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February 2015
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:
- Log in to web-DENIS.
- 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 |
77301, 77338, 77385, 77386, 77387 |
Medical Policy
Intensity modulated radiation therapy of the breast and lung
Breast cancer:
Intensity-modulated radiotherapy may be considered established as a technique to deliver whole-breast irradiation in patients receiving treatment for left-sided breast cancer after breast-conserving surgery when all the following conditions have been met:
- Significant cardiac radiation exposure cannot be avoided using alternative radiation techniques.
- IMRT dosimetry demonstrates significantly reduced cardiac target volume radiation exposure.
IMRT may be considered established in individuals with large breasts when treatment planning with three-dimensional conformal results in hot spots (focal regions with dose variation greater than 10 percent of target) and the hot spots are able to be avoided with IMRT.
IMRT of the breast is considered experimental as a technique of partial-breast irradiation after breast-conserving surgery.
IMRT of the chest wall is considered experimental as a technique of postmastectomy irradiation.
Lung cancer:
IMRT may be considered established as a technique to deliver radiation therapy in patients with lung cancer when all of the following conditions are met:
- Radiation therapy is being given with curative intent
- 3D conformal will expose >35 percent of normal lung tissue to more than 20 Gy dose-volume (V20)
- IMRT dosimetry demonstrates reduction in the V20 to at least 10 percent below the V20 that is achieved with the 3D plan (eg, from 40 percent down to 30 percent or lower)
IMRT is considered not medically necessary as a technique to deliver radiation therapy in patients receiving palliative treatment for lung cancer.
IMRT is not medically necessary for the treatment of breast or lung cancer for all indications not meeting the criteria above.
This policy became effective Jan. 1, 2015. |
77301, 77338, 77385, 77386, 77387 |
Medical Policy
Intensity-modulated radiation therapy of the prostate
Intensity-modulated radiotherapy may be considered established in the treatment of localized prostate cancer at radiation doses of 75 to 80 Gy.
IMRT is considered experimental for the treatment of prostate cancer when the above criteria are not met. This policy became effective Jan. 1, 2015. |
| UPDATES TO PAYABLE PROCEDURES |
76376 |
Payment Policy
As of June 1, 2014, this procedure code became payable to cardiologists under the PPO Radiology Management Program . |
| POLICY CLARIFICATIONS |
75571-75574 |
Group Variations
Chrysler bargaining and non-bargaining member are allowing payment of computed tomography of the heart, under procedure codes *75572, *75573 and *75574, which can be reported with the corresponding revenue code 0359.
Procedure code *75571 is considered experimental.
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77301, 77338, 77385, 77386, 77387 |
Medical Policy
Intensity-modulated radiation therapy of the abdomen and pelvis
Intensity-modulated radiation therapy may be considered established as an approach to delivering radiation therapy for patients with cancer of the anus or anal canal.
When dosimetric planning with standard 3-D conformal radiation predicts that the radiation dose to an adjacent organ would result in unacceptable normal tissue toxicity, intensity-modulated radiation therapy may be considered established for the treatment of cancer of the abdomen and pelvis, including, but not limited to:
- stomach (gastric)
- hepatobiliary tract
- pancreas
- rectal locations
- gynecologic tumors (including cervical, endometrial and vulvar cancers)
IMRT would be considered experimental for all other uses in the abdomen and pelvis.
This policy became effective Jan. 1, 2015.
Inclusions
- As an approach to delivering radiation therapy for patients with cancer of the anus or anal canal
- For the treatment of cancer of the abdomen and pelvis when dosimetric planning with standard 3-D conformal radiation predicts that the radiation dose to an adjacent organ would result in unacceptable normal tissue toxicity
Exclusions
- All other indications are considered not medically necessary.
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77301, 77338, 77385, 77386, 77387 |
Basic Benefit Policy
Intensity-modulated radiation therapy may be considered established for the treatment of head and neck cancers.
Intensity-modulated radiation therapy may be considered established for the treatment of thyroid cancers in close proximity to organs at risk (esophagus, salivary glands and spinal cord) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue tolerance.
Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above.
This policy has been updated, effective Jan. 1, 2015. |
81220, 81221, 81222, 81223, 81224, 88299
Note: The procedure codes listed above may not be covered by all contracts or certificates. Please consult customer or provider inquiry resources to verify coverage. |
Medical Policy
Genetic testing for cystic fibrosis
The inclusionary and exclusionary guidelines have been updated for the genetic testing for cystic fibrosis medical policy. This change became effective March 1, 2014.
Inclusions:
- Individuals planning pregnancy who have a family history of CF and the reproductive partners of those with CF.
- The prenatal population and those in the early stages of pregnancy when the test results will be used to make informed decisions regarding childbearing or a need for fetal diagnosis
- Individuals who have not undergone newborn screening, have an inconclusive sweat chloride test and there remains a suspicion of CF, and when the testing results in a definitive plan of patient management
- Diagnostic testing in male infertility due to congenital bilateral absence of the vas deferens and carrier testing of their partners
- Prenatal ultrasound findings that indicate an increased risk for CF (e.g., echogenic bowel or dilated loops of bowel)
- G551D mutation testing in patients with cystic fibrosis, six years of age and older, for treatment with Kalydeco™.
Genetic testing should be performed in conjunction with appropriate pre- and post-test genetic counseling.
Exclusions:
- Complete analysis of the CFTR gene by DNA sequencing is not appropriate for routine carrier screening.
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83516**, 86343***
** payable for other indications
***not payable effective 2/1/2014 |
Basic Benefit Policy
The safety and effectiveness of selected allergy testing and immunotherapy treatment of allergies have been established.
Updates have been made to the exclusionary guidelines, published in July 2013, and became effective Feb. 1, 2014.
Group Variations:
An FEP claims will be sent to Washington, D.C., offices for consideration
Exclusionary Guidelines:
Additions:
- Leukocyte histamine release test
- Antigen leukocyte antibody test
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| EXPERIMENTAL PROCEDURES |
90620 |
Basic Benefit Policy
Bexsero®, a two-dose schedule intramuscular Serogroup B meningococcal recombinant protein and outer membrane vesicle vaccine, has not received approval for licensing by the U.S. Food and Drug Administration; therefore, it is considered experimental. This policy is effective Feb. 1, 2015. |
| GROUP BENEFIT CHANGES |
City of Eastpointe |
Effective Feb. 1, 2015, Medicare-eligible retirees of the City of Eastpointe will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60939 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. |
City of Southgate, Options 3 and 4
|
Effective Feb. 1, 2015, Medicare-eligible retirees of the City of Southgate Options 3 and 4 will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60861 with suffixes 604 and 605. 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. |
Upper Peninsula Power Company |
Effective Feb. 1, 2015, Medicare-eligible retirees of the Upper Peninsula Power Company will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60946 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. |
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