Billing chart: Blues highlight medical, benefit policy changes

A4555, E0766

Experimental: A9900, E1399, 77299

Basic benefit and medical policy

TTF therapy for the treatment of supratentorial glioblastoma

The safety and effectiveness of tumor-treatment fields, or TTF, therapy has been established for the treatment of supratentorial glioblastoma. TTF therapy may be medically necessary when used under the care of a doctor, in adults 22 and older and as an adjunct therapy to standard therapy; for a newly histologically confirmed supratentorial glioblastoma or upon reoccurrence as an alternative to chemotherapy.

This policy was effective May 1, 2016.

Inclusions:
Tumor treatment field therapy may be medically necessary, under the care of a doctor, in the treatment of glioblastoma multiforme in all of the following:

• Adults (22 and older)
• Newly diagnosed histologically confirmed supratentorial glioblastomas:
• In adults (22 and older) and
• When used as an adjunct therapy to standard treatments that include maximal debulking surgery and completion of radiation together with the chemotherapy drug temozolomide, or TMZ, or
• Reoccurrence of histologically or radiologically confirmed supratentorial glioblastoma
• The device may be used as a monotherapy or as an alternative to standard medical therapy

Exclusions:
Tumor treatment field therapy is considered experimental when:

• Combined with chemotherapy other than TMZ
• Used for any indications other than those listed above

20974, 20975, E0747

Basic benefit and medical policy

Use of monitored anesthesia care

The monitored anesthesia care for endoscopic, surgical and other diagnostic and therapeutic procedures policy is established. This policy was effective Sept. 1, 2016.

Medical policy statement
Use of monitored anesthesia care may be considered established for gastrointestinal endoscopy procedures when there is documentation by the proceduralist or anesthesiologist that specific risk factors or significant medical conditions are present supporting the opinion that the procedure can’t be done successfully or safely in the absence of monitored anesthesia care.

Inclusions:

Monitored anesthesia care is considered medically necessary for patients with risk factors or significant medical conditions that increase the risk of sedation, including any of the following:

• Increased risk for complications due to severe comorbidity (ASA P3* or greater)
• Morbid obesity (body mass index greater than 40)
• Documented sleep apnea
• Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
• Spasticity or movement disorder complicating procedure
• History or anticipated intolerance to standard sedatives, such as:
• Chronic opioid use
• Chronic benzodiazepine use
• Patients with active medical problems related to drug or alcohol abuse
• Patients younger than age 12 or age 70 or older
• Patients who are pregnant
• Patients with increased risk for airway obstruction due to anatomic variation, such as:
• History of stridor
• Dysmorphic facial features
• Oral abnormalities (e.g., macroglossia)
• Neck abnormalities (e.g., neck mass)
• Jaw abnormalities (e.g., micrognathia)
• Acutely agitated, uncooperative patients
• Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation (e.g., endoscopic retrograde cholangiopancreatography, transduodenal biopsy, double balloon enteroscopy).

Exclusions:

Monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopic, bronchoscopic or interventional pain procedures in patients at average risk for anesthesia and sedation.

J9310

Basic benefit and medical policy

Rituximab, 100 mg to treat patients with neuromyelitis optica

Blue Cross Blue Shield of Michigan has approved rituximab, 100 mg for off-label use to treat patients with neuromyelitis optica, also known as Devic's disease, when reported with procedure code J9310 and ICD 10 diagnosis G36.0.

The doctor who prescribes this drug for off-label use must determine the appropriate dose when used other than that approved by the FDA.

*Various, 81479

Basic benefit and medical policy

Genetic testing for carrier status of genetic diseases

The criteria for the genetic testing for carrier status of genetic diseases policy have been clarified. This policy is effective Nov. 1, 2016.

Inclusions:
Carrier testing for genetic diseases is established when one of the following criteria is met:

• One or both individuals have a first- or second-degree relative who is affected
• First degree includes biological: parent, sibling and child
• Second degree includes biological: grandparent, aunt, uncle, niece, nephew, grandchildren and half-sibling
• One individual is known to be a carrier
• One or both individuals are members of a population known to have a carrier rate that exceeds a threshold considered appropriate for testing for a particular condition

And all of the following criteria are met:

• The natural history of the disease is well understood and there is a reasonable likelihood that the disease is one with high morbidity in the homozygous or compound heterozygous state.
• Alternative biochemical or other clinical tests to definitively diagnose carrier status are not available, or, if available, provide an indeterminate result or are individually less efficacious than genetic testing.
• The genetic test has adequate sensitivity and specificity to guide clinical decision-making and residual risk is understood.
• An association of the marker with the disorder has been established.

Exclusions:
Expanded carrier screening panels are generally considered experimental. There is insufficient evidence that such tests affect clinical outcomes incrementally greater than traditional genetic testing.

Expanded carrier testing is excluded except when each individual genetic mutation included in the panel meets criteria listed above under “inclusions” (e.g., panel for Ashkenazi Jewish ethnicity).

Reimbursement for expanded carrier testing may receive individual consideration depending on comparative fees and charges.

99183, G0277

Basic benefit and medical policy

Systemic hyperbaric oxygen therapy Headline

The safety and effectiveness of systemic hyperbaric oxygen therapy have been established for some conditions. It may be considered a useful therapeutic option when indicated for specified conditions.

Topical hyperbaric oxygen therapy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes. The criteria have been updated, effective Nov. 1, 2016.

Inclusions:
Note: Some locations may be excluded, check with carrier for location restrictions.

The following conditions are effectively treated by systemic hyperbaric oxygen therapy (this list may not be all-inclusive):

• Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment
• Acute carbon monoxide intoxication
• Acute peripheral arterial insufficiency
• Acute traumatic peripheral ischemia: HBOT is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened
• Carbon monoxide poisoning, acute
• Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
• Crush injuries and suturing of severed limbs as an adjunctive treatment when loss of function, limb or life is threatened
• Cyanide poisoning, acute
• Decompression illness
• Gas embolism, acute
• Gas gangrene (i.e., clostridial myonecrosis)
• Osteoradionecrosis and soft tissue radiation necrosis as an adjunct to conventional treatment
• Pre- and post-treatment for patients undergoing dental surgery (non-implant related) of an irradiated jaw
• Preparation and preservation of compromised skin grafts (not for primary management of wounds)
• Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed
• Progressive necrotizing infections
• Refractory mycoses: mucormycosis, actinomycosis, Conidiobolus coronata only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment

Treatment of wounds using hyperbaric oxygen therapy may be appropriate when there have been no measurable signs of healing for at least 30 consecutive days or when there is failure to respond to standard wound care. Wounds must be evaluated at least every 30 days during administration of HBOT for measurable signs of improvement. Continued treatment with HBOT should be discontinued when there are no measurable signs of healing within any 30-day period of treatment.

Wounds, including diabetic wounds, being treated with hyperbaric oxygen therapy must be reviewed using clinical documentation that identifies measurable signs of healing, e.g., width, depth and length of the wound.

Additional criteria for diabetic wounds:
Diabetic wounds of the lower extremities in patients who meet the following three criteria:

• A diagnosis of type 1 or type 2 diabetes with a lower extremity wound that is due to diabetes
• A wound classified as Wagner grade III or higher. (The Wagner classification system of wounds is defined as follows: grade 0 = no open lesion; grade 1 = superficial ulcer without penetration to deeper layers; grade 2 = ulcer penetrates to tendon, bone, or joint; grade 3 = lesion has penetrated deeper than grade 2 and there is abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths; grade 4 = wet or dry gangrene in the toes or forefoot; grade 5 = gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation [at least at the below the knee level] is indicated.)
• The patient has failed an adequate course of standard wound therapy. Standard wound care in patients with diabetic wounds includes all of the following:
• The assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible
• The optimization of nutritional status
• Optimization of glucose control
• Debridement by any means to remove devitalized tissue
• Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings
• Appropriate off-loading
• Necessary treatment to resolve any infection that might be present

For several of the indications included, there is little published evidence to support the effectiveness of hyperbaric oxygen therapy. However, there is little likelihood of RCTs being done for such relatively rare indications. Generally, these patients present with clinically severe situations where therapeutic options are limited. Subject matter expert experience and limited available evidence support that hyperbaric oxygen treatment may offer therapeutic benefit in these cases.

Exclusions:
Hyperbaric oxygen pressurization is considered investigational in the treatment of the following conditions (this list may not be all-inclusive):

• Acute coronary syndromes and as an adjunct to coronary interventions, including percutaneous coronary interventions and cardiopulmonary bypass
• Acute or chronic cerebral vascular insufficiency
• Acute ischemic stroke
• Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
• Acute thermal burns
• Acute surgical and traumatic wounds
• Aerobic septicemia
• Anaerobic septicemia and infection other than clostridial
• Arthritic diseases
• Autism spectrum disorders
• Bell palsy
• Bisphosphonate-related osteonecrosis of the jaw
• Bone grafts
• Brown recluse spider bites
• Carbon tetrachloride poisoning, acute
• Cardiogenic shock
• Cerebral edema, acute
• Cerebral palsy
• Cerebrovascular disease, acute (thrombotic or embolic) or chronic
• Chronic arm lymphedema following radiotherapy for cancer
• Chronic peripheral vascular insufficiency
• Chronic aerobic refractory osteomyelitis and acute osteomyelitis, refractory to standard medical management
• Chronic wounds, other than those situations under the inclusions
• Cosmetic use
• Cutaneous, decubitus and stasis ulcers
• Delayed onset muscle soreness
• Demyelinating diseases, e.g., multiple sclerosis, amyotrophic lateral sclerosis
• Early treatment (beginning at completion of radiation therapy) to reduce side effects of radiation therapy
• Exceptional blood loss anemia
• Fibromyalgia
• Fracture healing
• Hepatic necrosis
• Herpes zoster
• Hydrogen sulfide poisoning
• Idiopathic femoral neck necrosis
• Idiopathic sudden sensorineural hearing loss
• Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
• Intra-abdominal and intracranial abscesses
• In vitro fertilization
• Lepromatous leprosy
• Meningitis
• Mental illness (i.e., posttraumatic stress disorder, generalized anxiety disorder or depression)
• Migraine
• Motor dysfunction associated with stroke
• Multiple sclerosis
• Myocardial infarction
• Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease)
• Organ storage
• Organ transplantation
• Pseudomembranous colitis (antimicrobial agent-induced colitis)
• Pulmonary emphysema
• Pyoderma gangrenosum
• Radiation myelitis, cystitis, enteritis or proctitis
• Radiation-induced injury in the head and neck, except as noted under the inclusions
• Refractory mycoses; mucormycosis, actinomycosis, conidiobolus coronato
• Retinal artery insufficiency, acute
• Retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment
• Senility
• Severe or refractory Crohn’s disease
• Sickle cell crisis and hematuria
• Skin burns (thermal)
• Spinal cord injury
• Systemic aerobic infection
• Tetanus
• Traumatic brain injury
• Tumor sensitization for cancer treatments, including radiotherapy or chemotherapy
• Vascular dementia

93050

Basic benefit and medical policy

SphygmoCor^® System for noninvasive measurement of central blood pressure

SphygmoCor^® System for noninvasive measurement of central blood pressure isn’t an established or medically necessary procedure. While SphygmoCor System for noninvasive measurement of central blood pressure may be safe, its effectiveness in this clinical indication has not been scientifically determined. Therefore, this service is experimental, effective Nov. 1, 2016.