Blues highlight medical, benefit policy changes

64566

Basic Benefit Policy
The safety and effectiveness of posterior tibial nerve stimulation for urinary dysfunction have been established. It may be considered a useful therapeutic option when indicated, effective May 1, 2014.

Group Variations
Excludes all auto groups and the UAW Retiree Medical Benefits Trust.

Inclusionary guidelines:
Posterior tibial nerve stimulation is established in patients who meet all of the following criteria:

• There is a diagnosis of urinary frequency, nocturia or urinary urgency.
• Active urinary tract infections and anatomical abnormalities of the lower urinary tract have been excluded as a cause of urinary dysfunction.
• The patient has tried and failed conservative behavioral therapies (e.g., biofeedback, fluid management, pelvic floor exercises) for at least a sufficient duration to fully assess its efficacy.
• There is documented failure or intolerance of pharmacologic treatment (anticholinergic drugs or a combination of an anticholinergic and a tricyclic anti-depressant).
• PTNS treatment consists of 30-minute weekly sessions for 12 treatments.
• For continuation of treatment, patients must report an improvement in symptoms of urinary frequency, nocturia or urinary urgency within the initial six weeks (six sessions) of PTNS treatment.
• After weekly 12 sessions, treatments may continue at a frequency of one per month, up to a total of two years. The two-year time period begins with the initiation of PTNS treatment.

Exclusionary guidelines:

• PTNS is not established for all other indications, including stress and neurogenic incontinence.
• PTNS should be discontinued if symptoms do not improve within the initial six treatment sessions.
• PTNS treatment beyond two years has not been extensively studied. It is, therefore, not established for long-term use.

32664, 64650, 64653, 69676, 64999

Experimental Procedures:
E1399, 97039

Basic Benefit Policy
The safety and effectiveness of hyperhidrosis treatments have been established. They may be considered a useful therapeutic option in specified situations.

Inclusionary guidelines:
Primary focal hyperhidrosis
Treatment of primary hyperhidrosis may be considered established with any of the following medical complications:

• Acrocyanosis of the hands
• History of recurrent skin maceration with bacterial or fungal infections
• History of recurrent secondary infections
• History of persistent eczematous dermatitis in spite of medical treatments with topical dermatologic systemic anticholinergic agents

Refer to the botulinum policy for its use in treating hyperhidrosis.

Secondary gustatory hyperhidrosis
The following treatments would be considered established for the treatment of severe gustatory hyperhidrosis:

• Aluminum chloride 20 percent solution
• Surgical options (for example, tympanic neurectomy) if conservative treatment has failed

Note: A chart addressing focal regions and the established versus experimental treatments is available on Page 3 of the medical policy titled Treatment of Hyperhidrosis, Excluding Botulinum.

Refer to the Botulinum Toxin Type A Injection: Botox™ (J0585), Dysport ™(J0586), Xeomin™ (J0588) policy for its use in treating hyperhidrosis.

Exclusionary guidelines:
The following treatment is considered experimental as a treatment for severe gustatory hyperhidrosis, including, but not limited to: Iontophoresis.

The treatment of hyperhidrosis is not covered in the absence of functional impairment or medical complications.

J3490

Basic Benefit Policy
Effective Sept. 28, 2014, the Food and Drug Administration-approved Iluvien™ (fluocinolone acetonide) will be covered under not-otherwise-clasified code J3490 for the FDA-approved indication of diabetic macular edema. The national drug code is 68611-0190-02.

Iluvien (fluocinolone acetonide) contains a corticosteroid and is indicated for the treatment of diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.

Established Procedures:
0191T, 66180, 66183, 66982, 66983, 66984

Experimental Procedures:
0123T, 0253T, 0376T

Basic Benefit 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.

Implantation of a single FDA-approved microstent in conjunction with cataract surgery may be considered established in patients with mild to moderate open-angle glaucoma currently being treated with ocular hypotensive medication. Inclusionary criteria have been updated. This policy is effective Jan. 1, 2015.

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

Currently available FDA-approved shunts include:

• Ahmed glaucoma implant
• Baerveldt seton
• Ex-PRESS™ mini glaucoma shunt
• Glaucoma pressure regulator
• Krupin-Denver valve implant
• Molteno implant
• Schocket shunt

Implantation of a single FDA-approved microstent in conjunction with cataract surgery may be considered established in patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication. The only FDA-approved stent system is the 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 intraocular lens
• When implantation has been without concomitant cataract surgery with IOL implantation for visually significant cataract
• The implantation of more than one iStent per eye; further clinical trials are needed to validate the effectiveness of multiple stents.

Established Procedures:
93797, 93798

Experimental Procedure:
S9472

Basic Benefit Policy
Short-term outpatient Phase II cardiac rehabilitation is established as safe and effective, and is an accepted standard therapy in patients with a history of specific cardiac conditions or procedures.

Cardiac rehabilitation must be a physician-supervised program that furnishes a prescribed exercise program, cardiac risk factor modification that includes education, counseling and behavioral intervention, as well as psychosocial assessment and outcomes assessment. This policy is effective Jan. 1, 2015. 

Inclusionary Guidelines
Must meet all:

• Phase II cardiac rehabilitation
• Member must be medically stable and able to tolerate exercise for 20 to 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

0347T, 0348T, 0349T, 0350T

Basic Benefit Policy
Radiostereometric analysis is considered experimental. It has not been scientifically demonstrated to improve patient clinical outcomes. This policy is effective Jan.  1, 2015.

84999, 81599

Basic  Benefit Policy
The peer-reviewed medical literature has not demonstrated the clinical utility of cardiovascular risk panels (other than simple lipid panels), consisting of multiple individual biomarkers to assess cardiac disease risk. Therefore, the service is considered experimental. This policy is effective Jan. 1, 2015.

Alternative Services Inc.

Alternative Services Inc., group number 71703, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2015. The group offers four PPO plans with medical-surgical benefits and three prescription drug plans.

Member ID cards will show alpha prefix ALS.

Bedrock Group LP

Bedrock Group LP, group number 71707, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2015. The company has changed its name from Bedrock Manufacturing Company to Bedrock Group.  It will offer two PPO plans with medical-surgical benefits, two prescription drug plans and a consumer-directed health plan.

Member ID cards will show alpha prefix BPW.

Christian Financial Credit Union

Effective Jan. 1, 2015, Medicare-eligible retirees of the Christian Financial Credit Union 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 60816 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.

City of Dearborn Heights

Effective Jan. 1, 2015, Medicare-eligible retirees of the City of Dearborn Heights 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 60764 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 PPO plan, go to bcbsm.com/provider/ma.

City of Southgate

Effective Jan. 1, 2015, Medicare-eligible retirees of the City of Southgate 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 60861 with suffix 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.

County of Marquette

Effective Jan. 1, 2015, Medicare-eligible retirees of the County of Marquette 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 44650 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.

Kalamazoo County Government

Effective Jan. 1, 2015, Medicare-eligible retirees of Kalamazoo County Government 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 60858 with suffixes 600, 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.

UAW retirees of Daimler Truck North America

Effective Jan. 1, 2015, Medicare-eligible retirees of UAW Retirees of Daimler Truck North America will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue^SM Group PPO, for their medical and surgical benefits. The group number is 60911 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.

Henniges Automotive

Effective Jan. 1, 2015, Henniges Automotive, group number 71325,  is adding:

• A new consumer-directed health plan with a health savings account
• An alternative network
• Prescription drugs benefits (adding telemedicine). The group already offers a PPO plan with medical-surgical benefits.

Member ID cards will show the following alpha prefixes:

• PPO coverage - MZP
• Alternate network - HNX

McKechnie Vehicle Components USA Inc.

McKechnie Vehicle Components USA Inc., group number 71706, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2015. The group will offer PPO plans with medical-surgical benefits and prescription drug plans.

Member ID cards will show alpha prefix MVI.