Blues highlight medical, benefit policy changes

19281-19288

Basic Benefit and Medical Policy
The safety and effectiveness of radioactive seed localization for nonpalpable breast lesions have been established. It may be considered a useful diagnostic option when indicated, effective July 1, 2014.

Inclusionary Guidelines
Individuals with breast tissue abnormalities identified by mammography or other imaging that are non-palpable or difficult to palpate.

77605, 96446, 96549

Basic Benefit and Medical Policy
The safety and effectiveness of hyperthermic intraperitoneal chemotherapy when used in combination with cytoreductive surgery have been established. It may be considered a useful therapeutic option for patients meeting patient selection criteria, effective May 1, 2013.

Inclusionary Guidelines
The patient must meet all of the following criteria:

• A diagnosis of either pseudomyxoma peritonei, peritoneal carcinomatosis of gastrointestinal origin (except colorectal), or peritoneal mesothelioma has been confirmed by the treating physician.
• The patient must be able to tolerate the extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.
• Peritoneal disease must be potentially completely resectable or could be significantly reduced.
• There must be no metastases to other organs or to the retroperitoneal space.

Exclusionary Guidelines

• A diagnosis of peritoneal carcinomatosis from colorectal cancer.
• Metastatic spread to distant organs outside the peritoneal cavity
• Pulmonary, cardiac, renal, hepatic, central nervous system, metabolic or bone marrow dysfunction
• Active viral, bacterial or fungal infections
• Incomplete cytoreduction >2mm
• Unresectable deep subperitoneal tissue metastasis.

47371, 47380- 47382

Group Variations
The listed surgical procedure codes are now payable for MPSERS when reported on professional claims. Facility claims are already payable.

90281, 90283, 90371, 90376, 90389

Basic Benefit and Medical Policy
Inclusionary Guidelines
Procedure codes *90281, *90283, *90371, *90376 and *90389 are no longer considered payable without cost sharing under National Healthcare Reform preventive services, effective Nov. 1, 2014. These services may be considered payable under the member’s basic group or individual medical benefits.

Established
29868

Experimental
G0428

Basic Benefit and Medical Policy
The effectiveness of meniscal allograft transplants have been established for patients who meet specific criteria. It may be considered a useful therapeutic option when indicated.

Meniscal allograft transplantation has been shown to be safe and effective when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation, osteochondral allografting or osteochondral autografting for focal articular cartilage lesions. It may be considered a useful therapeutic option when indicated.

Other meniscal implants incorporating materials, such as collagen and polyurethane, have not been shown to be an effective treatment for repairing meniscal defects and are considered experimental

This policy is effective July 1, 2014.

Inclusionary Guidelines
Meniscal allograft transplantation is established in patients who have had a prior meniscectomy and have symptoms related to the affected side, when all of the following criteria are met:

• Adult patients should be too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., younger than 55 years)
• Disabling knee pain with activity that is refractory to conservative treatment
• Absence or near absence (more than 50 percent) of the meniscus, established by imaging or prior surgery
• Documented minimal to absent degenerative changes in the surrounding articular cartilage
• Normal knee biomechanics or alignment and stability achieved concurrently with meniscal transplantation

Meniscal allograft transplantation, when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation, osteochondral allografting or osteochondral autografting for focal articular cartilage lesions, has been shown to be safe and effective. 

Exclusionary Guidelines
Use of other meniscal implants incorporating materials, such as collagen and polyurethane, are considered experimental.

81211-81217

Basic Benefit and Medical Policy
The guidelines for the Genetic Testing for Hereditary Breast and/or Ovarian Cancer Policy were reviewed and updated. This policy is effective July 1, 2014.

It is highly recommended that genetic testing should be performed in a setting that has suitably trained health care providers who can give appropriate pre- and post-test counseling and that has access to a Clinical Laboratory Improvement Amendments — licensed laboratory that offers comprehensive mutation analysis.
                      
Note:

• For the purpose of familial assessment, 1st-, 2nd-, and 3rd-degree relatives are blood relatives on the same side of the family (maternal or paternal), such as:
• 1st-degree relatives, which are parents, siblings and children
• 2nd-degree relatives, which are grandparents, aunts, uncles, nieces, nephews, grandchildren and half-siblings
• 3rd-degree relatives, which are great-grandparents, great-aunts, great-uncles, great-grandchildren and first cousins
• For the purpose of familial assessment, aggressive prostate cancer is defined as Gleason score ≥7.
• Testing for Ashkenazi Jewish or other founder mutation(s), if applicable, should be performed first.

Inclusionary Guidelines
Patients with cancer (affected patients):
Genetic testing for BRCA1 and BRCA2 mutations in cancer-affected individuals may be considered appropriate under any of the following circumstances:

• Individual from a family with a known BRCA1 or BRCA2 mutation
• Personal history of breast cancer and ≥1 (one or more) of the following:
• Diagnosed age ≤45 years;
• Two primary breast cancers when the 1st breast cancer diagnosis occurred age ≤50 years;
• Diagnosed age ≤50 years and:
• One or more 1st-, 2nd-, or 3rd-degree relative with breast cancer at any age or
• Unknown or limited family history
• Diagnosed age ≤60 years with a triple negative (ER–, PR–, HER2–) breast cancer
• Diagnosed any age and ≥1 1st-, 2nd-, or 3rd-degree relative with breast cancer diagnosed ≤50 years;
• Diagnosed any age and ≥2 1st-, 2nd-, or 3rd-degree relatives with breast cancer at any age;
• Diagnosed any age and ≥1 1st-, 2nd-, or 3rd-degree relatives with epithelial ovarian/fallopian tube/primary peritoneal cancer;
• Diagnosed any age and ≥2 1st-, 2nd-, or 3rd-degree relatives with pancreatic cancer or prostate cancer (Gleason score ≥7) at any age;
• A 1st-, 2nd-, or 3rd-degree male relative with breast cancer;
• Ethnicity associated with deleterious founder mutations, e.g., Ashkenazi Jewish descent.
• Personal history of epithelial ovarian**/fallopian tube/primary peritoneal cancer
• Personal history of male breast cancer
• Personal history of pancreatic cancer or prostate cancer (Gleason score ≥7) at any age and ≥2 1st-, 2nd-, or 3rd-degree relatives with any of the following at any age. For pancreatic cancer, if Ashkenazi Jewish ancestry, only one additional affected relative is needed.
• Breast cancer
• Ovarian, fallopian tube or primary peritoneal cancer
• Pancreatic or aggressive prostate cancer

** If there is a family history of ovarian cancer, it may not be possible to determine if the pathology was epithelial ovarian cancer, germ cell, or some other type. Since up to 90 percent of ovarian cancers are epithelial in origin, determining the exact cell type is not necessary.

Testing for genomic rearrangements of the BRCA1 and BRCA2 genes for patients who meet criteria for BRCA testing and whose testing for point mutations is negative.

Patients without cancer (unaffected patients):
Testing of unaffected individuals should ideally only be considered when an appropriate affected family member is unavailable for testing.

• Individual from a family with a known BRCA1 or BRCA2 mutation
• A 1st- or 2nd-degree blood relative meeting any criterion listed above for patients with cancer
• 3rd-degree blood relative with breast cancer or ovarian or fallopian tube or primary peritoneal cancer and ≥2 1st-, 2nd- or 3rd-degree relatives with breast cancer (at least one at age 50 years or below) or ovarian, fallopian tube or primary peritoneal cancer

Exclusionary Guidelines

• Patients not meeting any of the above criteria
• Genetic testing for BRCA1 and BRCA2 mutations in minors
• BRCA and BART testing as a screening test for cancer in women in the general population.
• Testing for CHEK2 genetic abnormalities (mutations, deletions, etc.)
• BRCA and BART testing for unaffected individuals of high-risk populations (e.g., Ashkenazi Jewish descendant) who have no relatives with a history of breast, ovarian, fallopian tube or primary peritoneal cancer at any age
• Genetic testing using multi-gene panels, including, but not limited to, BreastNext, OvaNext, BRCAPlus and BROCA tests

Established
81406, 81407

Experimental
81403, 81405

Basic Benefit and Medical Policy
The effectiveness of targeted genetic testing for familial dilated cardiomyopathy has been established. This testing is a useful diagnostic option for patients meeting selection criteria. This policy is effective July 1, 2014.

Inclusionary Guidelines
Targeted genetic testing for familial dilated cardiomyopathy for the LMNA, MYH7, TNNT2 and SCN5A genes is appropriate for:

• Pre-symptomatic individuals (no indications of left ventricular enlargement and dilatation in conjunction with significant systolic dysfunction or symptoms of heart failure) who do not meet the clinical features of idiopathic dilated cardiomyopathy but who have:
• A close relative (i.e., a first- or second-degree relative) with a known genetic mutation for DCM, or
• A close relative (i.e., a first- or second-degree relative) diagnosed with idiopathic DCM by clinical means whose genetic status is unknown or unable to be obtained
• Symptomatic individuals with significant cardiac conduction disease (e.g., first-, second- or third-degree AV block) or who have been diagnosed with DCM and have two or more close relatives diagnosed with idiopathic DCM

In addition to the above:

• The genetic testing should preferably be ordered by a specialist in cardiology or genetics.
• It is strongly recommended that genetic counseling be done in conjunction with genetic testing. The counselor will evaluate medical problems or risks present in a family, analyze and explain an inheritance pattern of any disorders found, provide information about the management and treatment of these disorders and discuss available treatment options with the family or individual.

Exclusionary Guidelines

• Genetic testing for any genes other than the LMNA, MYH7, TNNT2 and SCN5A genes
• Patients not meeting the above selection criteria
• Genetic screening in the general population in absence of symptoms or family history of DCM

93701, 93799

Basic Benefit and Medical Policy
In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart failure utilizing thoracic bioimpedance, inert gas rebreathing, arterial pressure/Valsalva, and implantable direct pressure monitoring of the pulmonary artery is considered experimental. These methods have not been scientifically demonstrated to improve patient clinical outcomes. This policy is effective July 1, 2014.

0334T

Basic Benefit and Medical Policy
Sacroiliac joint fusion for the treatment of mechanical low back pain due to sacroiliac joint syndrome and sacral insufficiency fractures is considered experimental. There is insufficient evidence in medical literature to determine the impact on health outcomes and long-term efficacy. This policy is effective July 1, 2014.

Comau Inc

Comau Inc. will migrate from the Blues’ Michigan Operating System to the NASCO platform under new group number 71587 on Aug. 1, 2014. The group will offer four PPO plans for its medical and surgical benefits, two vision plans, four prescription drug plans, two dental plans and one consumer-directed health plan with a health savings account.

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