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June 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
POLICY CLARIFICATIONS

32701, 77520, 77522, 77523, 77525

Basic Benefit and Medical Policy
The inclusionary and exclusionary guidelines for the Charged Particle (Proton or Helium) Radiation policy have been updated. This policy is effective July 1, 2013.

Inclusionary Guidelines
Charged particle irradiation with proton or helium ion beams is established for the following indications:

  • Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height.
  • Postoperative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine.  Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
  • In the treatment of pediatric (through 21 years of age) central nervous system tumors.

Exclusionary Guidelines

  • All other applications of charged particle irradiation, including localized prostate cancer and non-small-cell lung cancer at any stage or for recurrence are experimental. 
  • Pediatric non-central nervous system tumors
  • Tumors of the head and neck (other than skull-based chordoma or chondrosarcoma).

75572-75574

Basic Benefit and Medical Policy
Coronary computed tomography-angiography is an established procedure. It is a useful diagnostic procedure when indicated for patients meeting selection criteria. 

Inclusionary Guidelines
Update to guidelines (effective July 1, 2013):
Membership in the BCBSM Collaborative Quality Initiative for Emerging Non-Invasive Cardiovascular Imaging is not required when CCTA services are delivered for an approved indication (as stated in Inclusionary Guidelines section) in the emergency department.

Complete guidelines published in the November 2012  Record.

81201-81203, 81292-81301, 81317-81319, S3833, S3834

Basic Benefit and Medical Policy
The inclusionary and exclusionary guidelines for the Genetic Testing for Lynch Syndrome and Other Inherited Intestinal Polyposis Syndromes policy have been updated. This policy is effective July 1, 2013.

Inclusionary and Exclusionary Guidelines
These guidelines refer to the different types of genetic tests available for colorectal cancer.

  1. Genetic testing of the adenosis polyposis coli gene is established in the following:
    • Patients with greater than 20 colonic polyps
    • First-degree relatives (siblings, parents or offspring) of patients with FAP, AFAP or a known APC mutation.
  2. Genetic testing for MYH gene mutations is established in any of the following:
    • Individuals with personal history of adenomatous polyposis who have negative APC mutation testing and a negative family history for adenomatous polyposis
    • Individuals with personal history of adenomatous polyposis whose family history is consistent with recessive inheritance (family history is positive only for siblings)
    • Asymptomatic siblings of individuals with known MYH polyposis
  3. Genetic testing for MLH1 and MSH2 gene mutations to determine the carrier status of Lynch syndrome (HNPCC) is established in any of the following:
    • Patients with colorectal cancer to test for the diagnosis of Lynch syndrome
    • Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer, for the diagnosis of Lynch syndrome
    • Patients without colorectal cancer, but who have a first- or second-degree relative with a known MMR mutation
    • At-risk relatives of patients with Lynch syndrome with a known MMR mutation
    • Patients without colorectal cancer but with a family history meeting the Amsterdam or Revised Bethesda criteria, when no affected family members have been tested for MMR mutations.
    • Amsterdam II Criteria:  Must meet all of the following:
      • Three or more relatives with a histologically verified Lynch syndrome-associated cancer (colorectal cancer or cancer of the endometrium, small bowel, ureter or renal pelvis), one of whom is a first-degree relative of the other two
      • HNPCC-associated cancer involving at least two successive generations
      • Cancer in one or more affected relatives diagnosed before 50 years of age
      • Familial adenomatous polyposis excluded in any cases of colorectal cancer
      • Tumors should be verified by pathologic examination whenever possible
    • Revised Bethesda Guidelines: Patients must meet any one of the following:
      • Individuals diagnosed with colorectal cancer under the age of 50
      • Individuals with Lynch syndrome-related cancer, including synchronous and metachronous colorectal cancers or associated extracolonic cancers** regardless of age
      • Individuals with colorectal cancer with the MSI-H histology diagnosed in a patient less than age 60
      • Individuals with colorectal cancer and one or more first-degree relatives with colorectal cancer or Lynch syndrome-related extracolonic cancer**; if one of the cancers was diagnosed in a patient younger than 50
      • Individuals with colorectal cancer and colorectal cancer diagnosed in two or more first- or second-degree relatives with Lynch syndrome-related tumors**, regardless of age

      **Extracolonic cancers include stomach, bladder, ureter and renal pelvis, biliary tract, brain (usually glioblastoma), pancreas, sebaceous gland adenomas, keratoacanthomas, carcinoma of the small bowel and endometrial or ovarian cancer.

  4. MSH6 or PMS2 gene sequence analysis is established in patients meeting the Bethesda Criteria for genetic testing for Lynch syndrome:
    • Who do not have mutations in either the MLH1 or MSH2 genes
    • Who also meet the first Amsterdam II Criteria which describes the relatives
    • Single-site MSH6 or PMS2 testing is established for testing family members of persons with Lynch syndrome with an identified MSH6 or PMS2 gene mutation.
  5. Genetic testing for EPCAM mutations is established in any of the following:
    • Patients with colorectal cancer, for the diagnosis of Lynch syndrome when all of the three criteria are met:
      • Tumor tissue shows a high level of microsatellite instability
      • Tumor tissue shows lack of MSH2 expression by immunohistochemistry
      • Patient is negative for a germline mutation in MSH2, MLH1, PMS2 and MSH6
    • At-risk relatives of patients with Lynch syndrome with a known EPCAM mutation
    • Patients without colorectal cancer but with a family history meeting the Amsterdam or Revised Bethesda Criteria, when no affected family members have been tested for MMR mutations and when sequencing for MMR mutations is negative

    Pre- and post-test genetic counseling should be provided as an adjunct to genetic testing.

90870

Basic Benefit and Medical Policy
The inclusionary and exclusionary guidelines for the Electorconvulsive Therapy policy have been updated. This policy is effective July 1, 2013.

Single electroconvulsive therapy is considered established. It may be considered a useful therapeutic option in specified situations. Multiple electroconvulsive therapy that is performed in one session is considered experimental.

Inclusionary Guidelines
Single electroconvulsive therapy that is performed in one session when each of the following criteria are met:

  1. The member has an index condition that is one of the following diagnoses:
    1. Bipolar Disorder
    2. Major Depressive Disorder
    3. Schizophrenia
    4. Schizoaffective Disorder
    5. Catatonia
    6. Neuroleptic Malignant Syndrome
  2. The index condition is the primary cause of the member’s symptomatology and functional impairment
  3. The degree of symptomatology and functional impairment experienced by the member because of his or her index condition is characterized by at least one of the following:
    1. Is severe
    2. Is moderate and long standing (symptoms have been present for years)
    3. Is marked by catatonia
  4. For schizophrenia and psychosis related to schizoaffective disorder, antipsychotic medications, unless otherwise contraindicated, are given concomitantly with ECT
  5. For schizophrenia and psychosis related to schizoaffective disorder, one of the following additional criteria is met:
    1. The member is experiencing an acute exacerbation of positive symptoms.
    2. The member is catatonic.
    3. The member is experiencing life-threatening inanition, stupor, suicidal risk or homicidal risk.
    4. At least two trials of maintenance antipsychotic medications, including clozapine, have failed to adequately treat the member’s chronic positive symptoms.
      Note: Intolerance of a medication or dangerous side effects such as agranulocytosis associated with clozapine can result in “failure” despite adequate symptomatic improvement.
  6. For all conditions, at least one of the following additional criteria is met:
    1. Failure, at adequate dosages (as indicated by current literature) and duration of therapy, of at least two medications indicated for the treatment of the member’s condition. “Failure” in this context means either:
      1. Lack of response: no response at maximum dosage after a period of time adequate for assessing initial response (for antidepressants, three weeks)
      2. Effect plateau: no continued improvement, at maximal dosage following a partial but inadequate initial response, over a period of time adequate for assessing whether a plateau has been reached (for antidepressants, two weeks)
      3. Intolerable or dangerous side effect regardless of clinical response
    2. A rapid response is required due to life-threatening inanition, stupor, suicidal risk or homicidal risk.
    3. Required medications cannot be safely taken by the member (for example, antipsychotics in the context of NMS)
  7. The member has received a second opinion evaluation by a psychiatrist who regularly performs ECT or attends on patients receiving ECT and who is not involved in the direct care of the member. This opinion concurs with the plan for ECT.
  8. An appropriate subspecialist has evaluated the patient and cleared him or her for ECT if the member is suffering from any of these relative contraindications for ECT:
    1. Recent myocardial infarction
    2. Cardiac arrhythmia
    3. Intracranial space-occupying lesion
    4. Severe pulmonary disease
    5. Severe osteoporosis
    6. Aneurism
    7. Arterio-venous malformation
    8. Severe hypertension
    9. Any other serious medical condition of concern to either the physician to be performing ECT or anesthesia

Exclusionary Guidelines

  • Multiple electroconvulsive therapy that is performed in one session
  • Electroconvulsive therapy performed in the provider office setting
EXPERIMENTAL PROCEDURES

95199

Basic Benefit and Medical Policy
Sublingual immunotherapy is considered experimental as a technique of allergy immunotherapy, as clinical efficacy has not been established. This policy is effective July 1, 2013.

L8699, L9900, V5267, V5298

Basic Benefit and Medical Policy
Intraoral bone conduction hearing devices are not established for the treatment of hearing loss. While these devices may be safe, their effectiveness in this clinical indication has not been scientifically determined. Therefore, this service is experimental, effective July 1, 2013.
GROUP BENEFIT CHANGES

County of Jackson (formerly known as Jackson County Road Commission)

Effective June 1, 2013, Medicare-eligible retirees of the County of Jackson 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 60086 with suffixes 600 and 601. 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.

Please note: The Jackson County Road Commission has changed its legal name to County of Jackson. Its original effective date was April 1, 2013, but was changed to an effective date of June 1, 2013.

DFCU Financial

DFCU Financial will migrate from the Michigan Operating System to the NASCO platform, under new group number 71573, with the Blues on June 1, 2013. The group will offer one PPO plan with medical-surgical coverage and one prescription drug plan.

Member ID cards will show the following alpha prefixes:

  • DOU – PPO coverage
  • DOF – Medicare PPO

Michigan Education Special Service Association (MESSA)

Effective July 1, 2013, Magellan Behavioral of Michigan will begin to perform inpatient mental health preauthorization for Michigan Education Special Service Association members. MESSA members can be identified by group numbers 71452-71455. Please continue to call the phone number on the back of the member’s BCBSM ID card at 1-800-336-0022 for these requests.

National Employee Health Plan

Effective June 1, 2013, Medicare-eligible retirees of the National Employee Health Plan 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 60220 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.

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.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.