Blues highlight medical, benefit policy changes

J0178

Basic Benefit and Medical Policy
Aflibercept, 1 mg injection is now payable for diabetic macular edema.

Q0138

Basic Benefit and Medical Policy

Feraheme^® (ferumoxytol) is now payable under the Physician Office Infusion Therapy, Home Infusion and Outpatient Infusion Therapy Programs. 

Feraheme is an iron replacement product indicated for the treatment of iron deficiency anemia in adult patients with chronic kidney disease. This benefit is dated back to the effective date the U.S. Food and Drug Administration approved Feraheme as an infusion, June 1, 2013.

Group Variations
Payable for groups that cover these benefits.

When this drug is reported as physician office infusion therapy, it will be payable for all groups except Ford Blue Preferred Plus^SM.

When reported as IV therapy in the outpatient department of a hospital or in the home, this change will be payable for all auto groups (hourly and salaried segments) and the UAW Retiree Medical Benefits Trust.

No code

Basic Benefit and Medical Policy

Blue Cross Medical Policy reviewed the Oral Surgery policy and updated the inclusionary and exclusionary guidelines. This policy is effective May 1, 2015.

Inclusionary Guidelines
Some procedures may be considered medical-surgical rather than dental. Examples of these procedures may include:

• Excision of a neoplasm
• Biopsy of an oral lesion
• Cyst biopsy when the cyst is primary or otherwise associated with the crown of the tooth
• Marsupialization of ranula (sublingual salivary gland retention cyst)
• Removal of midline palatal and lingual mandibular tori other than when done for the preparation for dentures (This does not include alveolar ridge irregularities or multiple exostoses of the mandible and maxilla.)
• Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth, including fractures, wounds and complicated suturing
• Extra-oral incision and drainage of an abscess or cellulitis
• Reductions of dislocations
• Surgery for osteomyelitis
• Foreign body removal
• Surgery on the temporomandibular joint, including those to treat intracapsular disorders, which can include arthrocentesis, arthroplasty or condylotomy
• Reconstruction of the jaw
• Correction of jaw deformities that have an associated functional problem
• Oral surgery to address complications related to radiation therapy of the head and neck (for example, bone loss, infection)
• Cleft lip or palate

Exclusionary Guidelines

• Routine dental procedures (for example, extraction of teeth, gingivectomy)
• Surgical preparation for dentures (alveoloplasty)
• Neoplasm biopsies associated with extractions, endodontic or periodontal treatment
• Excision of alveolar ridge irregularities or multiple exostoses of the mandibular and maxillary alveolus
• Intra-oral incision and drainage of abscess or cellulitis
• Surgical placement of implant body-endosteal implant, prefabricated and custom abutment-including placement

Basic Benefit and Medical Policy
A home or portable study is reimbursed on a per-episode basis.  One episode covers up to seven consecutive days of testing and will be reimbursed as a single test.

43644, 43645, 43770-43775, 43842, 43843, 43845-43848, 43886, 43887, 43888, 43999, 44130, 96101-96103, S2083

Basic Benefit and Medical Policy
Blue Cross Medical Policy reviewed the Bariatric Surgery policy and updated the inclusionary and exclusionary guidelines.This policy is effective May 1, 2015.

The safety and effectiveness of laparoscopic and open gastric restrictive procedures including, but not limited to, gastric-band, Roux-en-Y, gastric bypass, sleeve gastrectomy and biliopancreatic diversion have been established. They may be considered useful therapeutic options when specified criteria are met.

Note: Please check web-DENIS for BCBSM-specific plan criteria. Please check BCN benefit page at the end of the policy for BCN-specific plan criteria.

Inclusionary Guidelines
The surgical procedures for severe obesity, including sleeve gastrectomy, are considered established treatment options if all the following criteria are met:

• The patient has a BMI greater than 40 or a BMI greater than 35 with one or more comorbid conditions, including, but not limited to:
• Degenerative joint disease (including degenerative disc disease)
• Hypertension
• Hyperlipidemia, coronary artery disease
• Presence of other atherosclerotic diseases
• Type 2 diabetes mellitus
• Sleep apnea
• Congestive heart failure 
• Bariatric surgery may be indicated for patients 18 to 60 years old. Requests for bariatric surgery for patients younger than 18 should include documentation that the primary care physician has addressed the risk of surgery on future growth, the patient's maturity level and the patient’s ability to understand the procedure and comply with postoperative instructions, as well as the adequacy of family support.  Patients older than 60 may be considered if it is documented in the medical record that the patient’s physiologic age and comorbid conditions result in a positive risk-benefit ratio.
• The patient has been clinically evaluated by an M.D. or D.O. (or their authorized delegate, such as a physician assistant). The physician has documented failure of nonsurgical management, including a structured, professionally supervised (physician or nonphysician) weight loss program for a minimum of:
• Six full, consecutive months (180 days) within the last four years prior to the recommendation for bariatric surgery, for BCBSM patients
• Six full, consecutive months (180 days) within the last two years prior to the recommendation for bariatric surgery, for BCN patients 
• The six full consecutive month (180 days) weight loss program listed above is waived for super morbidly obese individuals who have a BMI greater than or equal to 50. Documentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.
• Documentation that the primary care physician and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all postsurgical requirements.
• A psychological evaluation must be performed as a presurgical assessment by a contracted mental health professional in order to establish the patient’s emotional stability, ability to comprehend the risk of surgery and to give informed consent, and ability to cope with expected postsurgical lifestyle changes and limitations. Such psychological consultations may include one unit total of psychological testing for purposes of personality assessment (for example, the MMPI-2 or adolescent version, the MMPI-A).
• The physician needs to be aware and follow up with individuals who have had gastric surgery for any long-term complications.
• In cases where a revision of the original procedure is planned because of failure due to anatomic or technical reasons (for example, obstruction, staple dehiscence, etc.), or excessive weight loss of 20 percent or more below ideal body weight, the revision is determined to be medically appropriate without consideration of the initial preoperative criteria. The medical records should include documentation of:
• The date and type of the previous procedure
• The factors that precipitated the failure or the nature of the complications from the previous procedure that necessitate the takedown
• If the indication for the revision is a weight gain or a failure of the patient to lose a desired amount of weight due to patient noncompliance, then the patient must requalify for the subsequent procedure and meet all of the initial preoperative criteria.

Exclusionary Guidelines
The following surgical procedures are considered experimental because their safety or effectiveness have not been proven:

• Gastric bypass using a Billroth II type of anastomosis, also known as mini gastric bypass
• Biliopancreatic bypass without duodenal switch
• Long-limb gastric bypass procedure (greater than 150 cm)
• Stomach stapling
• Endoscopic or endoluminal procedures (including but not limited to insertion of the StomaphyX™ device, insertion of a gastric balloon, endoscopic gastroplasty, or use of an endoscopically placed duodenojejunal sleeve) as a primary bariatric procedure or as a revision procedure, (such as to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches)
• Any bariatric surgery for patients with type 2 diabetes who have a BMI of less than 35
• Gastric bypass using a Billroth II type of anastomosis (mini-gastric bypass)
• Laparoscopic gastric plication
• Vagus nerve blocking (See separate policy, “Vagus Nerve Blocking for Morbid Obesity.”)