn’t address prenatal (in utero or preimplantation) genetic testing for α-thalassemia.

Genetic testing for alpha thalassemia
Evidence indicates that confirmation of diagnosis in individuals who have suspected alpha-thalassemia can be verified based on biochemical testing without the need for genetic testing.

There is some evidence for a genotype-phenotype correlation with disease severity in individuals with hemoglobin H disease (alpha-thalassemia intermedia). However, there is no current evidence to indicate that patient management or outcomes would be altered. Therefore, the evidence is insufficient to determine the effects of the technology on health outcomes.

Preconception (carrier) testing is intended to avoid the most serious form of alpha-thalassemia, hemoglobin Bart’s. This condition leads to intrauterine death or death shortly after birth and is associated with increased obstetrical risks for the mother. Screening of populations at risk is first done by biochemical tests, including hemoglobin electrophoresis and complete blood count, along with peripheral smear. For individuals who are considering conception and have biochemical confirmation of alpha thalassemia, the evidence is sufficient to determine that genetic testing for alpha-thalassemia results in a meaningful improvement in the net health outcome.

90785, 90791, 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90853

Basic benefit and medical policy

Licensed marriage and family therapists

Beginning June 1, 2018, licensed marriage and family therapists are eligible to bill Blue Cross Blue Shield of Michigan and Blue Care Network for services within their scope of practice. The behavioral health procedures listed will be payable to licensed marriage and family therapists at 80 percent of the Traditional Fee Schedule.

J3490

Basic benefit and medical policy

Cinvanti™ (aprepitant)

Effective Jan. 2, 2018, Cinvanti™ (aprepitant) is covered for the following Food and Drug Administration approved indications:

Cinvanti (aprepitant), an injectable emulsion for IV infusion, will be used to prevent chemotherapy-induced nausea and vomiting among adults. It must be used along with the other anti-emetic drugs, dexamethasone and a serotonin-3 (5-HT3) receptor inhibitor such as ondansetron. It can be administered to prevent chemotherapy-induced nausea and vomiting caused by chemo drugs that are either moderately or highly associated with chemotherapy-induced nausea and vomiting. Both acute and delayed episodes may be prevented, and Cinvanti can be used for first treatments as well as for subsequent rounds of chemo.

A substance P/neurokinin-1 (NK1) receptor antagonist, it works by blocking receptor sites in the brain. Doses are given as a 30-minute infusion about 30 minutes before the start of chemo on the first day. Recommended dosing is 130 milligrams for chemo that has a high risk of causing chemotherapy-induced nausea and vomiting and 100 milligrams for drugs with moderate risk. Packaged in single-dose 130mg vials, Cinvanti doesn’t contain polysorbate 80, an inactive ingredient that has caused infusion site reactions and hypersensitivity for some patients receiving products that include it.

Pharmacy doesn’t require preauthorization of this drug.

Note: This drug isn’t a benefit for URMBT.

J9999

Basic benefit and medical policy

FDA approves Lutathera

The Food and Drug Administration approved Lutathera as appropriate for use in the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), including foregut, midgut and hindgut neuroendocrine tumors in adults, effective Jan. 26, 2018.

Lutathera will be reviewed for individual consideration.

URMBT is excluded.

43644, 43645, 43770- 43775, 43842- 43848, 43886- 43888, 43999, 44130, 96101- 96103, S2083

Non-covered:
 43999**

** When used to indicate any of the following procedures:

• Loop gastric bypass gastroplasty, also known as mini-gastric bypass
• Stomach stapling

Basic benefit and medical policy

Bariatric surgery

The safety and effectiveness of laparoscopic and open gastric restrictive procedures including, but not limited to, gastric-band, Roux-en-Y, gastric bypass, sleeve gastrectomy and biliopancreatic diversion have been established. They may be considered useful therapeutic options when specified criteria are met.

The exclusionary criteria have been updated, effective July 1, 2018.

Basic benefit policy group variations
Reference member benefits

Inclusions:
The surgical procedures for severe obesity, including sleeve gastrectomy, are considered established treatment options if all the following criteria are met:

• The patient has a BMI >40 or a BMI of >35 with one or more co-morbid conditions including, but not limited to:
• Degenerative joint disease (including degenerative disc disease)
• Hypertension
• Hyperlipidemia, coronary artery disease
• Presence of other atherosclerotic diseases
• Type II diabetes mellitus
• Sleep apnea
• Congestive heart failure 
• Bariatric surgery may be indicated for patients ages 18 to 60. Requests for bariatric surgery for patients younger than 18 should include documentation that the primary care physician has addressed the risk of surgery on future growth, the patient's maturity level and the patient’s ability to understand the procedure and comply with postoperative instructions, as well as the adequacy of family support. Patients older than 60 may be considered if it’s documented in the medical record that the patient’s physiologic age and co-morbid conditions result in a positive risk/benefit ratio.
• The patient has been clinically evaluated by an M.D. or D.O. (or their authorized delegate (e.g., physician assistant, etc.). The physician has documented failure of nonsurgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of:
• For Blue Cross Blue Shield of Michigan patients, six full, consecutive months (180 days) within the last four years prior to the recommendation for bariatric surgery.
• For Blue Care Network patients, six full, consecutive months (180 days) within the last two years prior to the recommendation for bariatric surgery. 
• The weight loss program listed above (six full, consecutive months, or 180 days) is waived for super morbidly obese individuals who have a BMI ≥50. Documentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.
• Documentation that the primary care doctor and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post-surgical requirements.
• A psychological evaluation must be performed as a pre-surgical assessment by a contracted mental health professional to establish the patient’s emotional stability, ability to comprehend the risk of surgery and to give informed consent, and ability to cope with expected post-surgical lifestyle changes and limitations.  Such psychological consultations may include one unit total of psychological testing for purposes of personality assessment (e.g., the MMPI-2 or adolescent version, the MMPI-A).
• The physician needs to be aware and follow up with individuals who have had gastric surgery for any long-term complications.
• In cases where a revision of the original procedure is planned because of failure due to anatomic or technical reasons (e.g., obstruction, staple dehiscence, etc.), or excessive weight loss of 20 percent or more below ideal body weight, the revision is determined to be medically appropriate without consideration of the initial preoperative criteria. The medical records should include documentation of:
• The date and type of the previous procedure.
• The factors that precipitated the failure or the nature of the complications from the previous procedure that mandate (necessitate) the takedown.
• If the indication for the revision is a weight gain or a failure of the patient to lose a desired amount of weight due to patient nonadherence, then the patient must requalify for the subsequent procedure and meet all the initial preoperative criteria.

Exclusions:
The following surgical procedures are considered experimental because their safety or effectiveness have not been proven:

• Gastric bypass using a Billroth II type of anastomosis, also known as mini gastric bypass
• Biliopancreatic bypass without duodenal switch
• Long-limb gastric bypass procedure (i.e., >150 cm).
• Stomach stapling
• Endoscopic/endoluminal procedures (including, but not limited to, insertion of the StomaphyX™ device, insertion of a gastric balloon, endoscopic gastroplasty or use of an endoscopically placed duodenojejunal sleeve) as a primary bariatric procedure or as a revision procedure, (i.e., to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches)
• Any bariatric surgery for patients with Type 2 diabetes who have a BMI of less than 35
• Laparoscopic gastric plication
• Vagus nerve blocking (see separate policy, “Vagus Nerve Blocking for Morbid Obesity”)
• Single anastomosis duodenoileal bypass with sleeve gastrectomy, or ADI-S
• Stomach intestine pylorus sparing surgery, or SIPS
• Bariatric surgery for pre-adolescents
• Intragastric balloons
• Aspiration therapy device

81324, 81325, 81326, 81403, 81404, 81405, 81406, 81448, 81479

Basic benefit and medical policy

Genetic testing for the diagnosis of inherited peripheral neuropathies

The safety and effectiveness of genetic testing for inherited peripheral neuropathies have been established. It may be considered a useful diagnostic option for patients meeting the specified selection criteria.

Inclusionary and exclusionary criteria have been updated, effective July 1, 2018.

Inclusions:
Genetic testing for an inherited peripheral neuropathy is considered established when:

• The diagnosis of an inherited peripheral motor or sensory neuropathy is suspected due to clinical signs and symptoms but a definitive diagnosis can’t be made.

Exclusions:

• Genetic testing for an inherited peripheral neuropathy is excluded for all other indications.

19294

Basic benefit and medical policy

Accelerated breast irradiation after breast-conserving surgery for early stage breast cancer and breast brachytherapy as boost with whole-breast irradiation

Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation and interstitial or balloon brachytherapy may be considered established for patients who meet inclusionary guidelines. These procedures are useful therapeutic options for patients meeting selection criteria.
• Accelerated whole breast irradiation is considered experimental in all other situations involving treatment of early stage breast cancer after breast-conserving surgery.
• Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage I or II breast cancer when used as local boost irradiation in those who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.
• Accelerated partial breast irradiation and intra-operative APBI are established when meeting ASTRO guidelines.
• Noninvasive brachytherapy using Accuboost® for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy is considered experimental.

Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision is considered experimental. There is a lack of published data to validate the efficacy of brachytherapy without surgical excision of the tumor. This policy is effective May 1, 2018.

Inclusions:
Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation may be considered appropriate for both 1 and 2 stages of breast cancer. 
• Accelerated partial breast irradiation may be considered appropriate when all of the following criteria are met:
• Age 45 or older for invasive breast cancer and older than age 50 for DCIS
• Tumor less than or equal to three centimeters with pathologically negative surgical margins
• Lymph nodes are negative show only immune histochemical involvement.
• Intraoperative radiation therapy is appropriate when all the following criteria are met:
• Age 50 or older
• Tumor equal to or less than three centimeters with grossly uninvolved surgical margins
• Lymph nodes are grossly negative and negative on intraoperative frozen section if performed.
• Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.

Exclusions:

• Accelerated whole breast irradiation for patients not meeting the above inclusions
• Interstitial or balloon brachytherapy in all other situations not specified under the inclusions
• Noninvasive brachytherapy using Accuboost^® for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy
• Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision

78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, G0235

Noncovered:

G0219, G0252

Basic benefit and medical policy

Positron emission tomography for oncologic conditions

The safety and effectiveness of PET scanning for selected oncologic applications have been established.  It’s a useful diagnostic option for patients meeting patient selection criteria.

Inclusionary and exclusionary criteria have been updated, effective July 1, 2018.

Inclusions:
General statements
All inclusionary and exclusionary statements apply to both positron emission tomography scans and PET and CT scans, i.e., PET scans with or without PET or CT fusion.

A PET or PET and CT may be appropriate for a patient with a known diagnosis of a malignancy in order to determine the optimal anatomic site for a biopsy or other invasive diagnostic procedure if standard imaging is equivocal. It also may replace conventional imaging when conventional imaging would be inadequate for accurate staging and when clinical management will depend upon the stage of disease. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for staging, not diagnosis. If the results of the PET scan won’t influence treatment decisions, these situations would be considered not medically necessary.

PET scans may be considered appropriate for the following oncologic conditions:

Anal cancer
Inclusions:

• For the diagnosis, staging, restaging and monitoring of anal cancer

Exclusions:

• Conditions not listed above

Bone cancer
Inclusions:

• For the staging of Ewing sarcoma and osteosarcoma

Exclusions:

• For the staging of chondrosarcoma

Brain cancer
Inclusions:

• For diagnosis and staging, where lesions metastatic from the brain are identified but no primary is found
• For restaging, to distinguish recurrent tumor from radiation necrosis

Exclusions:

• Conditions not listed above

Breast cancer
Inclusions:

• Staging and restaging of breast cancer
• Detecting locoregional or distant recurrence or metastasis (except axillary lymph nodes) when suspicion of disease is high and other imaging is inconclusive.
• Staging axillary lymph nodes

Exclusions:

• For the differential diagnosis in patients with suspicious breast lesions, or an indeterminate or low suspicion finding on mammography
• Staging axillary lymph nodes
• For predicting pathologic response to neoadjuvant therapy for locally advanced disease

Cancers of unknown primary
Inclusions:

• Patients with an unknown primary who meet all the following criteria:
• In patients with a single site of disease outside the cervical lymph nodes
• Patient is considering local or regional treatment for a single site of metastatic disease.
• Patient has received a negative workup for an occult primary tumor.
• The PET scan will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or regional treatment.

Exclusions:

• For patients with an unknown primary including, but not limited to, the following:
• As part of the initial workup of an unknown primary
• As part of the workup of patients with multiple sites of disease

Cervical cancer
Inclusions:

• For the initial staging of patients with locally advanced cervical cancer
• For the evaluation of known or suspected recurrence

Exclusions:

• For the initial diagnosis of cervical cancer in all other situations

Colorectal cancer
Inclusions:

• Staging and restaging (initial and subsequent treatment strategy) to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer
• To evaluate a rising and persistently elevated carcinoembryonic antigen level when standard imaging, including CT scan, is negative

Exclusions:

• When used as a technique to assess the presence of scarring versus local bowel recurrence in patients with previously resected colorectal cancer
• When used as a technique contributing to radiotherapy treatment planning

Endometrial cancer
Inclusions include all of the following:

• Detection of lymph node metastases
• Assessment of endometrial cancer recurrence

Exclusions:

• Conditions not listed above

Esophageal cancer
Inclusions:

• Staging and restaging of esophageal cancer 
• Determining response to preoperative induction therapy

Exclusions:

• Detection of primary esophageal cancer

Gastric (stomach) cancer
Inclusions:

• Diagnosis, staging and restaging of gastric carcinoma if other imaging is inconclusive.
• Determining response to preoperative induction therapy

Exclusions:

• Conditions not listed above

Head and neck cancer
Inclusions:

• For the evaluation of the head and neck in the diagnosis of suspected head and neck cancer
• For the initial staging of the disease
• For restaging of residual or recurrent disease during follow up after treatment for their head and neck cancer

Exclusions:

• Conditions not listed above

Lung cancer
Inclusions:

• Patients with a solitary pulmonary nodule as a single-scan technique (not dual-time) to distinguish between benign and malignant disease when prior CT scan and chest X-ray findings are inconclusive or discordant
• To determine resectability for patients with a presumed solitary metastatic lesion from lung cancer
• As a staging or restaging technique in those with known non-small cell lung cancer

Exclusions:

• Conditions not listed above

Lymphoma, including Hodgkin’s disease
Inclusions:

• PET scanning as a technique for staging lymphoma either during initial staging or for restaging at follow-up

Exclusions:

• Conditions not listed above

Melanoma
Inclusions:

• Assessing extranodal spread of malignant melanoma at initial staging or at restaging during follow-up treatment

Exclusions:

• When used as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy

Multiple myeloma
Inclusions:

• For the initial and subsequent treatment strategy of multiple myeloma

Exclusions:

• Not applicable

Neuroendocrine tumors
Inclusions:

• For the diagnosis, staging, restaging and monitoring of neuroendocrine tumors

Exclusions:

• Conditions not listed above

Ovarian cancer
Inclusions:

• Initial staging of ovarian cancer
• For the evaluation of patients with signs or symptoms of suspected ovarian cancer recurrence (restaging) when standard imaging, including CT scan, is inconclusive.

Exclusions:

• For the initial evaluation (not staging) of known or suspected ovarian cancer in all other situations

Pancreatic cancer
Inclusions:

• For the initial diagnosis and staging of pancreatic cancer when other imaging and biopsy are inconclusive

Exclusions:

• Evaluating other aspects of pancreatic cancer

Penile cancer
Inclusions:

• Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis

Exclusions:

• All other indications

Prostate cancer
Inclusions:

• PET scanning with 11C-choline for evaluating response to primary treatment in prostate cancer

Exclusions:

• PET scanning with 68Gallium in all aspects of managing prostate cancer
• PET scanning for all other indications

Renal cell carcinoma
Inclusions:

• Not applicable

Exclusions:

• PET scanning in all aspects of managing renal cancer

Soft tissue sarcoma
Inclusions:

• For initial staging prior to resection of an apparently solitary metastasis
• When the grade of a unresectable tumor remains in doubt after biopsy.
• Differentiation of suspected tumor from radiation or surgical fibrosis
• Determination of response to therapy.
• Gastrointestinal stromal tumor for initial staging and re-staging when there is documented recurrence

Exclusions:

• When used in evaluation of soft tissue sarcoma including, but not limited to, the following applications:
• Distinguishing between benign lesions and malignant soft tissue sarcoma
• Distinguishing between low grade and high grade soft tissue sarcoma
• Detecting locoregional recurrence
• Detecting distant metastasis

Testicular cancer
Inclusions:

• PET scanning in the evaluation of residual mass following chemotherapy of stage IIB and III seminomas

Exclusions:

• All other indications

Thyroid cancer
Inclusions:

• For the initial treatment strategy of thyroid cancer types known not to concentrate radioactive iodine
• For subsequent treatment strategy for differentiated thyroid cancer of follicular cell origin that is known to concentrate radioactive iodine, in all the following situations:
• When done following prior treatment with thyroidectomy and radioiodine ablation
• With a current serum thyroglobulin > 10 ng/ml (except in the setting of documented anti-thyroglobulin antibodies)
• With a negative whole-body RAI scan in the past

Exclusions:

• For the evaluation of known or suspected differentiated or poorly differentiated thyroid cancer in all other situations

Cancer surveillance
Inclusions:

• Not applicable

Exclusions:

• When used as a surveillance tool for patients with cancer or with a history of cancer. A scan is considered surveillance if performed more than six months after completion of cancer therapy (12 months for lymphoma) in patients without objective signs or symptoms suggestive of cancer recurrence

Payable
Q4122

Experimental
Q4175

Basic benefit and medical policy

Skin and tissue substitutes

The safety and effectiveness of skin and tissue substitutes approved by the U.S. Food and Drug Administration and the Centers for Medicare & Medicaid Services have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Human tissue products are subject to the rules and regulations of banked human tissue by the American Association of Tissue Banks.

• Alloderm is a human tissue product that is established for use in breast reconstruction and treatment of severe burns.
• Theraskin is a human tissue product that is established for use in standard therapeutic compression for venous stasis ulcers and standard diabetic foot ulcer care for neuropathic diabetic foot ulcers.
• GraftJacket is a human tissue product that is established for the treatment of neuropathic diabetic foot ulcers.
• EpiFix is an amniotic membrane allograft that is established for the treatment of neuropathic diabetic foot ulcers and venous stasis ulcers that have failed to respond to conservative measures.

This policy is effective July 1, 2018.

Inclusions:
The following skin and tissue substitutes are considered established as they have been approved by the FDA.

This list may not be all-inclusive:

• Apligraft^®
• Biobrane^®
• Cytal^® Burn Matrix
• Cytal^® MicroMatrix™
• Cytal^® Wound Sheet
• Dermagraft^®
• Endoform Dermal Template™
• Epicel^® has FDA Humanitarian Device Approval
• E-Z Derm™
• Hyalomatrix^®
• Integra^® Bilayer Matrix
• Integra^® Dermal Regeneration Template
• Integra^® Flowable Wound Matrix
• MediSkin^®
• Oasis^® Burn Matrix
• Oasis^® Ultra Tri-Layer Wound Matrix
• Oasis^® Wound Matrix
• OrCel^®
• Permacol™ (Covidien)
• PriMatrix™
• PuraPly Wound Matrix (PuraPly)
• PuraPly Antimicrobial Wound Matrix (PuraPly AM)
• Strattice™
• Suprathel^®
• SurgiMend^®
• Talymed™
• TenoGlide™
• TheraSkin^®
• TransCyte^®

Exclusions:
All other uses of bioengineered skin and soft tissue substitutes listed above unless they meet the following criteria:

• FDA approval and provided in accordance with the FDA guidelines
• Covered by Centers for Medicare & Medicaid Services         

All other skin and soft tissue substitutes including, but not limited to:

• ACell^® UBM Hydrated/Lyophilized Wound Dressing
• AlloSkin™
• AlloSkin™ RT
• Aongen™ Collagen Matrix
• Architect^® ECM, PX, FX
• ArthroFlex™ (Flex Graft)
• Atlas Wound Matrix
• Avagen Wound Dressing
• AxoGuard^® Nerve Protector (AxoGen)
• CollaCare^®
• CollaCare^® Dental
• Collagen Wound Dressing (Oasis Research)
• CollaGUARD^®
• CollaMend™
• CollaWound™
• Collexa^®
• Collieva^®
• Conexa™
• Coreleader Colla-Pad
• CorMatrix^®
• Cymetra™ (Micronized AlloDerm™)
• Dermadapt™ Wound Dressing
• DermaPure™
• DermaSpan™
• DressSkin
• Durepair Regeneration Matrix^®
• ENDURAGen™
• Excellagen
• ExpressGraft™
• FlexiGraft^®
• GammaGraft
• Graftjacket^® Xpress, injectable
• Helicoll™
• hMatrix^®
• Keramatrix^®
• Kerecis™
• MariGen™/Kerecis™ Omega3™
• MatriDerm^®
• Matrix HD™
• MemoDerm™
• Microderm^® biologic wound matrix
• NeoForm™
• NuCel
• Pelvicol^®/PelviSoft^®
• Puros^® Dermis
• RegenePro™
• Repliform^®
• Repriza™
• StrataGraft^®
• TenSIX™ Acellular Dermal Matrix
• TissueMend
• TheraForm™ Standard/Sheet
• TruSkin™
• Veritas^® Collagen Matrix
• XCM Biologic^® Tissue Matrix
• XenMatrix™ AB

0494T, 0495T, 0496T

Basic benefit and medical policy

Ex vivo lung perfusion

Ex vivo lung perfusion is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

This policy is effective July 1, 2018.

81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112

Basic benefit and medical policy

Genetic testing — Human platelet antigen genotyping

Human platelet antigen genotyping for neonatal alloimmune thrombocytopenia, also known as NAIT, is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes, effective July 1, 2018.

81327, 81382, 81479, 82397, 82784, 83520, 84999, 86021, 86140, 86255, 87045, 87046, 87075, 87102, 87177, 87209, 87328, 88346, 88350

Basic benefit and medical policy

Miscellaneous genetic and molecular diagnostic tests

Diagnostic, prognostic and therapeutic genetic testing of :

1. An affected (symptomatic) individual’s germline to benefit the individual (excluding reproductive testing), or
2. Of an asymptomatic individual to determine future risk of disease is considered experimental for the following:
• Ceilac PLUS
• ColonSentry^®
• Crohn’s Prognostic
• DecisionDx-Melanoma™
• DecisionDx-Thymoma
• DNA Methylation Pathway Profile
• GI Effects^® (Stool)
• IBD sgi Diagnostic™
• ImmunoGenomic^® Profile
• Know Error™
• ResponseDX^®: Colon
• SEPT9 methylated DNA (for example: ColoVantage^®, Epi proColon^®)
• TransPredict Fc gamma 3A

This policy is effective July 1, 2018.

Established
A0430, A0431, A0435, A0436

Non-established

A0420, S9960, S9961

Basic benefit and medical policy

Air ambulance services

The safety and effectiveness of air ambulance services have been established. In order for medical necessity to be established, the attending/ordering physician must determine that the patient’s condition requires air ambulance transport and that any alternative form of transport (ground ambulance, commercial transport) would be clinically inappropriate or detrimental to the health or outcome of the patient.

Transport by fixed wing or rotary wing transport may also be required when the patient requiring transport is physically inaccessible by ground ambulance.

This policy is effective July 1, 2018.

Inclusions (must meet all):

• Clinical condition must support medical necessity and need for air transport
• Transport by commercial or ground ambulance is clinically inappropriate — usually due to clinical instability of the patient
• Ground ambulance transport may be appropriate but patient is physically inaccessible
• Transport is directed to the nearest facility capable of providing necessary care or to a capable facility within a 25-mile radius of the nearest facility.**

**Transport beyond the 25-mile radius of the nearest capable facility may be reviewed based on the patient’s case or care management needs and other factors as determined by the attending physician in collaboration with Blue Cross Blue Shield of Michigan and Blue Care Network.

Exclusions:

• Patients with contracts or certificates specifically excluding coverage for air ambulance
• Patients who are pronounced dead before the ambulance is called
• Transport where patient’s clinical condition doesn’t require air ambulance transport
• Transport by an entity that isn’t licensed to provide air ambulance services (e.g., commercial airlines)
• Transport provided by fire departments, rescue squads or other emergency transport providers whose fees are in the form of donations

(Services involving a destination other than an acute care facility such as a specialized nursing facility, rehabilitation facility or home are rarely considered to meet coverage criteria and should be preceded by a prior authorization communication with Blue Cross Blue Shield of Michigan/Blue Care Network.)

American Axle

American Axle acquired the following groups:

• Metaldyne Performance Group LLC (group number 71473)
• Hephaestus Holdings Inc. (group number 71343)
• Grede Holdings LLC (group number 71743)
• Cloyes Gear & Products Inc. (group number 71747)

Effective July 1, 2018, these groups will be canceled and the membership contracts will be transferred into American Axle — group number 75415.

New plans that will be created under American Axle, effective July 1, 2018, are as follows:

• Consumer Basic HSA Blue Cross Blue Shield of Michigan plan
• Consumer Basic HSA Aetna plan
• Consumer Plus HSA Aetna plan
• OMF PPO Legacy plan
• U.S. Salaried Inpatriates PPO plan

Group number: 75415
Alpha prefix: PPO (AXL)
Platform: NASCO

Plans offered:
Medical/surgical
Hearing
Prescription drugs: ESI Direct (carve-out) for all plans with an exception: AAM Brillion Retiree CMM-PPO