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February 2013
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 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 |
| UPDATES TO PAYABLE PROCEDURES |
0099T, 65710, 65760, 65765, 65767, 65770-65772, 65775, 66999, L8699, S0800, S0810, S0812 |
Basic Benefit and Medical Policy
Inclusionary and exclusionary guideline updates for refractive keratoplasties and implantation of intrastromal corneal ring segments are effective March 1, 2013.
Inclusionary Guidelines
- Epikeratophakia for the treatment of aphakia
- The patient must have deteriorating vision not correctable with eyeglasses or contact lenses, or must be unable to wear contact lenses.
- Implantation of intrastromal corneal ring segments (Intacs®) for the treatment of keratoconus is appropriate when all of the following criteria are met:
- The patient has experienced a progressive deterioration in his or her vision, such that he or she can no longer achieve adequate functional vision with contact lenses or spectacles.
- Corneal transplantation is the only alternative to improve the patient’s functional vision.
- The patient has a clear central cornea with a corneal thickness of 450 microns or greater at the proposed incision site.
Exclusionary Guidelines
- Keratophakia
- Refractive keratoplasty procedures that are cosmetic in nature
- Implantation of intrastromal corneal ring segments (Intacs®) for the treatment of myopia
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33140, 33141, 33999 |
Basic Benefit and Medical Policy
Inclusionary and exclusionary guideline updates for transmyocardial revascularization are effective March 1, 2013.
Inclusionary Guidelines
- For open transmyocardial laser revascularization, patients with Class III or IV angina who cannot tolerate major bypass surgery or percutaneous transluminal coronary angioplasty who meet all of the following criteria:
- Presence of class III or IV angina refractory to medical management
- Documentation of reversible ischemia
- Left ventricular ejection fraction greater than 30%
- No evidence of recent myocardial infarction or unstable angina within the past 21 days
- No severe comorbid illness such as chronic obstructive pulmonary disease
- As an adjunct to coronary artery bypass grafting in those patients with documented areas of ischemic myocardium that are not amenable to surgical revascularization.
Exclusionary Guidelines
- Patients not meeting the inclusion criteria above
- Percutaneous transmyocardial laser revascularization
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67221, 67225, J3396 |
Basic Benefit and Medical Policy
The safety and effectiveness of photodynamic therapy (PDT) with verteporfin for the treatment of choroidal neovascularization has been established. It is a useful therapeutic option for patients meeting patient selection guidelines.
All other uses for photodynamic therapy with verteporfin are experimental. Its effectiveness for other indications has not been established.
Inclusionary and exclusionary guidelines have been updated, effective March 1, 2012.
Inclusionary Guidelines
Use of Visudyne® followed by laser treatment.
Monotherapy of predominantly classic subfoveal CNV (predominantly classic CNV lesions are defined as those in which the classic component comprised 50% or more of the area of the entire lesion) due to:
- Age-related macular degeneration
- Chronic central serous chorioretinopathy
- Choroidal hemangioma
- Pathologic myopia
- Presumed ocular histoplasmosis
Exclusionary Guidelines
- The label notes that there is insufficient evidence for verteporfin use in predominately occult subfoveal CNV, and it is contraindicated.
- Use of phototherapy with verteporfin as monotherapy for conditions other than predominantly classic subfoveal choroidal neovascularization due to any of the above conditions
- When used in combination with one or more of the anti-vascular endothelial growth factor therapies, including but not limited to pegaptanib (Macugen®), ranibizumab (Lucentis®), bevacizumab (Avastin®), aflibercept (Eylea™) as a treatment of CNV associated with age-related macular degeneration, chronic central serous chorioretinopathy, choroidal hemangioma, pathologic myopia, presumed ocular histoplasmosis or for other ophthalmologic disorders
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69930, 92601-92604, L7510, L8614- L8619, L8621- L8624, L8627- L8629 |
Basic Benefit and Medical Policy
Exclusionary guidelines updates for cochlear implant are effective
March 1, 2013.
Inclusionary Guidelines
Adults: A cochlear implant is considered an established, safe and effective therapy if all of the following criteria are met:
- 18 years of age or older
- Bilateral severe to profound sensorineural hearing loss
- Limited benefit from appropriately fitted hearing aids (based on speech perception scores)
- Evidence of a functioning auditory nerve
- Freedom from middle ear infection, lesions in the auditory nerve and acoustic areas of the central nervous system
- Accessible cochlear lumen that is structurally suited for implantation
- Cognitive ability to use auditory clues and a willingness to participate in a rehabilitation program
Children: A cochlear implant is considered an established, safe and effective therapy if all of the following criteria are met:
- 12 months through 17 years of age
- Bilateral severe to profound sensorineural hearing
- Limited benefit from appropriately fitted hearing aids
- Evidence of a functioning auditory nerve
- Freedom from middle ear infection, lesions in the auditory nerve and acoustic areas of the central nervous system
- Accessible cochlear lumen that is structurally suited for implantation
- Motivated child or family who has appropriate expectations and is willing to participate in a rehabilitation program
In addition, there are criteria associated with the specific cochlear implant used.
Exclusionary Guidelines
Upgrades of an existing, functioning external system to achieve aesthetic improvement, such as smaller profile components or a switch from a body-worn, external sound processor to a behind-the-ear model. |
95965-95967, S8035 |
Basic Benefit and Medical Policy
The safety and effectiveness of magnetoencephalography and magnetic source imaging have been established. They may be considered useful diagnostic options when indicated for selected patients. Inclusionary and exclusionary criteria updates are effective March 1, 2013.
Inclusionary Guidelines
Magnetoencephalography and magnetic source imaging are considered established in the following situations:
- For the purpose of determining the laterality of language function, as a substitute for the Wada test, in patients being prepared for surgery for epilepsy, brain tumors and other indications requiring brain resection
- As part of the preoperative evaluation of patients with intractable epilepsy (seizures refractory to at least two first-line anticonvulsants) when standard techniques, such as MRI and EEG, do not provide satisfactory localization of epileptic lesions
Exclusionary Guidelines
Magnetoencephalography and magnetic source imaging are considered experimental for all indications not listed under the inclusionary guidelines. |
A7025, A7026, E0483 |
Basic Benefit and Medical Policy
Inclusionary Guidelines
Effective Jan. 1, 2013, high frequency chest wall oscillation devices are covered for patients who meet Criterion 1, 2 or 3 below and Criterion 4:
- There is a diagnosis of cystic fibrosis (ICD-9 277.00, 277.02).
- There is a diagnosis of bronchiectasis (ICD-9 011.50-011.56, 494.0, 494.1, 748.61) that has been confirmed by a high resolution, spiral or standard CT scan and that is characterized by one of the following:
• Daily productive cough for at least six continuous months
• Frequent (more than two years) exacerbations requiring antibiotic
therapy
Chronic bronchitis and chronic obstructive pulmonary disease in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion.
- The patient has one of the following neuromuscular disease diagnoses:
- Post-polio (138)
- Acid maltase deficiency (277.6)
Chronic bronchitis and chronic obstructive pulmonary disease in the absence of a confirmed diagnosis of brochiectasis do not meet this criterion.
- Anterior horn cell diseases (335.0-335.9)
- Multiple sclerosis (340)
- Quadriplegia (344.00-344.09)
- Hereditary muscular dystrophy (359.0, 359.1)
- Myotonic disorders (359.21-359.29)
- Other myopathies (359.4, 359.5, 359.6, 359.89)
- Paralysis of the diaphragm (519.4)
- There must be well-documented failure of standard treatments to adequately mobilize retained secretions.
If all of the criteria are not met, the claim will be denied as not reasonable and necessary.
It is not reasonable and necessary for a patient to use both an HFCWO device and a mechanical in-exsufflation device (E0482).
Replacement supplies, A7025 and A7026, used with patient-owned equipment are covered if the patient meets the criteria listed above for the base device, E0483. If these criteria are not met, claims will be denied as not reasonable and necessary.
Covered for the following conditions as listed above:
- 011.50 - Tuberculous bronchiectasis, confirmation unspecified
- 011.51 - Tuberculous bronchiectasis, bacteriological or histological examination not done
- 011.52 - Tuberculous bronchiectasis, bacteriological or histological examination unknown (at present)
- 011.53 - Tuberculous bronchiectasis, tubercle bacilli found (in sputum) by microscopy
- 011.54 - Tuberculous bronchiectasis, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture
- 011.55 - Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically
- 011.56 - Tuberculous bronchiectasis, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals)
- 138 - Late effects of acute poliomyelitis
- 277.00 - Without mention of meconium ileus
- 277.02 - With pulmonary manifestations
- 277.6 - Other deficiencies of circulating enzymes
- 335.0 - Werdnig-Hoffmann disease
- 335.10 - Spinal muscular atrophy, unspecified
- 335.11 - Kugelberg-Welander disease
- 335.19 - Other
- 335.20 - Amyotrophic lateral sclerosis
- 335.21 - Progressive muscular atrophy
- 335.22 - Progressive bulbar palsy
- 335.23 - Pseudobulbar palsy
- 335.24 - Primary lateral sclerosis
- 335.29 - Other
- 335.8 - Other anterior horn cell diseases
- 335.9 - Anterior horn cell disease, unspecified
- 340 - Multiple sclerosis
- 344.00 - Quadriplegia unspecified
- 344.01 - C1-C4 complete
- 344.02 - C1-C4 incomplete
- 344.03 - C5-C7 complete
- 344.04 - C5-C7 incomplete
- 344.09 - Other
- 359.0 - Congenital hereditary muscular dystrophy
- 359.1 - Hereditary progressive muscular dystrophy
- 359.21 - Myotonic muscular dystrophy
- 359.22 - Myotonia congenital
- 359.23 - Myotonic chondrodystrophy
- 359.24 - Drug-induced myotonia
- 359.29 - Other specified myotonic disorder
- 359.4 - Toxic myopathy
- 359.5 - Myopathy in endocrine diseases classified elsewhere
- 359.6 - Symptomatic inflammatory myopathy in diseases classified elsewhere
- 359.89 - Other myopathies
- 494.0 - Bronchiectasis without acute exacerbation
- 494.1 - Bronchiectasis with acute exacerbation
- 519.4 - Disorders of diaphragm
- 748.61- Congenital bronchiectasis
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| POLICY CLARIFICATIONS |
57267 |
Group Variations
General Motors approved the pelvic organ prolapse repair using synthetic mesh medical policy for GM hourly and salaried employees, effective July 1, 2012. The relative safety and effectiveness of the pelvic organ prolapse repair using synthetic mesh have been established. It may be considered a useful therapeutic option when indicated in carefully selected patients who have been thoroughly advised of possible risks and complications of the procedure. |
76376, 76377, 76645 |
Basic Benefit and Medical Policy
Procedure codes *76376, *76377 and *76645 are considered experimental when used to report stand-alone ultrasound for routine breast cancer screening. These procedure codes may be payable for services other than ultrasound of the breast in an exclusive screening situation.
Ultrasound imaging by any method for routine breast cancer screening has not been shown to be an effective alternative to the current standard of care. While breast ultrasound imaging may be a safe and useful supplement to mammography, its clinical utility as a stand-alone routine screening modality has not been scientifically demonstrated. Therefore, stand-alone ultrasound imaging for routine breast cancer screening is experimental, effective March 1, 2013. |
| EXPERIMENTAL PROCEDURES |
46999, L8605 |
Basic Benefit and Medical Policy
The use of injectable bulking agents for the treatment of fecal incontinence is experimental, effective March 1, 2013. There is insufficient evidence in the peer-reviewed scientific literature to demonstrate long-term safety and clinical utility of the use of bulking agents for fecal incontinence. |
88299 |
Basic Benefit and Medical Policy
Genetic testing for familal cutaneous malignant melanoma (CDKN2A) is considered experimental, effective March 1, 2013. The peer-reviewed medical literature has not yet demonstrated the clinical utility of genetic testing for familial cutaneous malignant melanoma. |
88299, S3721 |
Basic Benefit and Medical Policy
Genetic tests for the screening, detection and management of prostate cancer are considered experimental, effective March 1, 2013. This includes, but is not limited to the following:
- Single-nucleotide polymorphisms for risk assessment
- PCA3 for disease diagnosis and prognosis
- TMPRSS fusion genes for diagnosis and prognosis
- Multiple gene tests (gene panels) for prostate cancer diagnosis
- Gene hypermethylation for diagnosis and prognosis
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90739 |
Basic Benefit and Medical Policy
Effective Jan. 1, 2013, the HEPLISAV™ vaccine is considered experimental. It has not been approved by the FDA. |
| GROUP BENEFIT CHANGES |
Dort Federal Credit Union |
Effective Feb. 1. 2013, Medicare-eligible retirees of the Dort Federal Credit Union will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM for their medical, surgical and prescription drug benefits. The group number is 59945 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma. |
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