Billing chart: Blues highlight medical, benefit policy changes

J3490

Basic benefit and medical policy

OTIPRIO™ (ciprofloxacin) is covered for FDA-approved indications

Effective Dec. 10, 2015, OTIPRIO™ (ciprofloxacin) is covered for FDA-approved indications. OTIPRIO (ciprofloxacin) should be reported with code J3490 until a permanent code is established. Pharmacy doesn’t require preauthorization of this drug.

31295, 31296, 31297

Basic benefit and medical policy

Catheter-based inflatable device for treatment of chronic sinusitis

The safety and effectiveness of the use of a catheter-based inflatable device (balloon ostial dilation) for the treatment of chronic sinusitis have been established, effective March 1, 2016. It may be considered a useful therapeutic option when indicated.

Basic benefit policy group variations
This change doesn’t apply to Michigan Public School Employees Retirement System members.

Inclusions

• Documentation of chronic rhinosinusitis greater than three months
• Documented failure of medical therapy greater than three months demonstrated by persistent upper respiratory symptoms despite treatment consisting of all the following:
• Minimum of two different antibiotics
• Trial of steroid nasal spray
• Trial of antihistamine nasal spray or decongestant
• Radiological evidence, in the sinus to be dilated, of at least one of the following:
• Air fluid levels
• Mucosal thickening
• Opacification
• Nasal polyposis

Exclusions

• Ciliary dysfunction
• Cystic fibrosis
• Sinonasal tumors or obstructive lesions
• Severe/gross polypoid disease
• Adolescent or child with incomplete bony development

Balloon sinus ostial dilation used as an adjunct during functional endoscopic sinus surgery, or FESS, is considered integral to the primary FESS procedure and not separately reimbursable.

0042T

Basic benefit and medical policy

Computed tomography-based perfusion imaging

Computed tomography-based perfusion imaging may be considered established to select patients with stroke for mechanical embolectomy, effective May 1, 2016.
CT-based perfusion imaging of the brain is considered experimental for all other indications. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Payment policy
This procedure is excluded from the radiology management program and doesn’t require preauthorization.

Inclusions
CT-based perfusion imaging to select patients with stroke for mechanical embolectomy.

Exclusions
CT-based perfusion imaging of the brain for all other indications not specified under the inclusions.

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

**Used for open sleeve gastrectomy

Non-covered: 43999***

*** When used to indicate any of the following procedures:

• Loop gastric bypass gastroplasty, also known as mini-gastric bypass
• Stomach stapling

Basic benefit and medical policy

Laparoscopic, open gastric restrictive procedures
The safety and effectiveness of laparoscopic and open gastric restrictive procedures, including 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.

Exclusionary criteria have been updated, effective July 1, 2016.

Inclusions
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 of greater than 35 with one or more co-morbid conditions including:
• Degenerative joint disease (including degenerative disc disease)
• Hypertension
• Hyperlipidemia, coronary artery disease
• Presence of other atherosclerotic diseases
• Type II 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 doctor 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’s documented in the medical record that the patient’s physiologic age and co-morbid conditions result in a positive risk-to-benefit ratio.
• The patient has been clinically evaluated by an M.D. or D.O. (or their authorized delegate [e.g., physician assistant, etc.]).  The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight-loss program for a minimum of:
• Six full, consecutive months (180 days) within the last four years before the recommendation for bariatric surgery (for Blue Cross patients. Or six full, consecutive months (180 days) within the last two years before the recommendation for bariatric surgery (for Blue Care Network patients).
• The six full, consecutive month (180 days) weight-loss program listed above is waived for super morbidly obese individuals who have a BMI equal to or greater than 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 doctor and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post-surgical requirements.
• A psychological evaluation must be performed as a pre-surgical assessment by a contracted mental health professional 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 (e.g., 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 (e.g., 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 mandate (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 non-adherence, then the patient must qualify for the subsequent procedure and meet all of the initial preoperative criteria.

Exclusions
The following surgical procedures are considered experimental because their safety or effectiveness has 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 (i.e., greater than 150 centimeters)
• Stomach stapling
• Endoscopic or endoluminal procedures (including 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, (e.g., 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
• Laparoscopic gastric plication
• Vagus nerve blocking (see separate policy, “Vagus Nerve Blocking for Morbid Obesity”)
• Single anastomosis duodeno-ileal bypass with sleeve gastrectomy

90867, 90868, 90869

Basic benefit and medical policy

Transcranial magnetic stimulation of the brain

Transcranial magnetic stimulation of the brain has been established. It may be a useful treatment option in specified situations.

Inclusionary criteria have been updated, effective July 1, 2016.

Inclusions
Note: Transcranial magnetic stimulation must be administered by an approved U.S. Food and Drug Administration cleared device for the treatment of major depressive disorder, or MDD, according to specified stimulation parameters, five days a week for six weeks (total of 30 sessions), followed by a three-week taper of three transcranial magnetic stimulation treatments in one week, two transcranial magnetic stimulation treatments the next week and one transcranial magnetic stimulation treatment in the last week.

Must meet all of the following:

• The member is 18 to 70 years old.
• A urine drug screen is obtained if indicated by current clinical, history or a high degree of clinical suspicion.
• Has a confirmed diagnosis of severe major depressive disorder (single or recurrent episodes) without psychosis measured by evidence-based scales such as Beck Depression Inventory (score 30-63), Zung Self-Rating Depression Scale (>70), PHQ-9 (>20) or Hamilton Depression Rating Scale (>20)
• At least one of the following:
• Medication treatment resistance during the current depressive episode evidenced by  each of the following:
• Lack of a clinically significant response to four trials of psychopharmacologic agents. Trial criteria is six weeks of maximal FDA recommended dosing or maximal tolerated dose of medication with objectively measured evaluation at initiation and during the trial showing no evidence of response (i.e., less than 50 percent reduction of symptoms or scale improvement). At least two trials should be
• Two single agent trials of antidepressants of different classes
• Two augmentation agent trials with different classes of augmenting agents using either or both of the agents in the above single agent trials
• The patient is unable to tolerate a therapeutic dose of medications.  Intolerance is defined as severe somatic or psychological symptoms that can’t be modulated by any means, including additional medications to ameliorate side effects. Examples of somatic side effects include persistent electrolyte imbalance, pancytopenia, severe weight loss, poorly controlled metabolic syndrome or diabetes, as a result of the medication. Examples of psychological side effects of the medication would be suicidal-homicidal thinking or attempts, impulse dyscontrol.
  
  Note: A trial of less than one week of a specific medication wouldn’t be considered a qualifying trial to establish intolerance.
• Electroconvulsive therapy wouldn’t be clinically superior to transcranial magnetic stimulation (e.g., in cases with psychosis, acute suicidal risk, catatonia or life-threatening inanition rTMS should not be utilized)

• A trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms  (e.g., Becks Depression Inventory, Zung Self-Rating Depression Scale, PHQ-9, or Hamilton Depression Rating Scale)
• The following conditions are continuously present in the rTMS treatment setting during treatment:
• Treatment must be by a board-certified psychiatrist, trained in this therapy
• An attendant trained in basic cardiac life support, or BCLS, and  the management of complications such as seizures, as well as the use of the equipment must be present at all times
• Presence of adequate resuscitation equipment including, for example, suction and oxygen
• The facility must maintain awareness of response times of emergency services (either fire/ambulance or code team), which should be available within five minutes. These relationships are reviewed on at least a one-year basis and include mock drills.

Requests for repeat rTMS therapy in patients who have attained remission subsequent to initial rTMS therapy and experienced relapse will be reviewed for individual consideration.

Exclusions

• All other behavioral health, neuropsychiatric or medical conditions (e.g., anxiety disorders, mood disorders, schizophrenia, Alzheimer’s, dysphagia, seizures)
• Pregnancy
• Maintenance treatment
• Presence of psychosis in the current episode
• Seizure disorder or any history of seizure, except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence
• Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 centimeters from the TMS magnetic coil or other implanted metal items, including a cochlear implant, implanted cardioverter defibrillator, pacemaker, vagus nerve stimulator, or metal aneurysm clips or coils, staples, or stents

Note: Dental amalgam fillings aren’t affected by the magnetic field and are acceptable for use with TMS.

• If the patient or, when indicated, the legal guardian is unable to understand the risk and benefits of rTMS and provide informed consent
• Presence of a medical or co-morbid psychiatric contraindication to rTMS
• Patient lacks a suitable environmental, social or professional support system for post-treatment recovery.
• There isn’t a reasonable expectation that the patient will be able to adhere to post-procedure recommendations.

Note: Caution should be exercised in any situation where the patient’s seizure threshold may be decreased.  Examples include:

• Presence in the bloodstream of a variety of agents, including tricyclic antidepressants, clozapine, antivirals, theophylline, amphetamines, PCP, MDMA, alcohol and cocaine as these present a significant risk
• Presence of the following agents, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, some antipsychotics, chloroquine, some antibiotics and some chemotherapeutic agents as they present a relative risk and should be considered when making risk-benefit assessments

Withdrawal from alcohol, benzodiazepines, barbiturates and chloral hydrate also present a strong relative hazard.

S8930, 97813, 97814, E1399, 97139, 63650, 64555, 99070, L8680

Basic benefit and medical policy

Cranial electrotherapy is experimental

Cranial electrotherapy (also known as cranial electrostimulation therapy, or CES) and electrical stimulation of auricular acupuncture points are experimental. These therapies haven’t been scientifically demonstrated to be as effective as conventional treatment. The policy was reviewed and updated, effective July 1, 2016.

21120, 21121, 21122,  21123, 21141, 21196, 21198, 21199, 42140, 42145

Experimental:

Basic benefit and medical policy

Obstructive sleep apnea surgical procedures

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

Exclusionary criteria have been updated, effective July 1, 2016.

Inclusions

• Uvulectomy or uvulopalatopharyngoplasty for the treatment of clinically significant** obstructive sleep apnea syndrome in adult patients who haven’t responded to or don’t tolerate continuous positive airway pressure, or CPAP
• 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 haven’t responded to or don’t tolerate CPAP
• Adenotonsillectomy in pediatric patients with OSA and hypertrophic tonsils and one of the following:
• AHI or respiratory disturbance index, or RDI, of at least five per hour
• 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 one of the following:

• AHI or RDI greater than or equal to 15 events per hour
• 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

Exclusions

• Implantable hypoglossal nerve stimulators
• 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 (i.e., somnoplasty)
• Tongue base suspension (i.e., Repose system)
• All other minimally invasive surgical procedures not described above
• All interventions for the treatment of snoring in the absence of documented OSA

Established: 27415, 27416, 28446
29866, 29867

Basic benefit and medical policy

Autografts and allografts in the treatment of focal articular cartilage lesions

The criteria have been updated for the autografts and allografts in the treatment of focal articular cartilage lesions policy. This policy is effective July 1, 2016.

The safety and effectiveness of osteochondral allografting and autografting for defects of the knee have been established. It’s a useful therapeutic option for patients meeting specific patient selection criteria. 

Osteochondral allografting
The safety and effectiveness of osteochondral allografting to repair large (e.g., 10cm2) full-thickness chondral defect of the knee caused by acute or repetitive trauma have been established. It’s a useful therapeutic option for selected patients.

Osteochondral allografting for all other joints (other than the knee) is experimental. It hasn’t been shown to improve patient outcomes better than conventional treatment.

Osteochondral autografting
The safety and effectiveness of osteochondral autografting, using one or more cores of osteochondral tissue, have been established for the treatment of symptomatic full-thickness cartilage defects of the knee caused by acute or repetitive trauma in patients who have had an inadequate response to a prior surgical procedure, when the inclusionary criteria are met.

Osteochondral autografting for all other joints, including talar, and any indications other than those listed above, is considered experimental. Treatment of focal articular cartilage lesions with autologous or allogeneic minced cartilage is considered experimental.
 
Inclusions

• For osteochondral allografting: This procedure is appropriate for patients with large full-thickness chondral defect of the knee caused by acute or repetitive trauma in patients

• For osteochondral autografting: This procedure is appropriate for patients with full-thickness chondral defect of the knee caused by acute or repetitive trauma in patients who have had an inadequate response to a prior surgical procedure. In addition, all of the following criteria must be met:
• Patient age:
• Adolescent patients should be skeletally
  mature with documented closure of growth plates (e.g., 15 or older).
• 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).
• Focal, full-thickness (grade III or IV) unipolar lesions on the weight-bearing surface of the femoral condyles, trochlea or patella that are between 1 and 2.5 cm² in size
• Documented minimal to absent degenerative changes in the surrounding articular cartilage (outerbridge grade II or less) and normal-appearing hyaline cartilage surrounding the border of the defect
• Normal knee biomechanics or alignment and stability achieved concurrently with osteochondral grafting

Exclusions

• Osteochondral allografting or autografting for all other joints, including shoulder, elbow, talar and any indications other than those listed above is considered experimental.
• Treatment of focal articular cartilage lesions with autologous or allogenic minced cartilage

Established: 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, 95056, 95070, 95071, 95076, 95079

Specified immunotherapy codes: 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95133, 95134, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180

Specified laboratory codes: 82785, 86001, 86003, 86005

Basic benefit and medical policy

Allergy testing and immunotherapy

The safety and effectiveness of selected allergy testing and immunotherapy treatment of allergies have been established. They may be considered useful diagnostic and therapeutic options when indicated. This policy is effective July 1, 2016.

Inclusions

Allergy testing:

• Bronchial challenge tests
• Direct skin test (percutaneous [scratch, prick or puncture] or intracutaneous [intradermal])
• Double-blind food challenge test
• Patch test (application test)
• Photo patch test
• Specific IgE in vitro tests (radioallergosorbent test, or RAST; multiple-antigen simultaneous test, or MAST; fluoro-allergosorbent testing, or FAST; enzyme-linked immunosorbent assay, or ELISA; ImmunoCAP)
• Total serum IgE concentration
• Serial end point titration (SET or Rinkel method) when there’s a high likelihood for a severe allergic reaction to specific agents such as antibiotics, nuts or other high-risk allergens

Immunotherapy treatments: Appropriate in patients with demonstrated allergic hypersensitivity that can’t be managed by medications or avoidance.

Note: Injections of airborne insect venom allergens should be prepared individually for each patient.

Exclusions

Allergy testing:

• Antigen leukocyte cellular antibody, or ALCAT, automated food allergy testing (also see separate JUMP policy titled “Antigen Leukocyte Antibody Test”)
• Applied kinesiology or Nambudripad’s allergy elimination test, or NAET (i.e., muscle strength testing or measurement after allergen ingestion)
• Anti-Fc Epsilon receptor antibodies
• Anti-IgE receptor antibody testing
• Blood, urine or stool micro-nutrient assessments
• Candidiasis test
• Chemical analysis of body tissues (e.g., hair)
• Chlorinated pesticides (serum)
• Clifford materials reactivity testing
• Complement (total or components)
• Complement antigen testing
• Conjunctival challenge test (ophthalmic mucous membrane test)
• C-reactive protein
• Cytokine and cytokine receptor assay
• Cytotoxic food tests
• Cytotoxic testing for environmental or clinical ecological allergy testing (Bryans test, ACT)
• Direct nasal mucous membrane test
• Electrodermal testing or electro-acupuncture
• Electromagnetic sensitivity syndrome/disorder (allergy to electricity, electro-sensitivity, electrohypersensitivity and hypersensitivity to electricity)
• Environmental cultures and chemicals
• Eosinophil cationic protein, or ECP, test
• Food immune complex assay, or FICA, or food allergenic extract immunotherapy
• General  immune system assessments
• Immune complex assay
• Immunoglobulin G (IgG) testing for allergy
• Iridology
• Leukocyte antibodies testing
• Leukocyte histamine release test (LHRT)/basophil histamine release test
• Live cell analysis
• Lymphocytes (B or T subsets)
• Lymphocyte function assay
• Mediator release test, or MRT, or the LEAP program
• Metabolic assessments
• Multiple chemical sensitivity syndrome (aka, idiopathic environmental intolerance, or IEI, clinical ecological illness, clinical ecology, environmental illness, chemical AIDS, environmental/chemical hypersensitivity disease, total allergy syndrome, cerebral allergy, 20th century disease)
• Nasal challenge test
• Passive transfer
• Prausnitz-Kustner, or P-K testing – passive cutaneous transfer test
• Provocative tests for food or food additive allergies
• Pulse response test
• Qualification of  nutritional assessments
• Rebuck skin window test
• Secretory IgA (saliva)
• Sage complement antigen test
• Specific immunoglobulin (IgG) (e.g., by RAST, seldom used or enzyme-linked immunosorbent assay)
• Sublingual provocative neutralization testing and treatment with hormones
• Total serum IgG, immunoglobulin A (IgA) and immunoglobulin M (IgM)
• Venom blocking antibodies
• Volatile chemical panels (blood testing for chemicals)

Immunotherapy:

• Provocative and neutralization therapy for food allergies, using intradermal and subcutaneous routes
• Rinkel, also known as serial dilution endpoint titration therapy, for ragweed pollen hay fever
• Enzyme -potentiated desensitization, or EPD
• Repository emulsion therapy
• Urine auto injections (autogenous urine immunization)
• Rhinophototherapy

36511, 37799, S2107

Basic benefit and medical policy

Adoptive immunotherapy (CAR-T therapy) 

Adoptive immunotherapy (CAR-T therapy) of all applications are considered investigational. Autologous lymphocytes used as part of adoptive immunotherapy may be harvested in a pheresis procedure or may be isolated from re-sected tumor tissue. This policy is effective July 1, 2016.

S1090, 0406T, 0407T

Basic benefit and medical policy

Implantable sinus stents for postoperative use after endoscopic sinus surgery 

The use of implantable sinus stents for postoperative treatment after endoscopic sinus surgery and for treatment of recurrent sinonasal polyposis is considered investigational. This policy is effective July 1, 2016.

Sheet Metal Workers’ Local 80 Insurance Trust Fund

Effective June 1, 2016, Medicare-eligible retirees of Wayne County 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.

Group number: 67791
Suffixes: 600, 601, 602
Alpha prefix: XYL

Plans offered:
Medicare Advantage PPO
Medicare Plus Blue Group PPO, medical, surgical, prescription drug

For more information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.