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 on 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

0245T-0248T

Basic Benefit and Medical Policy
Open treatment of rib fractures using internal fixation

The safety and effectiveness of open reduction and internal
fixation of rib fractures has been established. It is a useful
therapeutic option for patients meeting select criteria. This policy is effective Nov. 1, 2013.

Group Variations
Payable for all groups.

Inclusionary Guidelines
Open reduction and internal fixation for rib fractures is appropriate for patients:

With a confirmed diagnosis of flail chest and paradoxical chest movement and
Inability to be weaned from ventilator (> 5 days post-injury) and
Painful, displaced rib fractures with failure of narcotics or epidural pain catheter to control pain

Exclusionary Guidelines

Unstable cardiopulmonary status
Presence of pulmonary contusion
Severe head injury with increased intracranial pressure
Other severe associated organ injuries that would make general anesthesia unsafe

0330T-0334T

Group Variations
Payable for Federal Employee Program^® members only, effective July 1, 2013.

81321-81323

Basic Benefit and Medical Policy
The safety and effectiveness of genetic testing for a phosphatase and tensin homolog, or PTEN, mutation is established to confirm the diagnosis when a patient displays clinical signs of a PTEN hamartoma tumor syndrome or in a first-degree relative of a proband (typically the individual being studied or reported on) with a known PTEN mutation. It may be considered a useful diagnostic option when indicated.

Genetic testing for a PTEN mutation is considered experimental for all other indications, including, but not limited to, prenatal testing. The peer-reviewed medical literature has not demonstrated the clinical utility of genetic testing for a PTEN mutation for indications not listed in this policy.

This policy is effective Jan. 1, 2014.

Inclusionary Guidelines

Genetic testing for a PTEN mutation to confirm the diagnosis of a PTEN hamartoma tumor syndrome when a patient displays clinical signs of any of the following suspected PTEN hamartoma tumor syndromes (see Policy Description section of the medical policy for detailed criteria):

Bannayan-Riley-Ruvalcaba syndrome
Cowden syndrome
PTEN-related proteus syndrome
Proteus-like syndrome

Genetic testing for a PTEN mutation in a first-degree relative of a proband with a known PTEN mutation.

Exclusionary Guidelines

Prenatal genetic testing for a PTEN mutation
All other indications not listed in the inclusion section

Group Exclusions

Chrysler, Ford, General Motors, Delphi or URMBT
State of Michigan
Michigan Public School Employees Retirement System

A7016

Basic Benefit and Medical Policy
Effective Sept. 1, 2013, procedure code A7016 is now payable. This procedure will pay for all accounts with the durable medical equipment benefit.

Group Variations
Includes Chrysler, Ford, General Motors and URMBT groups.

J3590

Basic Benefit and Medical Policy
Varithena is established as safe and effective for its FDA approved indication for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein system above and below the knee. This policy is effective Nov. 26, 2013.

Varithena™ should be reported with NOC code J3590 until a permanent code is established.

This product is for intravenous use under ultrasound guidance only. Use up to 5 ml per injection and 15 ml per treatment session. S Treatments sessions should be separated by a minimum of five days.

Inclusionary Guidelines

Indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein system above and below the knee.
Liquid or foam sclerotherapy is considered medically necessary as an adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory and perforator veins 2.5 mm or greater in diameter for persons who meet medical necessity criteria for varicose vein treatment and who have previously been treated for incompetence (e.g., reflux) at the saphenofemoral junction or saphenopopliteal junction.

Exclusionary Guidelines

Although sclerotherapy can be used to treat visible subcuticular veins (e.g., spider angiomas, and telangiectasias) less than 2.5 mm in size, these small veins do not cause symptoms and their treatment is considered cosmetic- not payable.

UPDATES TO PAYABLE PROCEDURES

Established procedures
61624, 61630, 61635

Experimental procedures
37184, 37185

Basic Benefit and Medical Policy
Endovascular Procedures for Intracranial Arterial Disease
The safety and effectiveness of intracranial stent placement is considered established as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment is not appropriate and standard endovascular techniques do not allow for complete isolation of the aneurysm; e.g., wide-neck aneurysm (4 mm or more) or sack-to-neck ratio less than 2:1.

Intracranial stent placement is considered experimental in the treatment of intracranial aneurysms except as noted above.

Intracranial percutaneous transluminal angioplasty with or without stenting is considered experimental in the treatment of atherosclerotic cerebrovascular disease.

Endovascular interventions (mechanical embolectomy, angioplasty, stenting) are considered experimental in the treatment of acute stroke.

Criteria has been updated, effective May 1, 2014.

73500, 73510, 73520

Basic Benefit and Medical Policy
Payable to rheumatologists under the PPO Radiology Management Program, effective May 1, 2013.

Federal Employee Program^® and State of Michigan are excluded from the PPO Radiology Management Program.

99495

Procedure code *99495 is not payable, effective Aug. 1, 2014.

This change excludes FEP members.

POLICY CLARIFICATIONS

0310T

Basic Benefit and Medical Policy
Navigated transcranial magnetic stimulation is considered experimental for all purposes, including but not limited to the preoperative evaluation of patients being considered for brain surgery, when localization of eloquent areas of the brain are an important consideration in surgical planning. This policy is effective May 1, 2014.

Established procedures
21120-21123, 21141, 21196, 21198, 21199, 42140, 42145

Experimental procedures
41512, 41530, 42299, S2080

Basic Benefit and Medical Policy
The Obstructive Sleep Apnea and Snoring-Surgical Treatment Policy has been updated. This policy is effective May 1, 2014.

Certain surgical procedures have been established as safe and effective for the treatment of clinically significant obstructive sleep apnea when conservative therapies or CPAP alone have failed. The choice of the procedure should be tailored to the individual patient’s need based on anatomy and etiology.

Inclusionary Guidelines

Uvulectomy or uvulopalatopharyngoplasty for the treatment of clinically significant** obstructive sleep apnea syndrome in adult patients who have not responded to or do not tolerate continuous positive airway pressure
Hyoid suspension, surgical modification of the tongue, or maxillofacial surgery, including mandibular-maxillary advancement in adult patients with clinically significant** OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP
Adenotonsillectomy in pediatric patients with OSA and hypertrophic tonsils and:

AHI or respiratory disturbance index of at least five per hour or
AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems or hyperactivity

**Clinically significant obstructive sleep apnea is defined as failure of conservative treatments for sleep apnea, such as weight loss, modification of the patient's sleep position, medications to relieve nasal obstruction and avoidance of evening alcohol and hypnotics, use of CPAP or oral appliances and polysomnography with:

AHI or RDI greater than or equal to 15 events per hour, or
AHI or RDI greater than or equal to five events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke

Exclusionary Guidelines

Laser-assisted palatoplasty
Midline glossectomy
Palatal stiffening procedures, such as cautery-assisted and injection snoreplasty
Palatal implants
Radiofrequency volumetric tissue reduction of the tongue
Radiofrequency reduction of the palatal tissues (e.g., somnoplasty)
Tongue base suspension (e.g., repose system)
All other minimally invasive surgical procedures not described above

All interventions for the treatment of snoring in the absence of documented OSA.

33999, 93799, A4649

Basic Benefit and Medical Policy
Open Repair of Right Ventricular Outflow Obstruction Using a Pulmonary Bovine Valved Conduit Graft System
The open implantation of a pulmonary bovine valved conduit graft is established for patients meeting specific selection criteria under a humanitarian device exemption. They are useful therapeutic options for these patients when indicated.

This policy is effective May 1, 2014.

Inclusionary Guidelines
Pulmonary bovin-valved conduits (e.g., Contegra) are indicated for implantation into patients less than 18 years of age presenting with one of the following clinical conditions:

Correction or reconstruction of the right ventricular outflow tract in congenital heart malformations (e.g., pulmonary atresia, tetralogy of Fallot, truncus arteriosis, transposition with ventricular septal defect pulmonary stenosis, etc.)
Replacement of a previously implanted but dysfunctional pulmonary homograft or a failed pulmonary prosthesis

Exclusionary Guidelines
Pulmonary bovine-valved conduits are contraindicated for use in the following clinical conditions:

Patients 18 years of age and older needing RVOT-reconstructive surgery, Ross procedure or replacement of dysfunctional pulmonary homograft or failed pulmonary prosthesis
Left heart surgical procedures
If, after the physician assesses the risk-to-benefit ratio, established alternative medical or surgical techniques suggest superior clinical results.

77520,77522, 77523, 77525

Basic Benefit and Medical Policy
The criteria for the Charged-Particle (Proton or Helium Ion) Radiation Therapy policy have been updated. This policy is effective March 1, 2014.

Charged-particle irradiation with proton or helium ion beams may be considered established in the following clinical situations:

Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height
Postoperative therapy (with or without conventional high-energy x-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
In the treatment of pediatric central nervous system tumors.

Charged-particle irradiation with proton beams using standard treatment doses is considered not medically necessary in patients with clinically localized prostate cancer because the clinical outcomes with this treatment have not been shown to be superior to other approaches including intensity-modulated radiation therapy or conformal radiation therapy, yet proton beam therapy is generally more costly than these alternatives.

Other applications of charged-particle irradiation with proton beams are considered experimental. These include, but are not limited to:

Non-small-cell lung cancer at any stage or for recurrence
Pediatric non-central nervous system tumors
Tumors of the head and neck (other than skull-based chordoma or chondrosarcoma)

Inclusionary Guidelines**
Charged-particle irradiation with proton or helium ion beams is established for the following indications:

Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height
Postoperative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II), chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
In the treatment of pediatric (through 21 years of age) central nervous system tumors.

**Effective July 1, 2014, use of PBT may require prior authorization to verify that BCBSM or BCN criteria are met and, where appropriate, to explore the appropriateness of using alternative therapeutic modalities; e.g., IMRT, 3-D conformal radiation therapy). Mail or fax preauthorization requests to

Write:	Preauthorization, Provider Inquiry Services Blue Cross Blue Shield of Michigan P.O. Box 2227 Detroit, MI 48231-2227
Fax:	1-866-311-9603

Exclusions Guidelines

Proton beam therapy for the treatment of prostate cancer is not medically necessary.
All other applications of charged-particle irradiation, including non-small-cell lung cancer at any stage or for recurrence, are considered experimental.
Pediatric non-central nervous system tumors
Tumors of the head and neck (other than skull-based chordoma or chondrosarcoma)
Proton beam therapy for the treatment of macular degeneration or choroidal neovascularization and hemangiomas

78608, 78609, 78811, 78812, 78813

Basic Benefit and Medical Policy
The safety and effectiveness of positron emission tomography scanning have been established. It is a useful diagnostic option for patients meeting patient selection criteria. Inclusionary and exclusionary criteria have been updated, effective May 1, 2014.

This service may be subject to the PPO Radiology Management Program, where applicable.

Inclusionary Guidelines
Positron emission tomography using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be considered established in:

The assessment of selected patients with epileptic seizures who are candidates for surgery or
The diagnosis of chronic osteomyelitis (Note: See Medicare exceptions.)

Exclusionary Guidelines
The use of PET for all other miscellaneous indications is considered experimental for other conditions, including, but not limited to:

Central nervous system diseases

Autoimmune disorders with CNS manifestations, including:

Behçet's syndrome
Lupus erythematosus

Cerebrovascular diseases, including:

Arterial occlusive disease (arteriosclerosis, atherosclerosis)
Carotid artery disease
Cerebral aneurysm
Cerebrovascular malformations (AVM and Moya-Moya disease)
Hemorrhage
Infarct
Ischemia

Degenerative motor neuron diseases, including:

Amyotrophic lateral sclerosis
Friedreich's ataxia
Olivopontocerebellar atrophy
Parkinson's disease
Progressive supranuclear palsy
Shy-Drager syndrome
Spinocerebellar degeneration
Steele-Richardson-Olszewski disease
Tourette's syndrome

Dementias, including: (Note: see Medicare exceptions)

Alzheimer's disease
Multi-infarct dementia
Pick's disease
Frontotemporal dementia
Dementia with Lewy-Bodies
Presenile dementia

Demyelinating diseases, such as multiple sclerosis
Developmental, congenital or inherited disorders, including:

Adrenoleukodystrophy
Down's syndrome
Huntington’s chorea
Kinky-hair disease (Menkes’ syndrome)
Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses

Miscellaneous

Chronic fatigue syndrome
Sick building syndrome
Post-traumatic stress disorder

Nutritional or metabolic diseases and disorders, including:

Acanthocytes
Hepatic encephalopathy
Hepatolenticular degeneration
Metachromatic leukodystrophy
Mitochondrial disease
Subacute necrotizing encephalomyelopathy

Psychiatric diseases and disorders, including:

Affective disorders
Depression
Obsessive-compulsive disorder
Psychomotor disorders
Schizophrenia

Pyogenic infections, including:

Aspergillosis
Encephalitis

Substance abuse, including the CNS effects of alcohol, cocaine, and heroin
Trauma, including brain injury and carbon monoxide poisoning
Viral infections, including:

Acquired immune deficiency syndrome (AIDS)
AIDS dementia complex
Creutzfeldt-Jakob syndrome
Progressive multifocal leukoencephalopathy
Progressive rubella encephalopathy
Subacute sclerosing panencephalitis

Mycobacterium infection
Migraine
Anorexia nervosa
Cerebral blood flow in newborns
Vegetative versus "locked-in" state

Pulmonary diseases

Adult respiratory distress syndrome
Diffuse panbronchiolitis
Emphysema
Obstructive lung disease
Pneumonia

Musculoskeletal diseases

Spondylodiscitis
Joint replacement follow-up

Other

Giant cell arteritis
Vasculitis
Inflammatory bowel disease

81403-81406, 81479, S3800

Basic Benefit and Medical Policy
The Genetic Testing for Amyotrophic Lateral Sclerosis Policy has been updated. This policy is effective May 1, 2014.

Preconception genetic counseling and testing of any genes associated with familial amyotrophic lateral sclerosis are considered established when the test results will impact decisions regarding family planning.

Inclusionary Guidelines
Preconception genetic testing for familial ALS in individuals of reproductive years is indicated when any of the following criteria are met:

A known mutation of any ALS-associated gene exists in a parent or sibling
There are two or more first-degree relatives with ALS of unknown genetic cause

Exclusionary Guidelines

Genetic testing for ALS in individuals not considering conception

84999

Basic Benefit and Medical Policy
Mass spectrometry-based proteomic profiling to determine treatment for non-small-cell lung cancer is considered experimental. There is insufficient evidence in medical literature to demonstrate that the use of this testing results in improved patient clinical outcomes. This policy is effective May 1, 2014.

87535-87539, 87900, 87901, 87903, 87904, 87906

Basic Benefit and Medical Policy
The safety and effectiveness of human immunodeficiency virus genotyping or phenotyping have been established. They may be considered useful diagnostic options when indicated for patients meeting selection criteria. This policy is effective May 1, 2014.

Inclusionary Guidelines (must meet one)

HIV genotyping or phenotyping in patients who (must meet one):

Have active HIV and are on a current treatment regimen, to assist in the selection of active drugs when changing antiretroviral regimens in cases of virologic failure
Have achieved a suboptimal response after the initiation of antiretroviral therapy
Have an acute or recent infection, for the purpose of guiding treatment decisions
Are antiretroviral naïve and are entering treatment
Have been infected with HIV for less than 12 months
Are undergoing the first ART regimen regardless of duration of infection
Are entering pregnancy with detectable HIV RNA in plasma while on therapy
Are pregnant but have not had prior initiation of therapy

Drug susceptibility phenotype prediction using genotypic comparison to a known genotypic/phenotypic database (virtual phenotyping).

Genotyping is typically done first, followed by virtual phenotyping in order to direct therapy. Both genotyping and full phenotyping may be necessary when genotyping and virtual phenotyping fail to provide the necessary information needed to guide therapy.

Exclusionary Guidelines

Routine use of combined genotyping and phenotyping.

E0830, E0941, E1399

Basic Benefit and Medical Policy
The use of pneumatic, autotraction and gravity-dependent (axial spinal unloading) lumbar traction devices are considered experimental in any setting. These devices have not been scientifically demonstrated to be safe and effective for the treatment of low back pain, herniated disc or other indications and have not been shown to improve patient outcomes. This policy is effective May 1, 2014.

Exclusionary Guidelines
Non-established lumbar traction devices include, but are not limited to:

Pneumatic lumbar traction devices (e.g., Saunders Lumbar HomeTrac, Saunders STx, Orthotrac Pneumatic Vest).
Autotraction devices (e.g., the Spinalator Spinalign massage intersegmental traction table, the Arthrotonic stabilizer, the Quantum 400 intersegmental traction table and the Anatomotor)
Axial spinal unloading (gravity-dependent traction) devices (e.g., LTX 3000).
Conventional lumbar traction using a type of pelvic harness attached to pulleys and weights, now considered to be obsolete.

EXPERIMENTAL PROCEDURES

0338T, 0339T

Basic Benefit and Medical Policy
Radiofrequency ablation of the renal sympathetic nerves as a treatment of resistant hypertension is considered experimental. The evidence is insufficient to determine whether radiofrequency ablation of the renal sympathetic nerves improves health outcomes in patients with resistant hypertension. This policy is effective May 1, 2014.

81287

Basic Benefit and Medical Policy
The peer-reviewed medical literature has not demonstrated the validity and clinical utility of MGMT (methyl guanine methyl transferase) promoter methylation testing for prognostic value or as a predictive biomarker for response to treatment with alkylating agents. Therefore, this test is considered experimental. This policy is effective May 1, 2014.

81401, 81403-81407, 81479

Basic Benefit and Medical Policy
Genetic testing for epilepsy is considered experimental. The peer reviewed medical literature has not demonstrated the clinical utility of this testing or its impact on patient outcomes. This policy is effective May 1, 2014.

81401, 81405, 81408

81599

Basic Benefit and Medical Policy
Gene expression analysis to guide management of prostate cancer is considered experimental in all situations. There is insufficient evidence in the peer reviewed medical literature to establish the analytic validity, clinical validity, or clinical utility of this testing. This policy is effective May 1, 2014.

GROUP BENEFIT CHANGES

Covisint Corporation

The Covisint Corporation, group number 71581, joined the Blues, effective April 1, 2014. The members in this group were previously under a Compuware contract.

The group is offering three PPO and two health savings account plans with medical, hearing and prescription drug coverage.

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

Lutheran Church Michigan District Associationn

Effective May 1, 2014, Medicare-eligible retirees of the Lutheran Church Michigan District Association 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 60609, with suffixes 600, 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.

Visteon – Hourly & Salary

Effective June 1, 2014, Visteon hourly and salaried members will have their prescription drug plan with Express Scripts^® and will now be handled through BCBSM. The current medical benefits will not change.

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 2013 American Medical Association. All rights reserved.