Blues highlight medical, benefit policy changes

0318T, 33363-33365, 33367-33369,

Basic Benefit and Medical Policy
Transcatheter aortic valve replacement performed via any approach with a device approved by the U.S. Food and Drug Administration has been shown to be safe and effective. It is established for patients with severe aortic stenosis who meet the clinical criteria outlined in this policy. The approach used must be determined by the attending physician based on individual clinical, anatomic and prognostic factors. Inclusions have been updated, effective July 1, 2013

Group Variations
Excludes Chrysler

Inclusionary Guidelines
Transcatheter aortic valve replacement performed via any approach with a device approved by the U.S. Food and Drug Administration is established for patients with aortic stenosis when all of the following conditions are present:**

1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
• An aortic valve area of less than 0.8 cm²
• A mean aortic valve gradient greater than 40 mmHg
• A jet velocity greater than 4.0 m/sec
2. New York Heart Association heart failure Class II, III or IV symptoms
3. Patient is not a candidate for open surgery, as judged by at least two cardiovascular specialists (cardiologist or cardiac surgeon).

**Individuals with annulus diameters measuring greater than 26 mm may be eligible for an Investigational Device Exemption, as the currently FDA-approved devices accommodate annulus diameters measuring 18-26 mm.

Exclusionary Guidelines

• Transcatheter aortic valve implantation using alternate approaches (e.g., transapical or transventricular)

The presence of any of the following conditions:

• Noncalcified aortic annulus
• Congenital unicuspid or congenital bicuspid
• Mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation >3+)
• Pre-existing or prosthetic heart valve or prosthetic ring in any position
• Severe mitral annular calcification, severe (>3+) mitral insufficiency or Gorelin syndrome
• Blood dyscrasias defined as: leukopenia (WBC<3000 mm³), acute anemia (Hgb <9 mg%), thrombocytopenia (platelet count <50,000 cells/mm³, or history of bleeding diathesis or coagulopathy
• Hypertrophic cardiomyopathy with or without obstruction
• Left ventricular ejection fraction < 20%
• Active bacterial endocarditis within 6 months (180 days) of procedure
• Echocardiographic evidence of intracardiac mass, thrombus or vegetations, or other active infections
• A known hypersensitivity or contraindication to aspirin, heparin, ticlopidine (Ticlid), or clopidogrel (Plavix), or sensitivity to contrast media, which cannot be adequately premedicated
• Native aortic annulus diameter of < 18mm or > 25mm as measured by echocardiogram
• Abdominal aortic or thoracic aneurysm (defined as maximal luminal diameter 5 cm or greater)
• Significant aortic disease, including abdominal aortic or thoracic aneurysm defined as maximal luminal diameter 5 cm or greater, marked tortuosity (hyperacute bend), aortic arch atheroma (especially if thick [> 5 mm], protruding or ulcerated) or narrowing (especially with calcification and surface irregularities) of the abdominal or thoracic aorta, severe “unfolding” and tortuosity of the thoracic aorta
• Ililiofemoral vessel characteristics that would preclude safe placement of 22F or 24F introducer sheath such as severe obstructive calcification, severe tortuosity or vessels size less than 7 mm in diameter and bulky calcified aortic valve leaflets in close proximity to coronary ostia (applicable for transfemoral introduction)
• Evidence of an acute myocardial infarction < 1 month (30 days) before the intended treatment; substantial coronary artery disease requiring revascularization
• Any therapeutic invasive cardiac procedure resulting in a permanent implant that is performed within 30 days of the index procedure (e.g., PCI). Implantation of a permanent pacemaker is not excluded.
• Active upper GI bleeding within three months (90 days) prior to procedure
• Clinically (by neurologist) or neuroimaging-confirmed stroke or transient ischemic attack within 6 months (180 days) of the procedure
• Renal insufficiency (creatinine> 3.0 mg/dL) or renal replacement therapy at the time of screening
• Estimated life expectancy < 24 months (730 days) due to carcinomas, chronic liver disease, chronic renal disease or chronic end stage pulmonary disease
• The individual was offered surgery but refused.

81235, 81252-81254, 81321-81326, 81506, 81508, 81510, 81512, G0452

Group Variations
Listed procedure codes are payable for Federal Employee Program^® members, effective Jan. 1, 2013

99441-99443

Group Variations
Payable for Federal Employee Program members, effective July 1, 2013

J7665

Basic Benefit and Medical Policy
The safety and effectiveness of inhaled dry powder mannitol in the diagnosis and management have been established. It may be considered a useful diagnostic option when indicated, effective July 1, 2012.

Group Variations

• Not covered for MPSERS, Chrysler and URMBT members
• Payable for GM hourly and salaried members, effective Nov. 1, 2012
• Payable for Ford hourly and salaried members, effective Jan. 1, 2013

Inclusionary Guidelines

• As an aid in the diagnosis of asthma
• To assess response to steroid therapy
• To guide steroid reduction

Exclusionary Guidelines

• Children under age 6

Q4131-Q4136

Group Variations
Payable for Federal Employee Program members, effective Jan. 1, 2013

0308T

Basic Benefit and Medical Policy
The safety and effectiveness of the implantable miniature telescope for the treatment of end stage, age-related wet macular degeneration have been established. It is a useful therapeutic option for patients meeting specified criteria.

Group Variations
Payable for URMBT members, effective Dec. 1, 2012

47370

Group Variations
Procedure code 47370 is now payable for MPSERS for professional claims. Facility claims are already payable.

76390

Basic Benefit and Medical Policy
The safety and effectiveness of magnetic resonance spectroscopy have been established for patients meeting specific patient selection criteria. Inclusionary guidelines were updated, effective May 1, 2013.

Payment Policy
May be subject to the PPO Radiology Management Program guidelines.

Inclusionary Guidelines
MRS is an appropriate clinical tool for diagnosing:

• Disorders of creatine metabolism
• Presence of mitochondrial disease.
• MRS may be used to assist in distinguishing tissue necrosis from persistent or recurrent brain tumor as an alternative to invasive brain biopsy.

Exclusionary Guidelines
MRS for any other condition than listed in the inclusions.

78015, 78016, 78018, 78020, 78070, 78075, 78099, 78102-78104, 78110, 78111, 78120-78122, 78130, 78135, 78140, 78185, 78190, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230-78232, 78258, 78261, 78262, 78264, 78267, 78268, 78270-78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451-78454, 78456-78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 78499, 78579, 78580, 78582, 78597-78601, 78605-78607, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699-78701, 78707-78710, 78725, 78730, 78740, 78761, 78799

Payment Policy
Effective Jan. 1, 2011, the listed procedure codes are payable to providers with a specialty of nuclear medicine under the PPO Radiology Management Program.

Group Variations
The Federal Employee Program is excluded from the Radiology Management Program.

E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036

Inclusionary Guidelines
A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the patient would be bed confined.

A patient lift described by procedure codes E0630 or E0635, E0639 or E0640 is covered if the basic coverage criteria are met. If the coverage criteria are not met, the lift will be denied as not reasonable and necessary. Procedure code E0625 is currently not payable.

A multi-positional patient support/transfer system (E0636, E1035, E1036) is covered if both of the following criteria  are met:

1. The basic coverage criteria for a lift are met
2. The patient requires supine positioning for transfers.

If either criterion 1 or 2 is not met, codes E0636, E1035 and E1036 will be denied as not reasonable and necessary.

If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive equipment, including but not limited to: canes, crutches, walkers, roll about chairs, transfer chairs, manual wheelchairs, power-operated vehicles or power wheelchairs.

Code E0621 is covered as an accessory when ordered as a replacement for a covered patient lift.

Modifier KX is the appropriate modifier for the patient lifts procedures.

The effective date is March 1, 2013.

Group Variations
Includes Delphi hourly and salaried, Chrysler nonbargaining consumer-directed health plan with a health savings account (group number 82100) only, GM and URMBT members when BCBSM has claim processing responsibility (POS 3 and others except POS 4)

Excludes Ford hourly and salaried, Chrysler bargaining and nonbargaining (except group number 82100), GM and URMBT members when vendor (NNPN/HMENN) has claim processing responsibility (POS 4).

This change does not apply to groups that have DME carved out to a vendor.

20245, 21556, 38510, 48100, 88311, 88312, 88346, 92520, 97027, 97535, 97750, 99284, D7210, E0486

Basic Benefit and Medical Policy
Procedure codes are either payable or non-payable to D.D.S. and oral surgeon specialties as identified.

Non-payable procedures to D.D.S. and oral surgeon
20245, 21556, 48100, 92520, 97027, 97535, 97750, 99284

Payable procedures to D.D.S., but not an oral surgeon
88311, 88312, 88346

Payable procedure to oral surgeon, but not a D.D.S.
38510 

Payable procedures to both D.D.S. and oral surgeon
D7210, E0486

64633-64636, 64999

Basic Benefit and Medical Policy
The inclusionary and exclusionary guidelines for the Facet Joint Denervation Policy have been updated, effective Nov. 1, 2013.

Inclusionary Guidelines
Candidates for radiofrequency facet denervation must meet all of the following criteria:

• No prior spinal fusion surgery in the vertebral level being treated
• Disabling low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations, and the pain is not radicular
• Pain has failed to respond to three months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy and a home exercise program.
• There has been a successful trial of controlled medial branch blocks.**
• If there has been a prior successful radiofrequency denervation, there should be a minimum time of six months since the prior RF treatment (per side, per anatomical level of the spine).

**A successful trial of controlled diagnostic medial branch blocks consists of two separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in at least a 50 percent reduction in pain for the duration of the local anesthetic used (e.g., three hours longer with bupivacaine than lidocaine). No therapeutic intra-articular injections (e.g., steroids, saline or other substances) should be administered for a period of at least four weeks prior to the diagnostic medial branch block. The diagnostic blocks should involve the levels being considered for RF treatment and should not be conducted under intravenous sedation unless specifically indicated (e.g., the patient is unable to cooperate with the procedure). These diagnostic blocks should be targeted to the likely pain generator. Single level blocks lead to more precise diagnostic information, but multiple single level blocks require several visits and additional exposure to radiation.

Exclusionary Guidelines

• Radiofrequency denervation is considered experimental for the treatment of chronic spinal or back pain for all uses that do not meet the criteria listed above, including, but not limited to, treatment of thoracic or sacroiliac facet joint pain.
• All other methods of denervation are considered experimental for the treatment of chronic spinalor back pain, including, but not limited to, pulsed radiofrequency denervation, laser denervation, chemodenervation, water-cooled radiofrequency denervation and cryodenervation.
• Therapeutic medial branch blocks
• If there has been a prior successful radiofrequency denervation, additional diagnostic medial branch blocks for the same level of the spine are not medically necessary.

Note: In June 2005, the American Medical Association’s CPT Editorial Panel determined that the unlisted CPT code 64999 should be used for pulsed RF treatment as opposed to other specific codes.

92499, S0515, V2531, V2627

Basic Benefit and Medical Policy
The criteria for the Corneal Liquid Bandage Lens for Corneal Epithelial Defects/Scleral Senses Policy have been updated, effective Nov. 1, 2013.

Guidelines
Note: Measuring and fitting of these therapeutic lenses may take several sessions at the provider’s office. The patient may have to undergo a number of fittings using trial lenses until the best match for the patient’s needs is found.

The choice of gas-permeable versus soft contact lenses is dependent on the patient’s disease process and physician determination of the appropriate therapy.

Inclusionary Guidelines
Rigid gas-permeable scleral contact lenses as corneal liquid bandages are considered established for patients who meet both of the following criteria:

• The individual has persistent epithelial defects of the cornea with documented, disabling symptoms (e.g., pain, photophobia) that have not responded to medical intervention, including topical medications or standard spectacle or contact lens fitting
• The individual has any of the following conditions for which surgery is undesirable or contraindicated. Note: This list may not be all-inclusive:
• Corneal stem cell deficiencies:
• Stevens-Johnson disease (a syndrome of systemic, as well as more severe, mucocutaneous lesions that results in corneal opacities, perforations or blindness)
• TEN (toxic epidermal neurolysis)
• Conditions that result from a chemical or traumatic injury
• Previous surgery
• Acquired aniridia
• Recurrent corneal erosion
• Postsurgical eyelid defect(s)
• Exposure keratitis
• Lacrimal or meibomian gland obliteration
• Superior limbal keratoconjunctivitis
• Inflammatory corneal degeneration
• Keratoconus
• PED resulting from superior limbic keratotomy
• Neurotrophic (anesthetic) corneas
• From acquired causes, including, but not limited to:
• Corneal denervation that is related to acoustic neuroma surgery
• Trigeminal ganglionectomy
• Herpes simplex or zoster of the cornea
• Complications of diabetes
• Idiopathic corneal stem cell deficiency
• From congenital causes, including, but not limited to:
• Seckle’s syndrome
• Congenital corneal anesthesia
• Congenital eyelid defect(s)
• Congenital dysautonomia (e.g., Riley-Day Syndrome)
• Severe dry eyes (keratoconjunctivitis sicca) due to
• Sjögren syndrome
• Graft vs. host disease
• Post-radiation treatment
• Eye surgery
• Severe meibomian gland deficiency
• Corneal disorders associated with:
• Systemic autoimmune diseases
• Rheumatoid arthritis
• Dermatological disorders such as atopic, epidermolysis bullosa, epidermal dysplasia)

The use of therapeutic soft contact lenses as corneal liquid bandages is considered established for patients who meet both of the following criteria:

• The individual has persistent epithelial defects of the cornea with documented, disabling symptoms (e.g., pain, photophobia) that have not responded to medical intervention, including topical medications or standard spectacle or contact lens fitting.
• The PED is associated with any of the following conditions (this list may not be all-inclusive):
• Bullous keratopathy
• Permanent keratoprosthesis
• Filamentary keratitis
• PEDs resulting from penetrating keratoplasty
• Following the use of cyanoacrylate (tissue) glue to provide protection to an adhesive plug over a corneal wound
• Severe dry eyes (due to conditions such as Stevens-Johnson syndrome, radiation, graft vs host disease, meibomian gland deficiency, etc.)
• Corneal disorders associated with systemic autoimmune diseases
• Corneal exposure (e.g., anatomic, paralytic).
• Neurotrophic (anesthetic) corneas

81324-81326

Basic Benefit and Medical Policy
Genetic testing to confirm a diagnosis of an inherited peripheral neuropathy is considered experimental. The diagnosis of an inherited peripheral neuropathy is generally made based on clinical assessment and as there is no specific therapy the benefit of a genetic confirmation of these disorders is not known. This policy is effective Nov. 1, 2013.

Federal Screw Works

Effective Nov. 1, 2013, Medicare-eligible retirees of the Federal Screw Works 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 26418 with suffixes 601, 602 and 603. 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.

UP Plumbers and Pipefitters

Effective Nov. 1, 2013, Medicare-eligible retirees of the UP Plumber and Pipefitters 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 60391 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.