Blues highlight medical, benefit policy changes

83861

Basic Benefit and Medical Policy
Tear osmolarity testing may be considered established as indicated for the diagnosis and monitoring of dry eye syndrome if the slit lamp test, as well as two other tests, fail to establish the suspected diagnosis of the condition. 

Additional tests may include:
- Schirmer’s test
- Tear evaporation test
- Tear break-up time
- Ocular staining

Tear osmolarity testing is considered experimental for all other indications.

This policy is effective Sept. 1, 2013.

Group Variations
Not a contract benefit for auto groups, URMBT, MPSERS, MESSA and State of Michigan.

90867-90869

Basic Benefit and Medical Policy
Transcranial magnetic stimulation of the brain has been established. It may be a useful treatment option in specified situations, effective Sept. 1, 2013.

This service requires pre-authorization, with the exception of the Federal Employee Program^®.

Group Variations
Payable for MESSA, MPSERS and underwritten groups with outpatient mental health benefits

Payment Policy
Magellan Behavioral of Michigan, Inc. reviews authorization requests, effective Oct. 1, 2013. Please check members’ mental health benefits by using the toll-free number listed for behavioral health authorizations.

Authorization will be based on BCBSM medical policy criteria administered by Magellan. Criteria is posted on web-DENIS by using the following steps:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Scroll down to 2013 updated Magellan Behavioral Health Medical Necessity Criteria.
• Click on 2013 BCBSM criteria for rTMS administered by Magellan.

BCBSM will not pay unauthorized claims.

Payable only to a board-certified psychiatrist. 

Authorization does not supersede member benefit limitations. Cost-sharing may apply.

Repetitive transcranial magnetic stimulation is a professional benefit only.

Inclusionary Guidelines
Note: Transcranial magnetic stimulation must be administered by an approved U.S. Food and Drug Administration  device for the treatment of major depressive disorder, according to specified stimulation parameters, five days a week for six weeks (total of 30 sessions), followed by a three-week course of three TMS treatments in one week, two TMS treatments the next week and one TMS treatment in the last week.

Must meet the following criteria:

1. Has a confirmed diagnosis of severe major depressive disorder (single or recurrent episodes) measured by evidence-based scales, such as the Beck Depression Inventory (score 30-63), Zung Self-Rating Depression Scale (>70), PHQ-9 (>20) or Hamilton Depression Rating Scale (>20)
2. At least one of the following:
• Medication treatment resistance during the current depressive episode, as evidenced by each of the following:
• Clinically significant response to four trials of psychopharmacologic agents. Trial criteria is six weeks of maximal FDA recommended dosing or maximal tolerated dose of medication with objectively measured evaluation at initiation and during the trial showing no evidence of response (e.g., < 50% reduction of symptoms or scale improvement).
• Two single-agent trials of antidepressants of different classes
• Two augmentation agent trials with different classes of augmenting agents in either (or both) of the above single agent trials
• The patient is unable to tolerate a therapeutic dose of medications. Intolerance is defined as: severe somatic or psychological symptoms that cannot be modulated by any means, including, but not limited to: additional medications to ameliorate side effects. Examples of somatic side effects include persistent electrolyte imbalance, pancytopenia, severe weight loss, poorly controlled metabolic syndrome or diabetes, as a result of the medication. Examples of psychological side effects of the medication would be suicidal-homicidal thinking or attempts and impulse dyscontrol.
  Note: A trial of less than one week of a specific medication would not be considered a qualifying trial to establish intolerance.
• Electroconvulsive therapy would not be clinically superior to transcranial magnetic stimulation (e.g., in cases with psychosis, acute suicidal risk, catatonia or life-threatening inanition).
3. A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms (e.g., Beck Depression Inventory, Zung Self-Rating Depression Scale, PHQ-9 or Hamilton Depression Rating Scale)
4. The following conditions are continuously present in the TMS treatment setting during treatment:
• Treatment must be rendered by a board-certified psychiatrist, trained in this therapy.
• An attendant trained in BCLS and the management of complications such as seizures, as well as the use of the equipment, must be present at all times.
• Presence of adequate resuscitation equipment, including, for example, suction and oxygen
• The facility must maintain awareness of response times of emergency services (either fire and ambulance or “code team”), which should be available within five minutes. These relationships are reviewed on at least a one-year basis and include mock drills.

Exclusionary Guidelines

• All other behavioral health, neuropsychiatric or medical conditions (e.g., anxiety disorders, mood disorders, schizophrenia, Alzheimer’s, dysphagia, seizures)
• Pregnancy
• Maintenance treatment
• Presence of psychosis in the current episode
• Seizure disorder or any history of seizure, except those induced by ECT, isolated febrile seizures in infancy without subsequent treatment or recurrence
• Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 centimeters from the TMS magnetic coil or other implanted metal items, including, but not limited to, a cochlear implant, implanted cardioverter defibrillator, pacemaker, vagus nerve stimulator or metal aneurysm clips or coils, staples or stents
  Note: Dental amalgam fillings are not affected by the magnetic field and are acceptable for use with TMS.
• If the patient (or, when indicated, the legal guardian) is unable to understand the risk and benefits of repetitive TMS and provide informed consent
• Presence of a medical or co-morbid psychiatric contraindication to rTMS
• Patient lacks a suitable environmental or social or professional support system for post-treatment recovery.
• There is not a reasonable expectation that the patient will be able to adhere to post-procedure recommendations.

Note: Caution should be exercised in any situation where the patient’s seizure threshold may be decreased. Examples include:

• Presence in the bloodstream of a variety of agents, including, but not limited to, tricyclic antidepressants, clozapine, antivirals, theophylline, amphetamines, PCP, MDMA, alcohol and cocaine, as these present a significant risk
• Presence of the following agents, including, but not limited to, SSRIs, SNRIs, bupropion, some antipsychotics, chloroquine, some antibiotics and some chemotherapeutic agents as they present a relative risk and should be considered when making risk-benefit assessments
• Withdrawal from alcohol, benzodiazepines, barbiturates and chloral hydrate also present a strong relative hazard.

Basic Benefit and Medical Policy
In utero repair fetal surgeries have been established in specific fetal anomalies. The safety and effectiveness of these surgeries have been proven. Guidelines have been updated, effective Sept. 1, 2013.

Group Variations
Excludes Chrysler, Ford and URMBT groups

Inclusionary Guidelines
Vesico-amniotic shunting when:

• Evidence of hydronephrosis due to bilateral urinary tract obstruction; and
• Progressive oligohydramnios; and
• Adequate renal function; and
• No other lethal abnormalities or chromosomal defects

Open in utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt when:

• Congenital cystic adenomatoid malformation or bronchopulmonary sequestration is identified; and
• The fetus is at 32 weeks’ gestation or less; and
• There is evidence of fetal hydrops, placentomegaly,  or the beginnings of severe pre-eclampsia (e.g., the maternal mirror syndrome) in the mother.

In utero removal of sacrococcygeal teratoma when:

• The fetus is at 32 weeks gestation or less; and
• There is evidence of fetal hydrops, placentomegaly or the beginnings of severe pre-eclampsia (e.g., maternal mirror syndrome) in the mother.

In utero repair of myelomeningocele when:

• The fetus is at less than 26 weeks gestation; and
• Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.

Exclusionary Guidelines
In utero repair of myelomeningocele when:

• Fetal anomaly unrelated to myelomeningocele; or
• Severe kyphosis; or
• Risk of preterm birth (e.g., short cervix or previous preterm birth); or
• Maternal body mass index of 35 or more

All other applications of fetal surgery, including, but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.

50593

Basic Benefit and Medical Policy
Effective Jan. 1, 2013, procedure code 50593 is payable for MPSERS.

G0245-G0247

Basic Benefit and Medical Policy
Payable with a diagnosis of Polyneuropathy in diabetes. 

Established procedures
0191T, 0192T

Experimental procedures
0123T, 0253T

Basic Benefit and Medical Policy
Aqueous shunts and stents for glaucoma
The safety and effectiveness of the insertion of U.S. Food and Drug Administration-approved aqueous shunts have been established. They are useful therapeutic options for reducing intraocular pressure in patients with glaucoma when medical therapy has failed to adequately control intraocular pressure.

Use of an aqueous shunt for all other conditions, including in patients with glaucoma when intraocular pressure is adequately controlled by medications, is considered experimental. This policy is effective Nov. 1, 2013.

Inclusionary Guidelines
Insertion of FDA-approved aqueous shunts is considered established as a method to reduce intraocular pressure in patients with glaucoma when conventional pharmacologic treatments have failed to control intraocular pressure adequately. 

Currently available FDA-approved implants include:

• Ahmed glaucoma implant
• Baerveldt seton
• Ex-PRESS™ mini glaucoma shunt
• Glaucoma pressure regulator
• Krupin-Denver valve implant
• Molteno implant
• Schocket shunt
• iStent Trabecular Micro-Bypass Stent System

Exclusionary Guidelines

• The use of an aqueous shunt for all other conditions, including patients with glaucoma when intraocular pressure is controlled by medications
• Insertion of aqueous shunts that are not FDA approved
• For the iStent Micro Bypass Stent, patients with the following conditions are not appropriate candidates and the insertion of this stent would be considered experimental:
• In children
• In eyes with significant prior trauma
• In eyes with abnormal anterior segment
• In eyes with chronic inflammation
• In glaucoma associated with vascular disorders
• In pseudophakic patients with glaucoma
• In uveitic glaucoma
• In patients with prior glaucoma surgery of any type including argon laser trabeculoplasty
• In patients with medicated intraocular pressure greater than 24 mm Hg
• In patients with unmedicated IOP less than 22 mm Hg nor greater than 36 mm Hg after "washout" of medications
• For implantation of more than a single stent
• After complications during cataract surgery, including but not limited to, severe corneal burn, vitreous removal or vitrectomy required, corneal injuries or complications requiring the placement of an anterior chamber IOL [intraocular lens]
• When implantation has been without concomitant cataract surgery with IOL implantation for visually significant cataract

86305

Basic Benefit and Medical Policy
Measurement of Serum Biomarker Human Epididymis Protein 4 (HE4) is considered experimental. This policy is effective Jan. 1, 2014.

Besse Forest Products

Claims processing for Besse Forest Products, in the Upper Peninsula, will be adding a new health savings account plan to its existing PPO plans, effective Jan. 1, 2014. The group will be offering a two-tier plan:

• Tier 1 — In-network PPO providers
• Tier 2 — Out-of-network providers

The group’s NASCO group number remains 72512. Section codes will be 4000, 4100. Package codes will be 080 and 081. Existing members will not be receiving new ID cards; new members will.

Besse Forest Products now offers this new high-deductible health plan medical with drugs plan, as well as their old PPO medical with drug plans to members. To verify a member’s benefits or eligibility, call 1-800-676-2583.

Charter Township of Hampton

Effective Feb. 1, 2014, Medicare-eligible retirees of the Charter Township of Hampton 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 60494 with suffix 600. You can identify members by the XYL prefix on their ID cards, as you do with those of other Medicare Plus Blue Group PPO plans.

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

Kalamazoo Regional Education Service Agency

Effective Jan. 1, 2014, Kalamazoo Regional Education Service Agency (KRESA) will be joining Western Michigan Health Insurance Pool (WMHIP) on our NASCO system. They will be offering PPO and health savings account (with HEQ) plans to their active enrollees. As a result, these members will be transferring from our MOS system under group number 007034955 to our NASCO system under group number 71565.

Precertification and individual case management are part of their cost containment program.