Blues highlight medical, benefit policy changes

81201-81203, 81292-81301, 81317-81319, 81401, 81406, S3833, S3834

Basic Benefit and Medical Policy
The criteria for genetic testing For Lynch syndrome and other inherited intestinal polyposis syndromes policy has been updated. This policy is effective Nov. 1, 2013.

Inclusionary 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 patients with one of the following:

• Patients with greater than 20 colonic polyps
• First-degree relatives (e.g., siblings, parents and offspring) of patients with FAP or AFAP or a known APC mutation.
• Genetic testing for MYH (MUTYH) 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, or
• Individuals with personal history of adenomatous polyposis whose family history is consistent with recessive inheritance (e.g., family history is positive only for sibling(s)), or
• Asymptomatic siblings of individuals with known MYH polyposis
• Genetic testing for MLH1 and MSH2 gene mutations to determine the carrier status of Lynch syndrome is established in any of the following:
• Patients with colorectal cancer to test for the diagnosis of Lynch syndrome, or
• 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, or
• At-risk relatives of patients with Lynch syndrome with a known MMR mutation, or
• 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. In cases when testing is proposed for an individual without a personal history of colorectal cancer, the Revised Bethesda or Amsterdam II criteria would be applicable to that individual’s first- or second-degree relatives.
• 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 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 younger 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 at age <50 years
• 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.

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 meet the first Amsterdam II criteria that 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.
• Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer who do not have mutations in either the MLH1 or MSH2 genes for the diagnosis of Lynch syndrome

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 following 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. In cases when testing is proposed for an individual without a personal history of colorectal cancer, the revised Bethesda criteria would be applicable to that individual’s first and second-degree relatives.

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

A9584

Group Variations
Dopamine transporter imaging with single photon emission computed tomography is a payable service for GM hourly and salaried members when specific clinical criteria are met. This change is effective Sept. 20, 2013.

Inclusionary Guidelines

• To aid in the diagnosis of a Parkinsonian syndrome (e.g., essential tremor versus Parkinson’s disease)
• To distinguish drug-induced Parkinsonism versus degenerative Parkinsonism or idiopathic Parkinson’s disease
• To discriminate psychogenic Parkinsonism from neurologically based Parkinsonism
• To be used prior to DBS surgery for intractable tremor of uncertain etiology to determine the appropriate site of DBS stimulation (e.g., VIM stimulation for essential tremor versus STN or GPi stimulation for Parkinson’s disease)
• DaTscan should only be prescribed by a board-certified neurologist who has evaluated the patient.

Exclusionary Guidelines

• As a screening or confirmatory test and for monitoring disease progression or response to therapy.
• Serial DaTscan studies

11100, 11101, 20220

Payment Policy
Effective Aug. 1, 2013, procedure codes *11100, *11101 and *20220 are no longer payable to dentists or oral surgeons.

17340, 17360

Basic Benefit and Medical Policy
These procedures will no longer be payable in an inpatient hospital location, effective Aug. 1, 2013. The codes are payable when performed in an outpatient hospital, ambulatory surgical facility and office setting only.

43644, 43645, 43770- 43775, 43842, 43843, 43845-43848, 43886- 43888, 43999, 44130, 96101- 96103, S2083

Basic Benefit and Medical Policy
The safety and effectiveness of laparoscopic and open gastric restrictive procedures, including, but not limited to, gastric-band, Roux-en-Y, gastric bypass, sleeve gastrectomy and biliopancreatic diversion have been established. They may be considered useful therapeutic options when specified criteria are met. Criteria have been updated, effective Jan. 1, 2014.

Note: Please check web-DENIS for BCBSM-specific plan criteria. Please check the BCN benefit page at the end of the policy for BCN- specific plan criteria.

Inclusionary Guidelines
The surgical procedures for severe obesity, including sleeve gastrectomy, are considered established treatment options if all the following criteria are met:

• The patient has a BMI >40 or a BMI of >35 with one or more comorbid conditions including, but not limited to:
• Degenerative joint disease (including degenerative disc disease)
• Hypertension
• Hyperlipidemia, coronary artery disease
• Presence of other atherosclerotic diseases
• Type 2 diabetes mellitus
• Sleep apnea
• Congestive heart failure
• Bariatric surgery may be indicated for patients 18 to 60 years of age. Requests for bariatric surgery for patients younger than 18 years of age should include documentation that the primary care physician has addressed the risk of surgery on future growth, the patient's maturity level and the patient’s ability to understand the procedure and comply with postoperative instructions, as well as the adequacy of family support. Patients older than 60 may be considered if it is documented in the medical record that the patient’s physiologic age and co-morbid condition(s) result in a positive risk-benefit ratio.
• The patient has been clinically evaluated by an M.D. or D.O. (or their authorized delegate (e.g.,, physician assistant, etc.). The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of one of the following:
  • Six full, consecutive months (180 days) within the last four years prior to the recommendation for bariatric surgery (for BCBSM patients)
  • Six full, consecutive months (180 days) within the last two years prior to the recommendation for bariatric surgery (for BCN patients) 

  The six full consecutive month (180 days) weight loss program listed above is waived for super morbidly obese individuals who have a BMI > 50. Documentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.

• Documentation that the primary care physician and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post-surgical requirements.
• A psychological evaluation must be performed as a pre-surgical assessment by a contracted mental health professional in order to establish the patient’s emotional stability, ability to comprehend the risk of surgery and to give informed consent and ability to cope with expected post-surgical lifestyle changes and limitations. Such psychological consultations may include one unit total of psychological testing for purposes of personality assessment (e.g., the MMPI-2 or adolescent version, the MMPI-A).
• The physician needs to be aware and follow up with individuals who have had gastric surgery for any long-term complications.
• In cases where a revision of the original procedure is planned because of failure due to anatomic or technical reasons (e.g., obstruction, staple dehiscence, etc.) or excessive weight loss of 20% or more below ideal body weight, the revision is determined to be medically appropriate without consideration of the initial preoperative criteria. The medical records should include documentation of:
• The date and type of the previous procedure
• The factor(s) that precipitated the failure or the nature of the complications from the previous procedure that necessitate the takedown
• If the indication for the revision is a weight gain or a failure of the patient to lose a desired amount of weight due to patient non-adherence, then the patient must re-qualify for the subsequent procedure and meet all the initial preoperative criteria.

Exclusionary Guidelines
The following surgical procedures are considered experimental because their safety or effectiveness has not been proven:

• Loop gastric gastroplasty, also known as mini gastric bypass
• Stomach stapling
• Endoscopic procedures (e.g., insertion of the StomaphyX™ device) as a primary bariatric procedure or as a revision procedure, (e.g.,, to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches).
• Any bariatric surgery for patients with Type 2 diabetes who have a BMI of less than 35
• Vertical-banded gastroplasty
• Gastric bypass using a Billroth II type of anastomosis (mini-gastric bypass)
• Biliopancreatic bypass without duodenal switch
• Long-limb gastric bypass procedure (e.g., >150 cm)

81500, 81503, 84999

Basic Benefit and Medical Policy
The safety and effectiveness of proteomics-based testing for the evaluation of ovarian (adnexal) masses (e.g., OVA1 and ROMA tests) have been established. It may be considered a useful diagnostic option for women meeting the patient selection criteria.

Group Variations
Payable for Delphi hourly and salaried members, effective March 1, 2013.

G0249

Payment Policy
BCBSM will allow procedure code G0249 to process with a maximum of three units every 85 days.

J7665

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

Group Variations
Not payable for Delphi hourly and salaried members, effective July 1, 2012

Established procedures
33215-33218, 33220, 33223, 33230, 33231,
33240, 33241, 33243, 33244, 33249, 33262-33264, 93282-93284, 93287, 93289, 93295, 93296

Experimental procedures
0319T-0328T

Medical Policy
The exclusionary coverage criteria for Implantable Cardioverter Defibrillator have been updated. This policy is effective Nov. 1, 2013.

Adults
The use of the automatic implantable cardioverter defibrillator may be considered established in adults who meet the following criteria:

Primary Prevention
Inclusionary Guidelines
Must meet one of the following criteria:

• Ischemic cardiomyopathy with New York Heart Association functional Class II or Class III symptoms, a history of myocardial infarction at least 40 days before ICD treatment and left ventricular ejection fraction of 35% or less
• Ischemic cardiomyopathy with NYHA functional Class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment and left ventricular ejection fraction of 30% or less
• Nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined
• Hypertrophic cardiomyopathy with one or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in one or more first-degree relatives younger than 50 years; left ventricular hypertrophy greater than 30 mm; one or more runs of nonsustained ventricular tachycardia at heart rates of 120 beats per minute or greater on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM

Exclusionary Guidelines
The use of the ICD is considered experimental in primary prevention patients who meet one of the following criteria:

• Have had an acute myocardial infarction (e.g.,., less than 40 days before ICD treatment)
• Have New York Heart Association class IV congestive heart failure (unless patient is eligible to receive a combination cardiac resynchronization therapy ICD device)
• Have had a cardiac revascularization procedure in past 3 months (coronary artery bypass graft [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) or are candidates for a cardiac revascularization procedure
• Have non-cardiac disease that would be associated with life expectancy less than 1 year

Secondary Prevention
Inclusionary Guidelines

• Patients with a history of a life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia.

Exclusionary Guidelines

• The use of the ICD is considered experimental for all other indications secondary prevention patients.

Pediatrics
Inclusionary Guidelines
The use of the ICD may be considered established in children who meet any of the following criteria:

• Survivors of cardiac arrest, after reversible causes have been excluded.
• Symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation
• Congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias

Exclusionary Guidelines
The use of the ICD is considered experimental for all other indications in pediatric patients.

Adult and Pediatrics
The use of a subcutaneous ICD is considered experimental for all indications.

Payable Code
81225

Nonpayable Codes
81226, 81227

Basic Benefit and Medical Policy
Genetic Testing for Cytochrome P450
Polymorphisms
BCBSM Medical Policy has determined that the safety and effectiveness of CYP450 genotyping for CYP2C19 *2 and *3 alleles have been established. It may be considered a useful diagnostic option for patients who meet specific patient selection criteria. This policy is effective Jan. 1, 2013.

Inclusionary Guidelines
One of the following criteria must be met:

• CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative anti-platelet agents
• CYP450 genotyping for the purpose of aiding in decisions on the optimal dosing for clopidogrel

Exclusionary Guidelines
CYP450 genotyping for the purpose of aiding in the choice of drug or dose to increase efficacy or avoid toxicity for all other drugs. This includes, but is not limited to, CYP450 genotyping for the following applications:

• Selection or dosing of selective serotonin reuptake inhibitors
• Selection or dosing of antipsychotic drugs
• Deciding whether to prescribe codeine for nursing mothers
• Selection and dosing of selective norepinephrine reuptake inhibitors including atomoxetine HCL (for treatment of attention-deficit hyperactivity disorder)
• Selection and dosing of tricyclic antidepressants
• Dosing of efavirenz (common component of highly active antiretroviral therapy for HIV infection)
• Dosing of immunosuppressant for organ transplantation
• Selection or dose of beta blockers (e.g., metoprolol)

93797, 93798, S9472

Basic Benefit and Medical Policy
The criteria for the Cardiac Rehabilitation, Outpatient policy have been updated. This policy is effective Jan. 1, 2014.

Inclusionary Guidelines
Must meet all:

• Phase II cardiac rehabilitation
• Member must be medically stable and able to tolerate exercise for 20-40 minutes. 
• Must have a least one diagnosis listed below:
• Acute myocardial infarction with documented diagnosis within the 12 preceding months
• Coronary artery bypass graft surgery
• Current stable angina pectoris
• Percutaneous transluminal coronary angioplasty or coronary stenting
• Heart valve surgery
• Heart or heart-lung transplant
• Compensated heart failure

Exclusionary Guidelines

• Phase I cardiac rehabilitation (performed during inpatient stay)
• Phase III cardiac rehabilitation
• Phase IV cardiac rehabilitation
• Intensive cardiac rehabilitation
• Does not meet diagnostic criteria
• Repeat participation in an cardiac rehabilitation program in the absence of another qualifying cardiac event

A6250, A9155

Basic Benefit and Medical Policy
Laparoscopic and percutaneous techniques of myolysis as a treatment of uterine fibroids are considered experimental. There is insufficient published evidence to assess the safety or impact on health outcomes in the treatment of uterine fibroids. This policy is effective Jan. 1, 2014.

Ascension Fully Insured Plan for Medical and Prescription Drug Benefits

he Ascension Fully Insured Plan for Medical and Prescription Drug Benefits will become effective Jan. 1, 2014. The group number is 71579 and the alpha prefix is HNZ. There will be four medical (three-tier) plans, which will also include prescription drug and hearing coverage.

City of Ypsilanti

Effective Dec. 1, 2013, Medicare-eligible retirees of the City of Ypsilanti will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue^SM Group PPO, for their medical, surgical and prescription drug benefits. The group number is 60008 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.

K.S. Kolbenschmidt

Correction: Effective Dec. 1, 2013, Medicare-eligible retirees of the K.S. Kolbenschmidt will have Blue Cross Blue Shield of Michigan’s Medicare Advantage prescription drug plan, Prescription Blue^SM for its prescription drug benefits. The group number is 60388 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.

For information about our Medicare Advantage PDP plan, go to bcbsm.com/provider/ma.

Spartan Stores Inc.

For this group, the group number is 71575, effective Jan. 1, 2014. The group will offer four PPO plans (Regular, Core and Select with a health reimbursement arrangement, and a high-deductible health plan compatible with a health savings account through Health Equity), two prescription drug plans and one hearing plan.

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