Blues highlight medical, benefit policy changes

E0675

Basic Benefit and Medical Policy
The safety and effectiveness of outpatient limb pneumatic compression devices for venous thromboembolism prophylaxis have been established. They may be considered useful therapeutic options when clinical criteria are met, effective July 1, 2013.

Inclusionary Guidelines:
Outpatient use of limb pneumatic compression devices for venous thromboembolism prophylaxis is indicated when one of the following criteria is met:

• After major orthopedic surgery** in patients with a contraindication to pharmacological agents (i.e., at high-risk for bleeding)
• After major non-orthopedic surgery in patients who are at moderate or high risk of venous thromboembolism with a contraindication to pharmacological agents (i.e., at high-risk for bleeding)
• After major orthopedic or non-orthopedic surgery, as an adjunct to pharmacological therapy, in patients who are at extremely high risk for venous thromboembolism

Exclusionary Guidelines:

• Patients who are at low-risk of venous thromboembolism
• Outpatient use of limb pneumatic compression devices for venous thromboembolism prophylaxis for periods longer than 30 days post-surgery

** Major orthopedic surgery includes total hip arthroplasty, total knee arthroplasty, or hip fracture surgery.

Group Variations

• In addition to underwritten groups, the following groups are included: Delphi hourly and salaried
• Chrysler nonbargaining unit CDHP/HSA (only group number 82100)
• General Motors and UAW Retiree Medical Benefits Trust when BCBS has claim processing responsibility (POS 3 and others; except POS 4)
• Federal Employee Program^®

The following groups are excluded from this policy:

• Ford hourly and salaried
• Chrysler bargaining unit and nonbargaining unit (except group number 82100)
• GM and UAW Retiree Medical Benefits Trust when vendor (NNPN/HMENN) has claim processing responsibility (POS 4)
• State of Michigan, MESSA and Michigan Public School Employee Retirement System

J9035

Basic Benefit and Medical Policy
Avastin^®, (bevacizumab) intravitreal injection is payable for intra-ocular diagnoses.

Medical Affairs has approved the off-label use of Avastin (bevacizumab) for intra-ocular treatment of the following diagnoses:362.01, 362.02, 362.03, 362.05, 362.06, 362.07, 362.15, 362.16, 362.29, 362.30, 362.35, 362.36, 364.42, 362.52, 362.53, 365.63, 362.83, 362.84, 365.89

30999, 82785, 86001, 86003, 86005, 86343, 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, 95056, 95060, 95065, 95070, 95071, 95076, 95079, 95115, 95117, 95120, 95125, 95130-95134, 95144-95149, 95165, 95170, 95180, 95199

Basic Benefit and Medical Policy
The exclusionary guidelines for the Allergy Testing and Immunotherapy policy has been updated. This policy is effective July 1, 2013.

Inclusionary Guidelines
Allergy testing:

• Certain bronchial challenge tests
• Direct skin test (percutaneous [scratch, prick or puncture] or intracutaneous [intradermal])
• Double blind food challenge test
• Patch test (application test)
• Photo patch test
• Specific IgE in vitro tests (RAST, MAST, FAST, ELISA)
• Total serum IgE concentration
• Leukocyte histamine release test
• Serial end point titration (SET or Rinkel method) when there is a high likelihood for a severe allergic reaction to specific agents such as antibiotics, nuts or other high-risk allergens

Immunotherapy treatments:
Appropriate in patients with demonstrated allergic hypersensitivity that cannot be managed by medications or avoidance. Note: Injections of airborne insect venom allergens should be prepared individually for each patient.

Exclusionary Guidelines
Allergy testing that is not medically necessary:

• IgG (ELISA) Tests
• Nasal challenge test
• Passive transfer pr P-X (Prausnitz-Kustner) test
• Provocative tests for food or food additive allergies
• Rebuck skin window test

Allergy testing that is experimental:

• Conjunctival challenge test (ophthalmic mucous membrane test)
• Direct nasal mucous membrane test
• Cytotoxic food tests
• Antigen leukocyte antibody test (ALCAT)
• Mediator Release test

Immunotherapy treatments that are not medically necessary:

• Provocative and neutralization therapy for food allergies, using intradermal and subcutaneous routes
• Rinkel, also known as serial dilution endpoint titration therapy, for ragweed pollen hay fever

Immunotherapy treatments that are experimental:

• Enzyme desensitivity therapy
• Repository emulsion therapy
• Urine auto injections (autogenous urine immunization)
• Rhinophototherapy

97532

Basic Benefit and Medical Policy
The safety and effectiveness of cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) have been established. It may be considered a useful therapeutic option in the rehabilitation of patients meeting specific selection criteria. This policy is effective July 1, 2013.

Note: Please check individual contract, certificate and rider for specific coverage information.

Inclusionary Guidelines
Cognitive rehabilitation is an established procedure when used an as adjunctive treatment of cognitive deficits (e.g., attention, language, memory, reasoning, executive functions, problem solving and visual processing) when all of the following criteria are met:

• The cognitive deficits have been acquired as a result of neurologic impairment due to traumatic brain injury or stroke.
• Services must be provided by a qualified licensed professional and must be prescribed by the attending physician as part of the written care plan.
• There must be documentation of potential for improvements based on the patient’s pre-injury function.
• Patients must be able to actively participate in the program. The patient must have sufficient cognitive function to understand and participate in the program, as well as adequate language expression and comprehension (i.e., the patient should not have severe aphasia).
• The member is expected to make significant cognitive improvement (e.g., member is not in a vegetative or custodial state).

Excluded diagnoses include, but are not limited to:

• Mental retardation
• Cerebral palsy
• Encephalopathy
• S/P brain surgery
• Dementia (e.g., from Alzheimer’s disease, HIV-infection or Parkinson’s disease)
• Cognitive decline in multiple sclerosis and chronic obstructive pulmonary disease
• Behavioral or psychiatric disorders such as attention-deficit hyperactivity disorder and schizophrenia
• Pervasive developmental disorders

City of Allen Park

Effective July 1, 2013, Medicare-eligible retirees of the City of Allen Park 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 26488 with suffix 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.

City of Farmington Hills

Effective July 1, 2013, Medicare-eligible retirees of the City of Farmington Hills will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PDP plan, Prescription Blue PDP^SM. The group number is 60253 with suffixes of 600, 601, 602, 603, 604 and 605.

You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

Macomb County

Effective July 1, 2013, Medicare-eligible retirees of Macomb County 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 59905 with suffix 602. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.