The Record - Blues highlight medical, benefit policy changes

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:

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

NEW PAYABLE PROCEDURES

J3490

Basic Benefit and Medical Policy
The Food and Drug Administration approved Skyla^®, Levonorgestrel-releasing intrauterine device system, effective Jan. 9, 2013. Skyla 13.5 mg is a hormone-releasing system placed in the uterus to prevent pregnancy for up to three years. It is now payable under the medical and surgical benefits for contracts that cover contraceptive services. It should be considered payable for all FDA-approved indications.

Until June 30, 2013, when billing Skyla, please report procedure code J3490, unclassified drugs. Please remember to submit your claims with the National Drug Code and supporting documentation required for unclassified procedures. Effective July 1, 2013, please use the established code for Skyla, Q0090.

UPDATES TO PAYABLE PROCEDURES

20974, 20975, E0748, E0749

Basic Benefit and Medical Policy
The safety and effectiveness of invasive or noninvasive methods of electrical bone growth stimulation of the spine have been established. They are useful therapeutic options for patients meeting selection criteria.

Inclusionary Guidelines
Invasive or noninvasive methods of electrical bone growth stimulation are appropriate for use as an adjunct to lumbar or cervical spinal fusion surgery in patients at high risk for fusion failure, defined as any one of the following criteria:

One or more previous failed spinal fusions
Grade III or worse spondylolisthesis
Fusion to be performed at more than one level
Current tobacco use
Diabetes
Renal disease
Alcoholism
Steroid use

Noninvasive electrical bone stimulation may be considered medically necessary as a treatment for patients with failed lumbar or cervical spinal fusion. Failed spinal fusion is defined as a spinal fusion that has not healed at a minimum of six months after the original surgery, as evidenced by serial X-rays over a course of three months.

Exclusionary Guidelines
Semi-invasive electrical stimulation

55706, G0417-G0419

Basic Benefit and Medical Policy
The safety and effectiveness of saturation biopsy (taking more than 20 samples) of the prostate have been established. It is a useful therapeutic option for patients meeting appropriate patient selection criteria, effective May 1, 2013.

Inclusionary Guidelines
Saturation biopsy of the prostate is considered established for the following indications in men with at least two prior extended transrectal prostate biopsies that are negative for invasive cancer and one of the following:

Elevated prostate specific antigen that is persistently rising
Men with histologic evidence of atypia on prior prostate biopsy
Men with histologic findings of high-grade prostatic intraepithelial neoplasia on a prior biopsy

Note: PSA values should be reported from the same laboratory, as techniques for measuring these values may vary from lab to lab.

Exclusionary Guidelines
Men not meeting the above criteria.

88299, S3854

Basic Benefit and Medical Policy
The safety and effectiveness of the use of the 21-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay (Oncotype DX^®) have been established. It is a useful diagnostic test for determining the likelihood of distant cancer recurrence in women for patients who meet the selection criteria.

Other genetic testing for determining the likelihood of distant cancer recurrence in women is considered experimental.

This policy update is effective May 1, 2013.

Inclusionary Guidelines
The use of Oncotype DX to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy may be considered established in women with breast cancer meeting all of the following characteristics:

Unilateral, non-fixed tumor
Hormone receptor positive (that is estrogen-receptive positive or progesterone-receptor positive)
Human epidermal growth factor receptor 2 negative
Tumor size 0.6-1 cm with moderate or poor differentiation or unfavorable features, or tumor size larger than 1 cm
Node negative (Lymph nodes with micrometastases [less than 2 mm in size] are considered node negative.)
Women who will be treated with adjuvant endocrine therapy, such as tamoxifen or aromatase inhibitors
When the test result will aid the patient in making the decision regarding chemotherapy (when chemotherapy is a therapeutic option)
When ordered within six months following diagnosis, since the value of the test for making decisions regarding delayed chemotherapy is unknown

The 21-gene RT-PCR assay Oncotype DX should only be ordered on a tissue specimen obtained during surgical removal of the tumor and after subsequent pathology examination of the tumor has been completed and determined to meet the above criteria. (The test should not be ordered on a preliminary core biopsy.) The test should be ordered in the context of a physician-patient discussion regarding risk preferences when the test result will aid in making decisions regarding chemotherapy.

For patients who otherwise meet the above characteristics but who have multiple ipsilateral primary tumors, a specimen from the tumor with the most aggressive histological characteristics should be submitted for testing. It is not necessary to conduct testing on each tumor; treatment is based on the most aggressive lesion.

Exclusionary Guidelines

All other indications for the 21-gene RT-PCR assay, including determination of recurrence risk in invasive breast cancer patients with positive lymph nodes or patients with bilateral disease, are considered experimental.
Use of a subset of genes from the 21-gene RT-PCR assay for predicting recurrence risk in patients with noninvasive ductal carcinoma in situ to inform treatment planning following excisional surgery is considered experimental.

The use of other gene expression assays (for example, MammaPrint 70-gene signature, Mammostrat Breast Cancer Test, the Breast Cancer Index, the BreastOncPx, NexCourse Breast IHC4 or PAM50 Breast Cancer Intrinsic Classifier) for any indication is considered experimental.

EXPERIMENTAL PROCEDURES

76498

Basic Benefit and Medical Policy
Magnetic resonance neurography is considered experimental. Its use has not been scientifically demonstrated to improve patient clinical outcomes, effective May 1, 2013.

82777

Basic Benefit and Medical Policy
Galectin-3 testing is considered experimental, effective May 1, 2013. The peer-reviewed medical literature has not yet demonstrated the clinical utility of this test for the assessment and management of patients with heart failure.

GROUP BENEFIT CHANGES

AG Simpson Michigan Inc.

Effective May 1, 2013, Medicare-eligible retirees of AG Simpson Michigan Inc. will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 60143 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.

City of Lathrup Village

Effective May 1, 2013, Medicare-eligible retirees of the City of Lathrup Village will have Blue Cross Blue Shield of Michigan’s Medicare Advantage prescription drug plan, Prescription Blue PDP^SM, for their prescription drug benefits. The group number is 60114 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.

City of Taylor

Effective May 1, 2013, Medicare-eligible retirees of the City of Taylor will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM. There are five options: Four options that include coverage for their medical, surgical and prescription drug benefits and one MA PPO only option for their medical and surgical benefits.

The MA PPO option has a group number of 59819 with suffix 600.

The MAPD option has a group number of 59819 with suffixes 601,
602, 603 and 604.

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

Decker Manufacturing

Effective May 1, 2013, Medicare-eligible retirees of Decker Manufacturing will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 60153 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.

Globe Midwest

Effective May 1, 2013, Medicare-eligible retirees of Globe Midwest will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 60211 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.

Huron Charter Township

Effective May 1, 2013, Medicare-eligible retirees of Huron Charter Township will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 60027 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.

Kaydon Corporation

Kaydon Corporation, group number 71504, is adding 100 new employees to BCBSM and new package codes 064, 065, 066 and 068, effective May 1, 2013. The group offers three PPO plans with medical-surgical coverage and one dental plan.

Member ID cards will show alpha prefix KYD for PPO coverage.

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 2012 American Medical Association. All rights reserved.