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August 2018

Professional

Appealing Medicare Plus Blue PPO acute inpatient authorization decisions

Our plan medical directors make denials of care for Medicare Plus Blue^SM PPO acute inpatient authorizations related to medical necessity or medical appropriateness based on:

Review of pertinent medical information
Consideration of the member’s benefit coverage
Information from the attending physician and primary care physician
Clinical judgment of the medical director

All providers have the right to appeal an adverse decision made by the Medicare Plus Blue PPO Utilization Management staff. The two-step appeal process for the provider is designed to be objective, thorough, fair and timely.

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or an external review board.

When we receive a provider appeal request and a member appeal is in-process, the member appeal takes precedence. When the member appeal process is complete, its decision is final and we won’t process the provider appeal.

Guidelines for provider appeal requests (for medical necessity or medical appropriateness determinations)
Expedited appeals	A practitioner may request expedited appeals when circumstances need a decision in a short period of time, because a delay may seriously jeopardize the life or health of the member. We won’t consider retrospective appeals (for service already provided to the member) for an expedited appeal. You may verbally request decisions about precertification of urgent care and concurrent cases that result in denial. Medicare Plus Blue notifies the provider of the decision within 72 hours of receiving the request. Start an expedited appeal by calling a plan medical director or designee at 1-866-807-4811. This decision is final and no other appeal choice is available to the provider.
Level One appeals	Are due to Medicare Plus Blue within 45 calendar days of the date noted on the written denial notification. Requests must include additional clarifying clinical information to support the request. Medicare Plus Blue notifies the provider of the decision within 30 calendar days of receiving all necessary information. Submit requests via any of the following methods. Fax: 1-877-495-3755 Email: MedicarePlusBlueInpatientAppeals@bcbsm.com Mail: Medicare Plus Blue Inpatient Provider Appeal Blue Cross Blue Shield of Michigan Mail Code 1516 600 E. Lafayette Blvd. Detroit, MI 48226-2998
Level Two appeals	Are due to Medicare Plus Blue within 21 calendar days of the date noted on the level-one appeal decision notification. Level-two appeal requests must include at least one of the following: New or clarifying clinical information A clear statement that the provider is requesting a Medicare Plus Blue physician reviewer who’s different from the one who reviewed the level-one appeal If neither the clinical information nor the request for a different physician reviewer is provided, Medicare Plus Blue isn’t bound to review the level-two appeal request. Send level-two requests to the same fax number, email or mailing address as level-one appeal requests. Medicare Plus Blue notifies the provider of the decision within 45 calendar days of receiving all the necessary information. This decision is final.

Time frames
Medicare Plus Blue isn’t obligated to review cases when it receives an appeal request outside of the allowed time frame. We’ll send a letter to the requesting provider — either advising that we didn’t review the appeal or notifying the physician of the outcome of the request (if the plan decides to review the case).

Preservice appeals
You can request a preservice adverse decision appeal only when a service hasn’t yet been rendered (the member isn’t yet admitted to inpatient status).

To request a preservice appeal, call Provider Service at 1-866-309-1719. If you’re unsatisfied with the decision, then submit an appeal in writing within 60 days of the initial decision to:
Medicare Advantage PRS- Appeals
Attn: First Level Appeal
Blue Cross Blue Shield of Michigan
P.O. Box 33842
Detroit, MI 48232-5842

For more information, see the provider manual.

Reminder: List primary procedure codes first when submitting claims

In response to recent billing issues that have caused some claims to be rejected, we’d like to remind you to list primary procedure codes first when submitting claims to ensure timely and correct processing. Without the primary code on the first line, the system may reject either part, or all, of the claim. The rejection will indicate “services not payable if not billed in combination with another payable service.”

For example, if 77067 (screening mammogram) is billed along with 77063 (screening digital add-on), 77067 should appear first in the claim with 77063 on a lower line.

What’s new about authorization criteria and e-referral questionnaires for certain services

For certain services for Blue Cross Blue Shield of Michigan Medicare Plus Blue^SM members, the authorization criteria and the questionnaires in the e-referral system have been updated. Click here to see which services have revised authorization criteria and questionnaires.

How the questionnaires work

If your responses to the questionnaire in the e-referral system indicate that the procedure meets the criteria, the authorization request will automatically be approved. If the criteria aren’t met, the request will be pended for clinical review by Blue Cross Utilization Management staff.

For cases that aren’t automatically approved via e-referral after you complete the questionnaire, you must include additional clinical information. You can type the information directly into the Case Communication section in the e-referral system or you can attach it to the case. The instructions for attaching clinical information to the case are outlined in the e-referral User Guide. Search for “Create New (communication)” and find the instructions for attaching a document to the case.

Where to find authorization criteria and preview questionnaires

The updated authorization criteria are available at ereferrals.bcbsm.com. Click on Blue Cross and then on Authorization Requirements & Criteria. Look under the For Blue Cross Medicare Plus Blue PPO members heading.

You’ll also find the new and updated preview questionnaires at that location. You can look over the preview questionnaires to see what questions you’ll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you’ll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

We’ve canceled the modifier 25 payment adjustment for evaluation and management services

In the April 2018 Record, we announced that evaluation and management services billed with modifier 25 would pay at 80 percent when billed with a surgery on the same day by the same provider, effective July 1, 2018. However, based on new information and provider feedback, we’ve canceled implementation of this policy.

Find out how to request peer-to-peer reviews for inpatient admissions

Blue Cross Blue Shield of Michigan and Blue Care Network allow facility onsite physician advisers to discuss reviews of inpatient admissions with a Blue Cross or BCN medical director. This applies to members with coverage through BCN commercial, BCN Advantage^SM, Medicare Plus Blue^SM and Blue Cross commercial products.

The purpose of these peer-to-peer conversations is to discuss the clinical and medical necessity nuances of a member’s medical condition that requires an inpatient admission or authorization for a service that’s not part of the InterQual^® criteria or our local rules. The facilities involved in the program agree to initiate peer-to-peer conversations only through their employed physician advisers and not through third-party advisers or organizations.

For patients with BCN coverage:
Here’s how to request a peer-to-peer review with a BCN medical director:

Call 248-799-6312.
Select prompt 3 for a peer-to-peer review.
Leave a message with the following information:

Physician adviser’s or physician’s name and phone number
Member’s name, date of birth and contract number
Reason for requesting a peer-to-peer review
Best date and time to reach the physician adviser or physician

For patients with Blue Cross coverage:
Here’s how to request a peer-to-peer review with a Blue Cross medical director:

Call 1-866-346-7299.
Select the prompt for “Facility Precertification Department” (press No. 2).
Select the prompt for “Provider Peer-to-Peer Review.”
Leave a message with the following information:

Physician adviser’s name and phone number
Member’s name, date of birth and contract number
Reason for requesting a peer-to-peer review
Best date and time to reach the physician adviser

For behavioral health cases
Here’s how to request a peer-to-peer review for inpatient admissions related to BCN, BCN Advantage and Medicare Plus Blue products:

Call 1-877-293-2788.
If the call isn’t answered live, leave a message with the following information:

Name of person calling and call-back number
Physician adviser’s or physician’s name and phone number
Member’s name, date of birth, contract number or case number
Reason for requesting a peer-to-peer review
Best date and times to reach the physician adviser or physician

Blue Cross PPO members should call the behavioral health number on the back of the member's Blue Cross ID card.

The peer-to-peer phone line is open 8 a.m. to 5 p.m. Monday through Friday, except for holidays. Calls will be returned within 48 business hours.

PT, OT and chiropractic prior authorizations not required for fully insured group members and members with individual coverage

In January, Blue Cross Blue Shield of Michigan began requiring prior authorization for lumbar spine fusion, radiation oncology and interventional pain management services provided to our fully insured group members and members with individual coverage. We also planned to require them to seek prior authorizations for physical therapy, occupational therapy and chiropractic services starting July 1.

However, we’ve decided that prior authorization for PT, OT and chiropractic services won’t be required for our fully insured group members and members with individual coverage at this time.

Keep in mind that prior authorization programs are commonly used for certain services (such as complex surgeries, diagnostic imaging and specialty drugs) and help to ensure quality care that aligns with our members’ benefits. These programs also let health care providers and members know in advance whether a service will be covered. Prior authorization programs are used by many health care plans across the country.

This change doesn’t affect prior authorization programs that are currently in place for other members, such as those with Medicare Plus Blue^SM, Blue Care Network or BCN Advantage^SM.

Recommendations for improving Medicare Advantage patient satisfaction

Practices with a high level of patient satisfaction benefit from patients who are more loyal and more likely to follow treatment plans. And practices with satisfied patients typically have higher levels of employee satisfaction and less employee turnover.**

CMS patient satisfaction surveys
Each spring, the Centers for Medicare & Medicaid Services measures patient satisfaction and outcomes with two separate surveys:

Consumer Assessment of Healthcare Providers and Systems — CAHPS assesses quality of care from a health plan member’s perspective.
Health Outcomes Survey — HOS measures patient-reported health outcomes.

CMS sends these annual surveys to a sampling of Medicare Advantage members by a certified survey vendor.

Results and recommendations for your practice
Based on results of the 2017 surveys, key areas that need improvement for both CAHPS and HOS surveys follow. We’ve included a detail of each measure, patient survey questions for your information, as well as recommendations that can help your practice achieve higher patient satisfaction.

CAHPS survey findings
Three key areas for improvement:

Administering the annual flu vaccine during flu season.
Ensuring that patients see the doctor or other health care practitioner within 15 minutes of an appointment time.
Sharing test results with patients promptly.

CAHPS measure: Annual flu vaccine

Patient survey question	Recommendation for providers
Have you had a flu shot since July 1, 2018?	Administer flu shot after July 1, 2018, and before Feb. 1, 2019.

CAHPS measure: Getting appointments and care quickly

Patient survey questions	Recommendations for providers
In the last six months, how often did you see the person you came to see within 15 minutes of your appointment time?	If you’re behind schedule, have the front office staff update patients often and explain why. Patients are more tolerant of delays if they know the reasons. Show respect to the patient if you’re behind schedule and apologize.
In the last six months, when you needed care right away, how often did you get care as soon as you thought you needed it?	Ensure that a few appointments are open each day for urgent visits, including post-inpatient-discharge visits.
In the last six months, not counting the times when you needed care right away, how often did you get care as soon as you thought you needed it?	Offer appointments with a nurse practitioner or physician’s assistant to patients who want to see you on short notice. Ask patients to make routine checkup and follow-up appointments in advance.

CAHPS measure: Overall rating of health care quality

Patient survey question	Recommendation for providers
Using any number between zero and 10, where zero is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the past six months?	Ask patients how they think you could improve their health care.

CAHPS measure: Care coordination

Patient survey questions	Recommendations for providers
When you visited your personal doctor for a scheduled appointment, how often did he or she have your medical records or other information about your care?	Before walking in the exam room, read the current complaints and decide if anything needs a follow-up from previous visits.
When your personal doctor ordered a blood test, x-ray or other test for you, did someone from your personal doctor’s office follow up to give you those results?	When ordering tests, let your patients know when they can expect results. Implement a system to ensure prompt notifications of results.
Did your personal doctor talk to you about all the prescription medicines you were taking? Did you get the help you needed from your personal doctor’s office to manage your care among these different providers and services? How often did your personal doctor seem informed and up to date about specialist care?	Ask your patients if they saw another provider since you last met with them. If you know patients received specialty care, discuss their visit and if the specialist prescribed any added medication.

Health Outcomes Survey findings
Three key areas for improvement:

Discussing the risk of falls with patients
Advising on physical activity
Inquiring about bladder control

HOS measure: Reducing the risk of falling

Patient survey questions

Recommendations for providers

Did you fall in the last 12 months?

Did you talk to your doctor about falling or problems with balance or walking?

Some things your patients might do to reduce the risk of falling are:

Using a cane or walker
Engaging in an exercise or physical therapy program
Having a vision or hearing test
Improve home safety

HOS measure: Improving or maintaining physical health

Patient survey questions

Recommendations for providers

During the past four weeks, has pain stopped you from doing things you want to do?

Have you had any of the following problems with your work or other regular daily activities because of your physical health?

Accomplished less than you would like
Didn’t do work or other activities as carefully as usual

Identify ways to improve the pain problem.

Determine if your patient could benefit from a consultation with a pain specialist or rheumatologist.

Consider physical therapy, cardiac or pulmonary rehabilitation when appropriate.

HOS measure: Improving bladder control

Patient survey questions

Recommendations for providers

In the past six months, have you accidentally leaked urine?

How much of a problem, if any, was the urine leakage for you?

Have you received other treatments for your current leakage problem?

When talking to patients, note that urinary leakage problems can be common as we grow older, but there are treatments that can help. This opens the conversation if they’re too embarrassed to bring it up.

Do they have leakage problems? Discuss potential treatments options, such as medications, exercises and surgery.

HOS measure: Improving or maintaining mental health

Patient survey questions

Recommendations for providers

Have you had any of the following problems with your work or other regular daily activities because of emotional problems?

Accomplished less than you would like
Didn’t do work or other activities as carefully as usual
Didn’t have a lot of energy or felt sad or depressed most days

Empathize with the patient.

Consider therapy with a mental health professional when appropriate.

Offer ideas to improve mental health: Take daily walks, socialize, stay involved with family, own a pet, do crossword puzzles, volunteer, attend church, go to senior community centers or try meditation.

Since loss of hearing can be isolating, consider a hearing test when appropriate.

HOS measure: Monitoring physical activity

Patient survey question

Recommendation for providers

In the past 12 months, did you talk with a doctor or other health care provider about your level of exercise of physical activity?

In the past 12 months, did a doctor or other health care provider recommend starting, increasing or maintaining your level of exercise or physical activity?

Offer physical activity suggestions based on the patient’s ability.

Offer ideas for where patients can engage in activities such as senior classes at the Area Agency on Aging, YMCA and community centers. These also offer opportunities for social interaction.

Do you have feedback?
If you have any suggestions for how we can improve the patient care experience, send an email to Laurie Latvis at LLatvis@bcbsm.com.

**Edgman-Levitan, Susan and others. The CAHPS Ambulatory Care Improvement Guide: Practical Strategies for Improving Patient Experience. Agency for Healthcare Research and Quality. December 2017.

Announcing updates to our Prepayment Utilization Review policy

Blue Cross Blue Shield of Michigan has updated its Prepayment Utilization Review policy. This policy update, which will become effective immediately, is as follows:

Prepayment Utilization Review

Prepayment Utilization Review, sometimes called PPUR, is a process we use to determine appropriate liability for covered health care services before paying claims for the services. We do this for a select group of providers who have been identified for medical record review before claims are paid.

Reasons for the review

We may recommend providers for PPUR for one or more reasons. These reasons may include the following:

A provider is under investigation or review for possible improprieties, or has been indicted or charged with improprieties.

A provider is under investigation or review by a regulatory board or agency involving the termination or suspension of licensure, certification, registration, certificate of need or accreditation.

A provider demonstrates a pattern of noncompliance with our policies, guidelines and procedures.

A provider fails to document the medical necessity for a significant number of services, following a final audit determination.

A provider demonstrates a pattern of overutilizing or inappropriately billing.

A provider is or has been departicipated.

To ensure appropriate liability for services.

How the process works

Once a determination is made that a provider should be placed on PPUR, we notify that provider, in writing, of our determination.

The provider must include supporting documentation with each claim submitted so we can verify that each procedure billed was medically necessary and that the claim was billed properly. If the provider doesn’t comply with these procedures, the claim can’t be reviewed; it will be denied and returned to the provider.

In addition, providers who are placed on PPUR must develop a corrective action plan that addresses the issues identified as problematic. They must submit that plan for our review and approval. While the provider is on PPUR, we evaluate his or her adherence to the corrective action plan with the prospect of removing the provider from the PPUR process. The provider may meet with us to discuss the evaluation.

Providers are reviewed on a six-month basis. They may be removed from PPUR if they meet all of these requirements:

They comply with their corrective action plan.
They comply with all Blue Cross policies and procedures.
They demonstrate a significant reduction in their error rate.

But a provider will remain on PPUR and may be subject to additional sanctions if he or she:

Doesn’t demonstrate compliance with his or her corrective action plan.
Fails to comply with Blue Cross policies and procedures.
Doesn’t demonstrate a significant improvement in his or her error rate.

Coding corner: How to handle coagulopathy

Coagulopathy can be challenging for coding professionals, specifically for patients with a current bleed being treated with an anticoagulant or antithrombotic for a separately diagnosed condition.

In ICD-9-CM, this scenario required the location of the bleeding to be coded, followed by the adverse effect of the anticoagulant or antithrombotic drug code.

In ICD-10-CM, coagulopathy is still represented by two codes, but the site of occurrence may not be required; it depends on the circumstances of the encounter. According to the first quarter 2016 Coding Clinic release, the appropriate ICD-10-CM code assignment for this scenario would be D68.32, hemorrhagic disorder due to extrinsic circulating anticoagulant, along with the appropriate adverse effect code for the drug. Support is in the inclusion terms for code D68.32, which state “drug-induced hemorrhagic disorder.”

Most codes in category D68 — other coagulation defects — are generally assigned for hemorrhagic disorders or coagulation defects and must be specifically stated and documented by the patient provider. But code D68.32 is unique to this category: It’s the only code pertaining to extrinsic factors, relating to a process within the body due to provocation, specifically anticoagulants.

Anticoagulant therapies are divided into four classes, depending on the mechanism of action:

Vitamin K antagonists

Warfarin (Coumadin, Jantoven)

Low molecular weight heparins and heparin

Enoxaparin (Lovenox)
Dalteparin (Fragmin)

Thrombin inhibitors

Bivalirudin (Angiomax)
Argatroban (Acova)
Dabigatran (Pradaxa)
Antithrombin III (Thrombate III)

Factor Xa inhibitors

Apixaban (Eliquis)
Fondaparinux (Arixtra)
Rivaroxaban (Xarelto)
Edoxaban (Savaysa)

We can’t assign this code to any patient on an anticoagulant with a prothrombin time and international normalized ratio or partial thromboplastin time that’s outside the therapeutic range. This code description refers to a “hemorrhagic disorder,” which, according to the Coding Clinic, includes bleeding such as:

Hemoptysis
Hematuria
Hematemesis
Hematochezia

In addition, an inclusion term for this code also includes hyperheparinemia, or excessive heparin in the blood.

Provider documentation must support the causal relationship between the bleed and the anticoagulation therapy. The Coding Clinic says, “An increased risk for bleeding is a side effect associated with anticoagulant therapy. The adverse effect code is assigned for bleeding resulting from an anticoagulant that is properly administered.” Code D68.32 includes a “use additional code” note to remind us to code the adverse effect (if applicable) to identify which drug the patient is taking, and thus causing the condition.

Clarification on waiving nursing orders for home infusion therapy

In the June 2017 Record, we published an article about waiving nursing requirements for home infusion services. We’d like to clarify the following: You may obtain a verbal order from the ordering physician to change the nursing orders.

Please include the following in your documentation:

That the member or personal caregiver has a proven and adequate sterile infusion technique
Confirmation that the member or caregiver is aware that nursing is available on an as-needed basis
The first and last name of the person you spoke with at the office, as well as the date and time of your conversation
A legible signature signed by the registered nurse or registered pharmacist who took the verbal order

Reminder: Injections (for example, subcutaneous or intramuscular) are only payable when administered on the same day as an approved medical intravenous therapy session, according to the Home Infusion Therapy Services Provider Manual.

Blue Cross won’t cover topical products containing urea

Effective July 15, 2018, Blue Cross Blue Shield of Michigan and Blue Care Network won’t cover topical products containing urea because they aren’t approved by the U.S. Food and Drug Administration. Affected members can continue to fill their prescriptions through Aug. 31, 2018. After this date, they’ll be responsible for the full cost.

Urea products help skin retain moisture and stay hydrated. They’re used to treat various skin conditions.

Our goal is to provide our members with safe, high-quality prescription drug therapies. We continuously review prescription drugs to provide the best value for our members, control costs and make sure they’re using the right medication for the right situation.

We’re sending letters to notify affected members, their groups and doctors about these changes and encourage members to speak with their doctors about their treatment options.

FEP helps members with their follow-up visits

The Blue Cross and Blue Shield Federal Employee Program^® offers case management services to help members with their follow-up visits after a hospital stay. The services identify barriers members face and then aid them in overcoming these challenges.

If getting to a follow-up visit is a problem, members can use Teladoc^®, FEP’s telehealth service.

Whether a patient has been admitted to a hospital for an illness, injury or behavioral/mental health or substance abuse issue, follow-up appointments are needed. Care coordination and member outreach are key to improving follow-up visit rates after hospitalization and lessening the chance of readmittance.

Discharge planners can help patients schedule follow-up appointments when the patient is discharged. And doctors’ offices can help by making reminder phone calls to patients before scheduled visits.

For more information about FEP’s care coordination and wellness programs, click here.

Managing acute low back pain in adults

Low back pain is one of the most common reasons for an outpatient visit, according to the American Academy of Family Physicians.

The evaluation for low back pain should include a complete, focused medical history looking for red flags. These include, but aren’t limited to:

Severe or progressive neurologic deficits
Fever
Sudden back pain with spinal tenderness
Trauma
An indication of a serious underlying condition

It’s also important to rule out non-spinal causes of back pain. These include:

Pyelonephritis
Pancreatitis
Penetrating ulcer disease or another gastrointestinal cause
Pelvic diseases

Many doctors recommend avoiding imaging for acute low back pain within the first six weeks, unless red flags are present. Studies show that imaging has a limited affect for patients with acute low back pain without red flags, and that a conservative approach is preferable as most patients improve over time regardless of treatment.

When red flags aren’t present, clinicians and patients should consider nonpharmacologic treatment such as superficial heat, massage, acupuncture or spinal manipulation.

If pharmacologic treatment is needed, clinicians and patients should consider non-steroidal anti-inflammatory drugs or skeletal muscle relaxants.

In March 2018, the Michigan Quality Improvement Consortium published a guideline for adults who have low back pain or back-related leg symptoms for more than six weeks. Its recommendation is to focus on patient reassurance, detailed history and physical exam, appropriate therapy, referrals and medication strategies.

None of the information included in this article is intended to be medical advice.

All Providers

Learn more about our new process for auditing paid claims

Blue Cross Blue Shield of Michigan and Blue Care Network have partnered with HMS^® to conduct various audits of paid claims.

For Blue Cross, HMS will conduct selective professional and nonhospital facility audits.
For both Blue Cross and Blue Care Network, HMS will conduct the diagnostic-related group, or DRG, audits.
Inpatient high-dollar audits will remain as they are.

Professional and nonhospital facility, and DRG audits are a retrospective review of paid claims. The review ensures that billed and paid services were ordered, medically necessary, documented and reported correctly. For these audits, medical records will be requested for review. Once the review has been completed, HMS will send the findings letter and information on how to request an appeal, if necessary.

For hospital, professional and nonhospital facility audits, the appeals process has been simplified to a two-step process:

For automated billing and compliance audits, disputed claims will be eligible for a one-step internal appeal, and findings will be adjusted at the claim level.
For complex, medical necessity audits, an independent external review is the second step in the appeal process. After the second level is completed, findings will be adjusted at the claim level.

For more information, refer to the Record article from January 2018 on commercial professional and facility claim audits. You can also refer to March and May 2018 Record articles defining the changes to provider audits and the new appeal time frames. The appeals process for DRG audits will remain the same.

We’re extending the retro-authorization period for eviCore MA PPO and commercial PPO programs

Previously, we communicated about prior authorization programs administered by eviCore healthcare for Blue Cross Blue Shield of Michigan commercial PPO and Medicare Plus Blue^SM members.

Now, Blue Cross is extending the retro-authorization period from 90 days to 365 from date of service for the eviCore authorization programs.

This will apply to:

Blue Cross commercial PPO

Radiation oncology
Interventional pain management
Spinal fusion

Medicare Plus Blue

Radiation oncology
Interventional pain management
Spinal fusion
Physical therapy and occupational therapy

It’s crucial that providers continue to check eligibility and complete the authorization prior to initiating any services. Keep in mind that the timely filing rules for claims will apply, and claims will be denied if the claim receipt date is greater than 365 days from the date of service. Providers must resubmit any previously denied claims in order for them to be reconsidered.

We encourage providers to complete retrospective authorizations as soon as possible to allow for claims submission and payment within the timely filing rules.

Note: MESSA and auto groups are excluded from the eviCore prior authorization program. Blue Care Network HMO^SM isn’t affected by this change.

Pilot program promotes effective pain control through limiting post-operative opioid dispensing

Blue Cross Blue Shield of Michigan is piloting an initiative for select surgeries aimed at promoting effective pain control through care processes that limit opioid dispensing.

Effective immediately, Blue Cross’ payment policy will be modified to allow surgeons to report modifier 22 for an additional 35 percent reimbursement when pain control optimization protocols are used to support the surgery. It’s expected that each claim reporting modifier 22 will include attestation that such processes were included as part of the surgery.

This initial period of the pilot program will include the following surgical categories:

Laparoscopic cholecystectomy
Inguinal hernia repair
Thyroidectomy
Endoscopic sinus surgery and septoplasty
Prostatectomy
Bariatric surgery

To bill the modifier 22 for adherence with the pain control optimization pathway, the physician agrees to follow the recommendations of Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN, as found on its prescribing recommendations website.**

The physician also agrees to the following guidelines:

No additional pills are prescribed after the initial discharge prescription.
No opioid prescriptions have been filled within 30 days before surgery, with certain exceptions.
For procedures with limited opioids recommended after surgery, Blue Cross will allow up to 10 percent to have an additional fill for an opioid within 30 days after surgery to accommodate unexpected excessive pain.

This pilot program is expected to last one to two years for these initial procedures, based on results. We’ll announce further details in future Record articles.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Battling the opioid epidemic: A roundup of news and information

CEO Loepp discusses opioid crisis with business leaders
Blue Cross Blue Shield of Michigan President and CEO Daniel J. Loepp shared some of the results of the company’s efforts in battling the opioid epidemic during the state’s Mackinac Policy Conference in late May. This annual event is sponsored by the Detroit Regional Chamber, and gathers prominent state and national speakers to discuss topics that are important to Michigan.

Loepp was a featured panelist in a discussion titled “Opioids in the Workplace: Impacting Michigan.” He was joined by Penske Corp. President Bud Denker, Gallagher Benefit Services Health Management Director Jenny Love and former U.S. Attorney Barbara McQuade. For more information, click here.

New Michigan law limits amount of opioids doctors can prescribe
A new state law limits the amount of opioids that doctors are allowed to prescribe patients suffering from acute pain, the Detroit Free Press reported June 28. Effective July 1, 2018, doctors are prohibited from prescribing more than a seven-day supply of opioid medication for patients in acute pain — pain from broken bones, bad backs, short illnesses and most surgeries, pain that's relatively short term.

Doctors won’t be allowed to write refills for the medications until the seven-day period has elapsed. To read more, click here.

Michigan requires providers to provide opioid education before prescribing
On June 1, 2018, the state of Michigan started requiring health care providers to educate patients about opioids before prescribing them to patients. Providers can use the state’s Opioid Start Talking form, or a similar form, when prescribing an opioid.

If providers use a different form, it must cover all the topics used on the Opioid Start Talking form. The form must be completed, signed and saved in the patient’s medical record. For more information about Michigan’s opioid laws, click here.

Study says number of opioid overdose deaths undercounted
According to University of Pittsburgh study, 216 opioid overdose deaths likely went unreported in 2015. That brings the total up to 1,402 accidental opioid overdose deaths in 2015, 14th in the nation. For more about the study, see the Detroit Free Press article titled “Michigan undercounted opioid overdose deaths in 2015, study suggests.”

SAMHSA updates its toolkit
The Substance Abuse and Mental Health Services Administration updated its Opioid Overdose and Prevention Toolkit. The toolkit is an education resource for community members, first responders, prescribers, patients and families.

HCPCS and CPT update: New codes added

The Centers for Medicare & Medicaid Services has added several new HCPCS and CPT codes. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

HCPCS codes

Outpatient Prospective Payment System — Injection

Code	Change	Coverage comments	Effective date
C9030	Added	Covered for facility only	July 1, 2018
C9032	Added	Requires manual review	July 1, 2018
C9469	Deleted	Deleted	June 30, 2018

Outpatient Prospective Payment System — Radiopharmaceuticals

Code	Change	Coverage comments	Effective date
C9031	Added	Covered for facility only	July 1, 2018

Medicine Supplementary — Injections

Code	Change	Coverage comments	Effective date
Q5105	Added	Covered	July 1, 2018
Q5106	Added	Covered	July 1, 2018

Modifiers

Modifier	Change	Coverage comments	Effective date
QQ	Added	Informational only	July 1, 2018

CPT codes

Pathology and Laboratory — Proprietary laboratory analysis codes

Code	Change	Coverage comments	Effective date
0045U	Added	Not covered	July 1, 2018
0046U	Added	Covered	July 1, 2018
0047U	Added	Not covered	July 1, 2018
0048U	Added	Not covered	July 1, 2018
0049U	Added	Covered	July 1, 2018
0050U	Added	Not covered	July 1, 2018
0051U	Added	Not covered	July 1, 2018
0052U	Added	Not covered	July 1, 2018
0053U	Added	Not covered	July 1, 2018
0054U	Added	Not covered	July 1, 2018
0055U	Added	Not covered	July 1, 2018
0056U	Added	Not covered	July 1, 2018
0057U	Added	Not covered	July 1, 2018
0058U	Added	Not covered	July 1, 2018
0059U	Added	Not covered	July 1, 2018
0060U	Added	Not covered	July 1, 2018
0061U	Added	Not covered	July 1, 2018

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

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
77061, 77062, 77063, G0279**	Basic benefit and medical policy Digital breast tomosynthesis Digital breast tomosynthesis (3D 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. Payment policy Diagnostic procedure codes are subject to cost-sharing requirements. Inclusions: Digital breast tomosynthesis, or DBT, may be considered established for screening when: DBT is used in combination with digital screening mammography in high-risk individuals. A qualified health care provider (ordering provider or radiologist) determines that DBT 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
90785, 90791, 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90853, 90875, 96102, 96150, 96151, 96152, 96153, 96154	Basic benefit and medical policy Limited license psychologists Effective June 1, 2018, limited license psychologists are eligible for direct reimbursement at 80 percent of the Traditional Fee Schedule for the behavioral health procedures listed at left.
J0897	Basic benefit and medical policy Approved indications for Xgeva Starting Jan. 4, 2018, Blue Cross Blue Shield of Michigan considered Xgeva (injection, denosumab, 1 milligram) established for the following indications: Prevention of skeletal-related events in patients with multiple myeloma and in patients with bone metastases from solid tumors. Treatment of adults and skeletally mature adolescents with giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity. Treatment of hypercalcemia of malignancy refractory to bisphosphonate therapy. Limitation of use: Xgeva isn’t indicated for the prevention of skeletal-related events in patients with multiple myeloma.
J3490	Basic benefit and medical policy Prevymis (letermovir) Effective Nov. 8, 2017, Prevymis (letermovir) is covered for the FDA-approved indications below. Prevymis (letermovir) is a CMV DNA terminase complex inhibitor indicated for prophylaxis of cytomegalovirus infection and disease in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant. Administer 480 mg once daily as an intravenous infusion over one hour through 100 days post-transplant. Dosage adjustment: If Prevymis (letermovir) is co-administered with cyclosporine, the dosage of Prevymis should be decreased to 240 mg once daily. The NDCs are 00006-5003-01 and 00006-5004-01. Prevymis (letermovir) isn’t a benefit for URMBT.
J3490, J3590	Basic benefit and medical policy Trogarzo (ibalizumab-uiyk) Effective March 6, 2018, Trogarzo (ibalizumab-uiyk) is covered for the FDA-approved indications below. Trogarzo (ibalizumab-uiyk) is a CD4-directed post-attachment HIV-1 inhibitor, in combination with other antiretrovirals, is indicated for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen. Trogarzo (ibalizumab-uiyk) is administered intravenously as a single loading dose of 2,000 mg followed by a maintenance dose of 800 mg every two weeks after dilution in 250 mL of 0.9% Sodium Chloride Injection. NDC: 62064-122-02.
J3590	Basic benefit and medical policy Fecal microbiota donor specimens Fecal microbiota donor specimens will be covered under not-otherwise-classified code J3590 for the cost of material, though we’re unable to comment on the success of using this code. The U.S. Food and Drug Administration has classified human stool as a biological agent and determined that its use in fecal microbiota transplantation therapy and other research should be regulated to ensure patient safety. Be sure to list the price of the unit in Box 19 of CMS 1500, as well as its concentration. Open biome preparations don’t have NDC numbers.
POLICY CLARIFICATIONS
96567, 96573, 96574, J3396	Basic benefit and medical policy Photodynamic therapy for dermatologic applications The safety and effectiveness of photodynamic therapy for dermatologic applications have been established. It may be considered a useful therapeutic option when indicated, effective May 1, 2018. Inclusions: Photodynamic therapy is considered established as a treatment of: Nonhyperkeratotic actinic keratoses of the face and scalp. Low-risk (e.g., superficial and nodular) basal cell skin cancer only when surgery and radiation are contraindicated Bowen disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated Exclusions: Photodynamic therapy is considered experimental for other dermatologic including, but not limited to: Acne vulgaris High-risk basal cell carcinomas Hidradenitis Suppurativa Mycoses When photodynamic therapy is used as a cosmetic procedure (e.g., as a technique of skin rejuvenation or hair removal) it’s not a covered benefit.
J3590	Basic benefit and medical policy Imfinzi (durvalumab) Imfinzi^® (durvalumab) is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma who: Have disease progression during or following platinum-containing chemotherapy Have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. Non-small cell lung cancer Imfinzi is indicated for the treatment of patients with unresectable, Stage III non-small cell lung cancer whose disease hasn’t progressed following concurrent platinum-based chemotherapy and radiation therapy. URMBT members are excluded from this policy. This policy is effective Feb. 16, 2018.
EXPERIMENTAL PROCEDURES
Established: 61885, 61886, 64553, 64568, 64569, 64570, 95970, 95974, 95975, L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689 Non-established: E0770	Basic benefit and medical policy Vagus nerve stimulation Vagus nerve stimulation has been established. It may be considered a useful therapeutic or diagnostic option when indicated. Non-implanted and transcutaneous vagal nerve stimulators are experimental. Their positive affect on clinical outcomes hasn’t been definitively demonstrated. This policy is effective July 1, 2018. Inclusions: Seizures that are refractory to medical treatment. Exclusions: Other conditions not listed in the inclusions include, but aren’t limited to: Depression Heart failure Upper-limb impairment due to stroke Essential tremor Headaches (cluster headaches, migraines, etc.) Fibromyalgia Tinnitus Traumatic brain injury Autism Schizophrenia Transcutaneous (nonimplantable) vagus nerve stimulation devices are considered experimental for all indications.
Established: 95782, 95783, 95800, 95805, 95806, 95807, 95808, 95810, 95811, E0486, G0398, G0399 Non-established: 95801, A7047, E0485, E1399, G0400	Basic benefit and medical policy Sleep disorders: Diagnosis and medical management Diagnosis Polysomnography, or PSG, is an attended (supervised) sleep study performed in a hospital or freestanding sleep laboratory. The safety and effectiveness of PSG, including a split-night PSG, have been established. It may be considered a useful diagnostic option when indicated. The safety and effectiveness of an unattended sleep study with a minimum of four recording channels (including oxygen saturation, respiratory movements, airflow and ECG or heart rate) in a home setting (home sleep study/test) have been established. It may be considered a useful diagnostic option when indicated. The safety and effectiveness of multiple sleep latency testing, or MSLT, have been established. It may be a useful tool in diagnosing narcolepsy. Medical management The safety and effectiveness of oral appliances to reduce upper airway collapsibility in the treatment of OSA have been established. Oral appliances may be considered a useful therapeutic option when indicated. Palate and mandible expansion devices are considered experimental for the treatment of OSA. There is insufficient evidence in the current medical literature to support their efficacy and use in clinical practice. Nasal expiratory positive airway pressure, or nasal EPAP, for the treatment of OSA is considered experimental. There is insufficient evidence in the current medical literature to support its efficacy and use in clinical practice. Oral pressure therapy for the treatment of OSA is considered experimental. There is insufficient medical literature found to support its efficacy. Inclusionary and exclusionary guidelines Diagnosis Unattended (unsupervised) home sleep study (with minimum of four recording channels, including oxygen saturation, respiratory movements, airflow and ECG or heart rate) Inclusions: Adult patients 18 years of age or older with high pretest probability for moderate to severe OSA Observed apneas during sleep, or A combination of at least two of the following: Excessive daytime sleepiness evidenced by an Epworth sleepiness > 10, inappropriate daytime napping (e.g., during driving, conversation or eating) or sleepiness that interferes with daily activities that isn’t explained by other conditions Habitual snoring or gasping/choking episodes associated with awakenings Treatment-resistant hypertension (persistent hypertension in a patient taking three or more antihypertensive medications) Obesity, defined as a body mass index (BMI) > 35 kg/m2 or neck circumference defined as > 17 inches in men or >16 inches in women Craniofacial or upper airway soft tissue abnormalities No exclusions or contraindications to a home sleep study Exclusions: Younger than 18 years of age Morbid obesity, defined as a body mass index (BMI) > 40 kg/m2 or the patient is 100 pounds over the ideal body weight for their height Obesity hypoventilation syndrome Narcolepsy Periodic limb disorder during sleep Central sleep disorder Parasomnias REM behavior disorder Moderate to severe congested heart failure – New York Heart Association class III or IV Moderate to severe pulmonary disease (e.g., pulmonary function test results with an arterial blood gas showing PO2 < 60 or PCO2 > 45, pulmonary congestion or left ventricular ejection fraction < 45 percent) Documented neuromuscular disease (e.g., Parkinson’s, myotonic dystrophy, ALS) Critical illness that would prevent the patient from using the equipment Repeat unattended (unsupervised) home sleep study (with a minimum of four recording channels, including oxygen saturation, respiratory movements, airflow and ECG or heart rate) Inclusions: To assess efficacy of surgery or oral appliances/devices, or To re-evaluate the diagnosis of OSA and need for continued continuous positive airway pressure, e.g., if there’s a significant change in weight or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued. Attended (supervised) sleep study performed in a sleep lab Inclusions for adults (18 years of age or older): Adult patients age 18 or older with a moderate to high pretest probability for OSA Observed apneas during sleep, or A combination of at least two of the following: Excessive daytime sleepiness evidenced by an Epworth sleepiness > 10, inappropriate daytime napping (e.g., during driving, conversation or eating), or sleepiness that interferes with daily activities and is not explained by other conditions Habitual snoring or gasping/choking episodes associated with awakenings Treatment-resistant hypertension (persistent hypertension in a patient taking three or more antihypertensive medications) Obesity, defined as a body mass index (BMI) > 30 kg/m2 or neck circumference > 17 inches in men or >16 inches in women Craniofacial or upper airway soft tissue abnormalities When unattended (unsupervised) home sleep study is contraindicated (see exclusions to unattended home sleep study above) Inclusions for children younger than age 18: Pediatric patients younger than age 18 with a moderate to high probability of OSA Habitual snoring in association with one or more of criteria below: Restless or disturbed sleep Behavioral disturbance or learning disorders including deterioration in academic performance, attention deficit disorder, hyperactivity Frequent awakenings Enuresis (bedwetting) Growth retardation or failure to thrive Excessive daytime somnolence or altered mental status not explained by other conditions, or Polycythemia not explained by other conditions, or Cor pulmonale not explained by other conditions, or Witnessed apnea with duration greater than two respiratory cycles, or Labored breathing during sleep, or Hypertrophy of the tonsils or adenoids in patients at significant surgical risk such that the exclusion of OSA would allow avoidance of surgery, or Suspected congenital central alveolar hypoventilation syndrome or sleep-related hypoventilation due to neuromuscular disease or chest wall deformities, or Clinical evidence of a sleep-related breathing disorder in infants who have experienced an apparent life-threatening event, or For exclusion of OSA in a patient who has undergone adenotonsillectomy for suspected OSA more than eight weeks previously, or The initial study was inadequate, equivocal or non-diagnostic and the child’s parents or caregiver report that the breathing patterns observed at home were different from those during testing Repeated (attended) sleep study performed in a sleep lab Inclusions: Equipment failure or less than six hours or recording To initiate and titrate CPAP in adult patients who have: An AHI of at least 15 per hour, or An AHI of at least 5 per hour in a patient with excessive daytime sleepiness or unexplained hypertension. Respiratory disturbance index may be used in place of AHI in unattended sleep studies. Note: A split-night study, in which moderate to severe OSA is documented during the first portion of the study using PSG, followed by CPAP during the second portion of the study, can eliminate the need for a second study to titrate CPAP. To initiate and titrate CPAP in children: In pediatric patients, an AHI greater than 1.5 is considered abnormal, and an AHI of 10 or more may be considered severe. To re-evaluate the diagnosis of OSA and need for continued CPAP (e.g., if there is a significant change in weight or change in symptoms suggesting that CPAP should be retitrated or possibly discontinued.) Note: This statement doesn’t imply that supervised studies are needed routinely following unattended studies. This statement means a re-evaluation based on a substantial change in symptoms or in the clinical situation. To assess efficacy of surgery (including adenotonsillectomy) or oral appliances/devices. Multiple sleep latency testing MSLT is considered experimental to diagnose obstructive sleep apnea except to exclude or confirm narcolepsy in the diagnostic workup of OSA syndrome. Medical management PAP therapies, i.e. continuous positive airway pressure, automatic positive airway pressure, bilevel positive airway pressure and variable positive airway pressure, may be considered medically necessary for the management of OSA, central sleep apnea or mixed apnea. These devices for treatment are addressed in our policy titled “Positive Pressure Airway Devices.” Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered established in adult patients with clinically significant OSA. (Verify coverage of intraoral appliances under the DME benefit.) Inclusions (all of the following): A trial of CPAP has failed or is contraindicated. The device is prescribed by a treating physician. The device is custom-fitted by qualified dental personnel. There is absence of temporomandibular dysfunction or periodontal disease. Exclusions: Prefabricated (not custom-fit) devices. Palate and mandible expansion devices are considered experimental. Nasal expiratory positive airway pressure is considered experimental. Oral pressure therapy is considered experimental. Policy guidelines Risk factors for OSA Although not an exclusive list, patients with all four of the following symptoms are considered to be at high risk for obstructive sleep apnea: Habitual snoring Observed apneas Excessive daytime sleepiness A body mass index greater than 35 kg/m2 If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA (e.g., age of the patient, male gender, thick neck, craniofacial or upper airway soft tissue abnormalities, or unexplained hypertension) may be considered. Objective clinical prediction rules are being developed; however, at the present time, risk assessment is based primarily on clinical judgment. The STOP-BANG questionnaire is a method developed for non-sleep specialists to assess the signs and symptoms of OSA (snore, tired, observed apnea, blood pressure, BMI, age, neck, gender) and has been shown to have 97 percent sensitivity and a negative predictive value of 96 percent (specificity of 33 percent) for the identification of patients with severe OSA (Apnea/Hypopnea Index [AHI] score >30 events per hour). Overnight oximetry has been used by some sleep specialists as a component of the risk assessment but isn’t adequate for the diagnosis of OSA. Therefore, a follow-up polysomnography or home sleep study would still be required to confirm or exclude a diagnosis of OSA. OSA in children The presentation of OSA in children may differ from that of adults. Children frequently exhibit behavioral problems or hyperactivity rather than daytime sleepiness. Obesity is defined as a body mass index greater than the 90th percentile for the weight/height ratio. Although the definition of severe OSA in children isn’t well established, an AHI greater than 1.5 events per hour is considered abnormal (an AHI score of >10 events per hour may be considered severe). In addition, the first-line treatment in children is usually adenotonsillectomy. Continuous positive airway pressure is an option for children who aren’t candidates for surgery or who have an inadequate response to surgery. Bariatric surgery patients Screening for OSA should be performed routinely in patients scheduled for bariatric surgery, due to the high prevalence of OSA in this population. The optimal screening approach isn’t certain. An in-laboratory PSG or home sleep study is the most accurate screening method. Some experts recommend a symptom-based screening instrument, followed by PSG in patients who exceed a certain threshold, as an alternative to performing PSG in all patients. It should be noted that there is a high prevalence of obesity hypoventilation syndrome in patients who are candidates for bariatric surgery. Therefore, obesity hypoventilation syndrome should be ruled out prior to home sleep testing in this population. Multiple sleep latency test The multiple sleep latency test, or MSLT, is an objective measure of the tendency to fall asleep in the absence of alerting factors, while the maintenance of wakefulness test, or MWT, is an objective measure of the ability to stay awake under soporific conditions (used to assess occupational safety). The MSLT and MWT aren’t routinely indicated in the evaluation and diagnosis of OSA or in assessment of change following treatment with CPAP. The MSLT may be indicated as part of the evaluation of patients with suspected narcolepsy to confirm the diagnosis (often characterized by cataplexy, sleep paralysis and hypnagogic/hypnopompic hallucinations) or to differentiate between suspected idiopathic hypersomnia and narcolepsy. Narcolepsy and OSA can co-occur. Because it isn’t possible to differentiate the excessive sleepiness caused by OSA and narcolepsy, OSA should be treated before confirming a diagnosis of narcolepsy with the MSLT. Specialist training In order to perform and get reimbursed for in-center and out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine. Any M.D. or D.O. may order a sleep test if it’s performed and interpreted by a doctor who is board-certified in sleep medicine. Follow our preauthorization program for in-lab sleep testing. Split-night studies American Academy of Sleep Medicine practice parameters indicate that a split-night study (initial diagnostic PSG followed by CPAP titration during PSG on the same night) is an alternative to one full night of diagnostic PSG followed by a second night of titration if the following four criteria are met: An AHI of at least 40 is documented during a minimum of two hours of diagnostic PSG. Split-night studies may sometimes be considered at an AHI of 20 to 40 events per hour, based on clinical judgment (e.g., if there are also repetitive long obstructions and major desaturations). However, at AHI values below 40, determination of CPAP-level requirements, based on split-night studies, may be less accurate than in full-night calibrations. CPAP titration is carried out for more than three hours (because respiratory events can worsen as the night progresses). PSG documents that CPAP eliminates or nearly eliminates the respiratory events during rapid eye movement and non-REM sleep, including REM sleep with the patient in the supine position. A second full night of PSG for CPAP titration is performed if the diagnosis of a sleep-related breathing disorder is confirmed, but criteria b and c aren’t met.
GROUP BENEFIT CHANGES
Cooper Standard	Cooper Standard, group number 71404, is now offering the Your Dedicated Nurse program, effective July 1, 2018. This is a tailored care management program that coordinates member care and manages health care costs through personalized member interventions. Group number: 71404 Alpha prefix: TDV Platform: NASCO Plans offered: PPO HSA CMM

Pharmacy

Clarification on waiving nursing orders for home infusion therapy

Please include the following in your documentation:

That the member or personal caregiver has a proven and adequate sterile infusion technique
Confirmation that the member or caregiver is aware that nursing is available on an as-needed basis
The first and last name of the person you spoke with at the office, as well as the date and time of your conversation
A legible signature signed by the registered nurse or registered pharmacist who took the verbal order

Blue Cross won’t cover topical products containing urea

Urea products help skin retain moisture and stay hydrated. They’re used to treat various skin conditions.

We’re sending letters to notify affected members, their groups and doctors about these changes and encourage members to speak with their doctors about their treatment options.

Facility

Appealing Medicare Plus Blue PPO acute inpatient authorization decisions

Our plan medical directors make denials of care for Medicare Plus Blue^SM PPO acute inpatient authorizations related to medical necessity or medical appropriateness based on:

Review of pertinent medical information
Consideration of the member’s benefit coverage
Information from the attending physician and primary care physician
Clinical judgment of the medical director

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or an external review board.

Guidelines for provider appeal requests (for medical necessity or medical appropriateness determinations)
Expedited appeals	A practitioner may request expedited appeals when circumstances need a decision in a short period of time, because a delay may seriously jeopardize the life or health of the member. We won’t consider retrospective appeals (for service already provided to the member) for an expedited appeal. You may verbally request decisions about precertification of urgent care and concurrent cases that result in denial. Medicare Plus Blue notifies the provider of the decision within 72 hours of receiving the request. Start an expedited appeal by calling a plan medical director or designee at 1-866-807-4811. This decision is final and no other appeal choice is available to the provider.
Level One appeals	Are due to Medicare Plus Blue within 45 calendar days of the date noted on the written denial notification. Requests must include additional clarifying clinical information to support the request. Medicare Plus Blue notifies the provider of the decision within 30 calendar days of receiving all necessary information. Submit requests via any of the following methods. Fax: 1-877-495-3755 Email: MedicarePlusBlueInpatientAppeals@bcbsm.com Mail: Medicare Plus Blue Inpatient Provider Appeal Blue Cross Blue Shield of Michigan Mail Code 1516 600 E. Lafayette Blvd. Detroit, MI 48226-2998
Level Two appeals	Are due to Medicare Plus Blue within 21 calendar days of the date noted on the level-one appeal decision notification. Level-two appeal requests must include at least one of the following: New or clarifying clinical information A clear statement that the provider is requesting a Medicare Plus Blue physician reviewer who’s different from the one who reviewed the level-one appeal If neither the clinical information nor the request for a different physician reviewer is provided, Medicare Plus Blue isn’t bound to review the level-two appeal request. Send level-two requests to the same fax number, email or mailing address as level-one appeal requests. Medicare Plus Blue notifies the provider of the decision within 45 calendar days of receiving all the necessary information. This decision is final.

Preservice appeals
You can request a preservice adverse decision appeal only when a service hasn’t yet been rendered (the member isn’t yet admitted to inpatient status).

For more information, see the provider manual.

Reminder: List primary procedure codes first when submitting claims

For example, if 77067 (screening mammogram) is billed along with 77063 (screening digital add-on), 77067 should appear first in the claim with 77063 on a lower line.

What’s new about authorization criteria and e-referral questionnaires for certain services

How the questionnaires work

Where to find authorization criteria and preview questionnaires

Find out how to request peer-to-peer reviews for inpatient admissions

For patients with BCN coverage:
Here’s how to request a peer-to-peer review with a BCN medical director:

Call 248-799-6312.
Select prompt 3 for a peer-to-peer review.
Leave a message with the following information:

Physician adviser’s or physician’s name and phone number
Member’s name, date of birth and contract number
Reason for requesting a peer-to-peer review
Best date and time to reach the physician adviser or physician

For patients with Blue Cross coverage:
Here’s how to request a peer-to-peer review with a Blue Cross medical director:

Call 1-866-346-7299.
Select the prompt for “Facility Precertification Department” (press No. 2).
Select the prompt for “Provider Peer-to-Peer Review.”
Leave a message with the following information:

Physician adviser’s name and phone number
Member’s name, date of birth and contract number
Reason for requesting a peer-to-peer review
Best date and time to reach the physician adviser

For behavioral health cases
Here’s how to request a peer-to-peer review for inpatient admissions related to BCN, BCN Advantage and Medicare Plus Blue products:

Call 1-877-293-2788.
If the call isn’t answered live, leave a message with the following information:

Name of person calling and call-back number
Physician adviser’s or physician’s name and phone number
Member’s name, date of birth, contract number or case number
Reason for requesting a peer-to-peer review
Best date and times to reach the physician adviser or physician

Blue Cross PPO members should call the behavioral health number on the back of the member's Blue Cross ID card.

The peer-to-peer phone line is open 8 a.m. to 5 p.m. Monday through Friday, except for holidays. Calls will be returned within 48 business hours.

PT, OT and chiropractic prior authorizations not required for fully insured group members and members with individual coverage

However, we’ve decided that prior authorization for PT, OT and chiropractic services won’t be required for our fully insured group members and members with individual coverage at this time.

This change doesn’t affect prior authorization programs that are currently in place for other members, such as those with Medicare Plus Blue^SM, Blue Care Network or BCN Advantage^SM.

Facility and Special Programs has a new mail code: 0403

On July 2, 2018, Facility and Special Programs changed to a new mail code: 0403. Please use this new code when sending any written communication to Facility and Special Programs.

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.