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

81228, 81229

Basic Benefit and Medical Policy
The safety and effectiveness of chromosomal microarray analysis have been established. It may be considered a useful diagnostic option when indicated for patients meeting specific patient selection criteria. Policy updates effective July 1, 2013, include two additional procedures.

Group Variations
Not payable for MPSERS enrollees

Payment Policy
Not payable in an office location.

81235

Basic Benefit and Medical Policy
The safety and effectiveness of analysis of two types of somatic mutation within the EGFR gene — small deletions in exon 19 and a point mutation in exon 21 (L858R) — have been established. They are an effective diagnostic option for predicting treatment response to erlotinib in patients with advanced non-squamous, non-small cell lung cancer, effective March 1, 2013.

The analysis of 2 types of somatic mutation within the EGFR gene — small deletions in exon 19 and a point mutation in exon 21 (L858R) — is considered experimental for patients with advanced squamous cell-type NSCLC.

The analysis for other mutations within exons 18-24 of the EGFR gene or other applications related to NSCLC is considered experimental.

Group Variations
Not payable for Chrysler and Delphi groups

Inclusionary Guidelines
The test is intended for use in patients with advanced NSCLC. Patients with either small deletions in exon 19 or a point mutation in exon 21 (L858R) of the tyrosine kinase domain of the epidermal growth factor gene are considered good candidates for treatment with erlotinib.

Exclusionary Guidelines
Patients found to be wild type are unlikely to respond to erlotinib. Other treatment options should be considered.

90875, 90876

**90901

Basic Benefit and Medical Policy
Neurofeedback training as an alternative therapy for children with attention deficit hyperactivity disorder has been established. It may be a useful treatment option when indicated for children through 18 years of age, effective May 1, 2013.

Neurofeedback training for other central nervous system disorders, such as autism spectrum disorder, substance abuse, epilepsy, and insomnia, is experimental. There is a lack of evidence in the peer reviewed published medical literature on the clinical utility and effectiveness of neurofeedback for these conditions.

**Biofeedback was previously established for urinary and fecal incontinence treatment only.

Group Variations
Not payable for Chrysler, GM, Delphi, the Federal Employee Program^®, MPSERS or URMBT groups.

Payment Policy
Payable to an M.D., D.O., fully licensed psychologist or C.L.M.S.W. Services are subject to all the rules and limitations of the member's mental health benefit.

Inclusionary Guidelines

The patient is 18 years of age or younger with a confirmed DSM-IV diagnosis of ADHD.
Neurofeedback training is performed by a qualified, licensed health practitioner.

Exclusionary Guidelines

All other central nervous system disorders
More than 40 neurofeedback sessions

J0718

Basic Benefit and Medical Policy
Injectable drug J0718 is reimbursable to a physician assistant.

UPDATES TO PAYABLE PROCEDURES

27415

Group Variations
Procedure code 27415 is payable for MPSERS, retroactive to Jan. 1, 2011. Payable to M.D. or D.O. Payable locations are impatient, outpatient and ambulatory surgery facility.

77058, 77059

Basic Benefit and Medical Policy
Magnetic resonance imaging for the assessment of silicone breast implants may be considered established in specified situations, effective Sept. 1, 2013.

Group Variations
Note: Refer to member’s certificate for benefit specific coverage of screening tests and procedures. (The PPO Radiology Management Program may apply.)

Inclusionary Guidelines
To confirm the clinical diagnosis of rupture of silicone breast implants

Exclusionary Guidelines
Monitoring the integrity of silicone gel-filled breast implants when there are no signs or symptoms of rupture

77424**, 77425**, 77469

**Facility benefit only

Basic Benefit and Medical Policy
The safety and effectiveness of intraoperative radiation therapy have been established for selected patients with specified cancers. Inclusionary and exclusionary guidelines have been updated, effective Dec. 1, 2012.

Group Variations
Not payable for GM and Delphi groups. For Ford, Chrysler and URMBT, service is based on individual consideration.

Inclusionary Guidelines
Established for the following recurrent or unresectable cancers without distant metastases, based on NCCN guidelines:

Rectal cancer: For patients with T4 or recurrent cancers with very close or positive margins after resection, as an additional boost
Colon cancer: For patients with T4 or recurrent cancers as an additional boost,
Central pelvic recurrent cervical cancer after radiation therapy should be considered for pelvic exenteration with or without IORT
Recurrent uterine endometrial adenocarcinoma in patients previously treated with external beam radiation at the site of recurrence
Soft tissue sarcomas

Exclusionary Guidelines
Considered experimental for all other indications.

A4604-A7039, A7046

Basic Benefit and Medical Policy
Effective Feb. 1, 2013, BCBSM will align our policy with CMS to reflect the listed quantity and frequency restrictions for the listed positive airway pressure supplies.

Procedure Code         Quantity and Frequency
A4604                            1 per 3 months
A7027                            1 per 3 months
A7028                            2 per 1 month
A7029                            2 per 1 month
A7030                            1 per 3 months
A7031                            1 per 1 month
A7032                            2 per 1 month
A7033                            2 per 1 month
A7034                            1 per 3 months
A7035                            1 per 6 months
A7036                            1 per 6 months
A7037                            1 per 3 months
A7038                            2 per 1 month
A7039                            1 per 6 months
A7046                            1 per 6 months

E0424, E0425, E0430, E0431, E0433-E0435, E0439-E0445, E1390-E1392, E1405, E1406, K0738

Accessories
A4606, A4608, A4615-A4617, A4619, A4620, A7525, A9900, E0455, E0580, E1353, E1354, E1356-E1358

Inclusionary Guidelines
Effective Jan. 1, 2014, BCBSM will adopt Medicare’s coverage of oxygen and oxygen equipment rental for up to 36 months. After that time, suppliers, have to furnish the necessary supplies and accessories from the 37th month though the 60th month (five years) for the member without charging the member. After that time, a recertification can be performed and new equipment can be acquired if considered medically necessary.

Arm of Chair
E0973, E2209, K0015, K0017-K0020

Footrest or Legrest
E0951, E0952, E0990, E0995, E1020, K0037- K0047, K0050-K0053, K0195

Nonstandard Seat Frame Dimensions
E1011, E2201-E2204, K0056

Rear Wheels for Manual Wheelchairs
E0961, E0967, E0988, E2205, E2206, E2211- E2222, E2224-E2228, K0065, K0069- K0073, K0077

Batteries and Chargers
E2358-E2367, E2371, E2372, E2397, K0733

Power Seating Systems
E1002-E1010, E2301, E2310-E2313, E2321-E2331, E2373-E2378

Other Power Wheelchair Accessories
E1016, E1018, E2351, E2368-E2370, E2381-E2392, E2394-E2396, K0098

Miscellaneous Accessories
A9900, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028-E1030, E1225, E1226, E2207, E2208, E2210, E2230, E2295, K0105, K0108

Basic Benefit and Medical Policy
The following reflects the inclusionary guidelines for wheelchair options and accessories:
Options and accessories for wheelchairs are covered if the member has a wheelchair that meets BCBSM coverage criteria and the option or accessory itself is medically necessary. Coverage criteria for specific items are described below.

Arm of Chair
Adjustable arm height option (E0973, K0017, K0018 and K0020) is covered if the member requires an arm height that is different than that available using nonadjustable arms and the member spends at least two hours per day in the wheelchair.

An arm trough (E2209) is covered if the member has quadriplegia, hemiplegia or uncontrolled arm movements.

Footrest or Legrest
Elevating legrests (E0990, K0046, K0047, K0053 and K0195) are covered if:

The member has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee; or
The member has significant edema of the lower extremities that requires an elevating legrest; or
The member meets the criteria for and has a reclining back on the wheelchair.

Nonstandard Seat Frame Dimensions
A nonstandard seat width or depth for a manual wheelchair (E2201-E2204) is covered only if the member’s physical dimensions justify the need.

Wheels and Tires for Manual Wheelchairs
A gear reduction drive wheel (E2227) or a lever activated wheel drive (E0988) is covered if all of the following criteria are met:

The member has been self-propelling in a manual wheelchair for at least one year; and
The member has had a specialty evaluation that was performed by a licensed or certified medical professional, such as a physical therapist or occupational therapist, or a physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member's home. The PT, OT or physician may have no financial relationship with the supplier; and
The wheelchair is provided by a supplier that employs a RESNA-certified assistive technology professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Batteries and Chargers
Up to two sealed batteries (E2359, E2361, E2363, E2365, E2371 and K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2358) will be reviewed retrospectively as not reasonable and necessary. Procedure codes E2360, E2362, E2364 and E2372 are covered by BCBSM.

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be reviewed retrospectively as not reasonable and necessary.
The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every three years. Only one battery is allowed at any one time.

Power Tilt or Recline Seating Systems
A power seating system — tilt only, recline only or combinations tilt and recline — with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5 or 6 is met:

The member meets all the coverage criteria for a power wheelchair described in the BCBSM durable medical equioment medical policy; and
A specialty evaluation that was performed by a licensed or certified medical professional, such as a physical therapist or occupational therapist or physician who has specific training and experience in rehabilitation wheelchair evaluations documents the member's seating and positioning needs. The PT, OT or physician may have no financial relationship with the supplier; and
The seating system is provided by a supplier that employs a RESNA-certified assistive technology professional (ATP) who specializes in rehabilitation wheelchairs and who has direct, in-person involvement in the selection of the seating system for the member; and
The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be reviewed retrospectively as not reasonable and necessary.

Power Wheelchair Drive Control Systems
An attendant control is covered in place of a member-operated drive control system if the member meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

Other Power Wheelchair Accessories
An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the member has a covered speech generating device. (Refer to BCBSM’s Speech Generating Devices medical policy issues for details.)

Miscellaneous Accessories
Anti-rollback device (E0974) is covered if the member self-propels and needs the device because of ramps.
A safety belt or pelvic strap (E0978) is covered if the member has weak upper body muscles, upper body instability or muscle spasticity that requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swing away, retractable or removable hardware (E1028) would be to move the component out of the way so that a member can perform a slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the member has one or more of the following conditions:

The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

If these criteria are not met, the manual reclining back will be reviewed retrospectively as not reasonable and necessary.
For information regarding a push-rim activated power assist device for a manual wheelchair, refer to the BCBSM DME medical policy.

Miscellaneous
The medical necessity for all options and accessories must be documented in the member's medical record and be available on request. This documentation might include information on why the member needs the item, the member's diagnosis, the member's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the member performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.
Accessories to the wheelchair base must be billed on the same claim as the wheelchair base itself.
When billing option or accessory codes as a replacement, documentation of the medical necessity for the item, make and model name of the wheelchair base it is being added to and the date of initial issue of the wheelchair must be available upon request.
Group Variations

Procedure codes E2207 and E2351 are not covered for the Federal Employee Program^®.

J0282

Payment Policy
BCBSM will allow procedure code J0282 to quantity process with no maximum.

POLICY CLARIFICATIONS

81211-81217, 88299

Basic Benefit and Medical Policy
The safety and effectiveness of simultaneous testing for inherited BRCA1 and BRCA2 mutations have been established. It may be considered a useful diagnostic option when indicated for individuals at high risk of breast or ovarian cancer.

Testing for genomic rearrangements of the BRCA1 and BRCA2 genes (e.g., BART testing) may be considered established in patients who meet criteria for BRCA1 and BRCA2 testing and whose testing for point mutations is negative.

Testing for CHEK2 genetic abnormalities (mutations, deletions, etc.) is considered experimental in affected and unaffected patients with breast cancer irrespective of the family history.

Use of the BreastNext™ Next-Gen Cancer Panel and the OvaNext™ is experimental. There is insufficient data on the analytical and clinical validity as well as clinical utility of this testing on patient management and outcomes.

Guidelines have been updated, effective May 1, 2013.

Inclusionary Guidelines
Please review the guidelines first to see if the patient falls into the high risk category for BRCA mutations, then apply the appropriate policy for affected (having a current cancer diagnosis) vs. unaffected patients (does not have a diagnosis of breast or ovarian cancer).

NCCN (2012) Guidelines for Family History Review and Background
Genetic cancer susceptibility is determined by a review of the patient’s personal and family history. At least one of the following criteria must be present to be considered high risk for hereditary breast or ovarian cancer:

Individual from a family with a known deleterious BRCA1 or BRCA2 mutation
Personal history of breast cancer plus one or more of the following:

Diagnosed at an early age (<45 years)
Diagnosed at age <50 years with at least one close blood relative** (see definition, following) with breast cancer at age <50 years or at least one close blood relative** with epithelial ovarian or fallopian tube or primary peritoneal cancer at any age
Two breast primaries when the first breast cancer diagnosis occurred prior to age 50 years
Diagnosed age <60 years with a triple negative breast cancer
Diagnosed age <50 years with a limited family history
Diagnosed at any age, with >2 close blood relatives** with breast or epithelial ovarian or fallopian tube or primary peritoneal cancer at any age
Close male relative** with breast cancer
For an individual of ethnicity associated with higher mutation frequency (e.g., Ashkenazi Jewish); no additional family history may be required

Personal history of epithelial ovarian or fallopian tube or primary peritoneal cancer
Personal history of male breast cancer
Personal history of breast or ovarian cancer at any age with >2 close blood relatives* with epithelial ovarian or fallopian tube or primary peritoneal cancer at any age
Personal history of pancreatic cancer at any age with >2 close blood relatives** with breast or ovarian cancer or pancreatic cancer at any age
Family history only:

Close blood relative** meeting any of the above criteria

**A close blood relative typically refers to first-degree (parent, full sibling or offspring) and second-degree (grandparent, grandchild, uncle, aunt, niece, nephew or half-sibling) relatives in diseases associated with high-penetrance gene mutations, such as BRCA1 and BRCA2 mutations. Accommodation may be made to include third-degree relatives (first cousin, great grandparent or great grandchild) in some cases, e.g., limited family history, particularly in tracing hereditary breast and ovarian and related cancers in the paternal lineage. Certified genetic counselors or other qualified genetics professionals are best able to assess exceptional cases.
The following guidelines for non-Ashkenazi Jewish women unaffected with cancer were derived by the USPSTF in 2005 after extensive literature review by the U.S. Preventive Services Task Force:

Three or more first- or second-degree relatives with breast cancer, regardless of age at diagnosis; or
Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 years or younger; or
Combination of both breast and ovarian or fallopian tube or primary peritoneal cancer among first- and second-degree relatives; or
First-degree relative with bilateral breast cancer; or
A combination of two or more first- or second-degree relatives with ovarian or fallopian tube or primary peritoneal cancer regardless of age at diagnosis; or
A first- or second-degree relative with both breast and ovarian or fallopian tube or primary peritoneal cancer at any age; or
A history of breast cancer in a male relative.

The USPSTF guidelines do not address women affected with breast cancer.

Inclusionary Guidelines
Affected patient:
Genetic testing for BRCA1 and BRCA2 mutations in cancer-affected individuals may be considered established under any one of the following circumstances:

Women who are affected with breast cancer or pancreatic cancer and are from families with a high risk of BRCA1 or BRCA2 mutation as defined in the guidelines, or
Women who are affected with breast cancer or pancreatic cancer who are not from families with a high risk of BRCA1 or BRCA2 mutation as defined in the guidelines, but are affected with any of the following:

Early onset breast cancer (<45 years) OR
Two breast primary cancers with the first cancer diagnosis occurring prior to age 50 years, or
Triple negative breast cancer (neither express estrogen receptor and progesterone receptor, nor over express HER2) diagnosed at younger than age 60, or
Two or more close blood relatives** with pancreatic cancer of any age.

Women affected with epithelia ovarian cancer or fallopian tube or primary peritoneal cancer
Men affected with breast cancer at any age
Those affected with breast cancer who are from an ethnic background, e.g., Ashkenazi Jewish descent, associated with deleterious founder mutations

Unaffected patients:
Genetic testing for BRCA1 and BRCA2 mutations of unaffected adults may be considered established under any of the following circumstances:

Unaffected individuals (male or female) from families with a known BRCA1 or BRCA2 mutation
Unaffected individuals from families with a high risk of BRCA1 or BRCA2 mutation based on a family history when the BRCA mutation status of affected family member is unknown (for any reason)
Unaffected individuals in populations at risk for specific founder mutations due to ethnic background (e.g., Ashkenazi Jewish descent) and with one or more relatives with breast, ovarian, fallopian tube or primary peritoneal cancer at any age

Testing for genomic rearrangements of the BRCA1 and BRCA2 genes (BART testing) when the original BRCA testing did not include the BART test) may be considered appropriate in patients who meet criteria for BRCA testing, whose initial test for the BRCA gene is negative.

J3490

Basic Benefit and Medical Policy
Injectafer (ferric carboxymaltose injection) is established when the FDA approved indications are met. The FDA approved Injectafer for the treatment of iron deficiency anemia in adult patients. This policy is effective July 25, 2013.

Injectafer should be reported with not-otherwise-classified code J3490 until a permanent code is established.

Dosage and Administration

Up to 750 mg can be delivered in a single dose.
Give two doses separated by at least seven days for a total cumulative dose of 1500 mg per course.
Administer intravenously by infusion over at least 15 minutes.
Slow push injection at the rate of approximately 100 mg (2 mL) per minute over at least 7.5 minutes.

For patients weighing less than 50 kg (110 lb), give each dose as 15 mg/kg body weight. When administered via infusion, dilute up to 750 mg of iron in no more than 250 mL of sterile 0.9% sodium chloride injection, USP, such that the concentration of the infusion is not <2 mg of iron per mL and administer over at least 15 minutes. When administering as a slow intravenous push, give at the rate of approximately 100 mg (2 mL) per minute.

J3590

Basic Benefit and Medical Policy
Kcentra (prothrombin complex concentrate, human) is established when the FDA-approved indications are met. The FDA approved Kcentra for the urgent reversal of anticoagulation in adults with major bleeding. This policy is effective April 29, 2013.

Kcentra should be reported with not-otherwise-classified code J3590 until a permanent code is established.

Dosage and administration for intravenous use only.

Kcentra dosing should be individualized based on the patient’s baseline internationalnormalized ratio value and body weight.
Administer Vitamin K concurrently to patients receiving Kcentra to maintain factor levels, once the effects of Kcentra have diminished.
Repeat dosing with Kcentra is not supported by clinical data and is not recommended.
Administer reconstituted Kcentra at a rate of 0.12 mL/kg/min (~3 units/kg/min) up to a maximum rate of 8.4 mL/min (~210 units/min.).

Inclusionary Guidelines
Indicated for the urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist (VKA, e.g., warfarin) therapy in adult patients with acute major bleeding.

Exclusionary Guidelines
Kcentra is not indicated for urgent reversal of VKA anticoagulation in patients without acute major bleeding

GROUP BENEFIT CHANGES

County of Charlevoix

Effective Oct. 1, 2013, Medicare-eligible retirees of the County of Charlevoix 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 60348 with suffixes 601 and 602. 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.