Billing chart: Blues highlight medical, benefit policy changes

38204-38215, 38220, 38221, 38230, 38232, 38241, 38242, S2140, S2142, S2150

Basic benefit and medical policy

Bone marrow/hematopoietic stem cell transplants for plasma cell dyscrasias

The safety and efficacy of specified bone marrow/hematopoietic stem cell transplants for plasma cell dyscrasias, including multiple myeloma and POEMS syndrome, have been established. They may be considered useful therapeutic options for patients meeting selection criteria. Inclusionary criteria have been updated, effective March 1, 2017.

Inclusions:
Multiple myeloma
The following hematopoietic stem-cell transplantations for multiple myeloma are considered established:

• Single or second (salvage) autologous hematopoietic stem-cell transplantation.
• Tandem autologous-autologous hematopoietic stem-cell transplantation for patients who fail to achieve at least a near-complete or very good partial response after the first transplant in the tandem sequence. (A near complete response, as defined by the European Group for Blood and Marrow Transplant, or EBMT, is the disappearance of M protein at routine electrophoresis, but positive immunofixation. A very good partial response has been defined as a 90 percent decrease in the serum paraprotein level.)
• Tandem transplantation with an initial round of autologous hematopoietic stem-cell transplantation followed by a non-marrow-ablative conditioning regimen and allogeneic hematopoietic stem-cell transplantation for the treatment of newly diagnosed multiple myeloma patients.
• Myeloablative or nonmyeloablative allogeneic hematopoietic stem-cell transplant is an acceptable option in patients with responsive or primary progressive disease as salvage therapy when these  patients  have undergone a prior autologous hematopoietic stem-cell transplant.

POEMS syndrome
Autologous hematopoietic stem-cell transplantation to treat disseminated POEMS syndrome.

Exclusions:
Multiple myeloma

• Allogeneic hematopoietic stem-cell transplantation, myeloablative or nonmyeloablative, as upfront therapy of newly diagnosed multiple myeloma is considered experimental.
• More than two tandem transplants, two single transplants or a single and a tandem transplant per patient for the same condition.
• The routine harvesting or storage of an individual’s umbilical cord blood for possible use at some unspecified time in the future.

POEMS syndrome
Allogeneic and tandem hematopoietic stem-cell transplantation to treat POEMS syndrome.

69710, 69711, 69714, 69715, 69717, 69718, L8690, L8691, L8692, L8693

Basic benefit and medical policy

Bone-anchored hearing devices

The safety and effectiveness of unilateral or bilateral fully or partially implanted bone-conduction (bone-anchored) hearing aids have been established. They may be considered a useful therapeutic option when indicated. Inclusionary criteria have been updated, effective March 1, 2017.

Inclusions:
Conductive hearing loss
Unilateral or bilateral fully or partially implantable bone-conduction (bone-anchored) hearing aids may be necessary as an alternative to an air-conduction hearing aid in patients aged 5 and older with conductive or mixed hearing loss who also meet at least one of the following criteria:

• Congenital or surgically induced malformations (e.g., atresia) of the external ear canal or middle ear
• Chronic external otitis or otitis media
• Tumors of the external canal or tympanic cavity
• Chronic dermatitis of the external canal prohibiting the usage of an air conduction hearing aid and meet the following audiologic criteria:
• A pure-tone average bone-conduction threshold measured at 0.5, 1, 2, and 3 kHz or better than or equal to 45 dB (OBC and BP100 devices), 55 dB (Intenso device) or 65 dB (Cordele II device).

For bilateral implantation, patients should meet the above audiologic criteria and have symmetrically conductive or mixed hearing loss as defined by a difference between left and right side bone-conduction threshold of less than 10 dB on average measured at 0.5, 1, 2 and 3 kHz (4 kHz for OBC and Ponto Pro), or less than 15 dB at individual frequencies.

Sensorineural hearing loss
A unilateral implantable bone-conduction (bone-anchored) hearing aid may be considered medically necessary as an alternative to an air-conduction contralateral routing of signal hearing aid in patients aged 5 and older with single-sided sensorineural deafness and normal hearing in the other ear.

Note: The Audiant^® bone conductor is a bone-conduction hearing device. While this product is no longer actively marketed, patients with existing Audiant devices may require replacement, removal or repair.

Exclusions:
Other uses of implantable bone-conduction (bone-anchored) hearing aids, including use in patients with bilateral sensorineural hearing loss, are considered experimental.

77058, 77059

Basic benefit and medical policy

MRI for detection and diagnosis of breast cancer

The safety and effectiveness of MRI of the breast have been established. It may be considered a useful diagnostic option for patients meeting defined criteria.

Inclusionary criteria have been updated, effective March 1, 2017.

Inclusions:

Note: All of the following policy statements refer to performing MRI of the breast with a breast coil and the use of contrast. MRI of the breast without the use of a breast coil, regardless of the clinical indication, is considered experimental.

1. MRI of the breast may be considered medically appropriate for screening for breast cancer in patients at high risk of breast cancer.

High-risk considerations
There is no standardized method for determining a woman’s risk of breast cancer that incorporates all possible risk factors. There are validated risk prediction models, but they are based primarily on family history.

Some known individual risk factors confer a high risk by themselves. The following list includes factors known to indicate a high risk of breast cancer:

• Lobular carcinoma in situ
• A known BRCA1 or BRCA2 mutation or
• Another gene mutation associated with high risk, e.g., TP53 (Li-Fraumeni syndrome), PTEN (Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome), CDH1 and STK11, ATM, CHEK2 and PALB2
• High risk (lifetime risk about 20 percent or greater) of developing breast cancer as identified by models that are largely defined by family history 
• Received radiotherapy to the chest between 10 and 30 years of age

Source: National Cancer Care Network,nccn.org.**

A number of other factors may increase the risk of breast cancer but don’t by themselves indicate high risk. It’s possible that combinations of these factors may be indicative of high risk, but it’s not possible to give quantitative estimates of risk. As a result, it may be necessary to individualize the estimate of risk taking into account numerous risk factors. A number of risk factors, not individually indicating high risk, are included in the National Cancer Institute Breast Cancer Risk Assessment Tool, also called the Gail Model. Risk factors in the model can be accessed at the National Cancer Institute website.**

National Cancer Care Network guidelines state there is insufficient evidence for any recommendations for breast MRI for patients with the following mutations:

• BARD1
• FANCC
• MRE11A
• MUTYH
• NF1
• NBN
• RAD50
• SMARCA
• XRCC2

Moreover, there are conflicting data regarding risks associated with MLH1, MSH2, MSH6, PMS2 and EPCAM gene deletion.
For NCCN guidelines, see Page 24 of the medical policy.

2. Medically appropriate for the following indications:
• Detection of a suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma (i.e., negative mammography and physical exam)
• Presurgical planning in patients with locally advanced breast cancer before and after completion of neoadjuvant chemotherapy to permit tumor localization and characterization
• Determining the presence of pectoralis major muscle or chest wall invasion in patients with posteriorly located tumor
• Evaluation of the contralateral breast in those patients with a new diagnosis of breast cancer when clinical and mammographic findings are normal
• Preoperative tumor mapping of the involved (ipsilateral) breast to evaluate the presence of multicentric disease in patients with clinically localized breast cancer who are candidates for breast-conservation therapy
• Evaluation of a documented abnormality of the breast before obtaining an MRI-guided biopsy when there is documentation that other methods, such as palpation or ultrasound, aren’t able to localize the lesion for biopsy

Exclusions:

• Screening technique in average-risk patients
• Screening technique for the detection of breast cancer when the sensitivity of mammography is limited (i.e., dense breasts, breast implants, scarring after treatment for breast cancer)
• Diagnosis of low-suspicion findings on conventional testing not indicated for immediate biopsy and referred for short-interval follow-up
• Diagnosis of a suspicious breast lesion in order to avoid biopsy
• Determination of a response during neoadjuvant chemotherapy in patients with locally advanced breast cancer, when surgery isn’t planned
• Evaluation of residual tumor in patients with positive margins after lumpectomy

** Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

Established: 81228, 81229, 81405, 88271, 88272, 88274, 88275, 59000, 59012

Basic benefit and medical policy

Invasive prenatal (fetal) diagnostic testing

The following criteria have been established. This policy is effective March 1, 2017.

Chromosomal microarray
In patients who are undergoing invasive diagnostic prenatal (fetal) testing, chromosome microarray analysis testing may be considered established, as an alternative to karyotyping.

Single-gene disorders
Invasive diagnostic prenatal (fetal) testing for molecular analysis for single-gene disorders may be considered established when a pregnancy has been identified as being at high risk:

• For autosomal dominant conditions, at least one of the parents has a known pathogenic mutation.
• For one of the autosomal recessive conditions:
• Both parents are suspected to be carriers or are known to be carriers.
• One parent is clinically affected and the other parent is suspected to be or is a known carrier.
• For X-linked conditions: a parent is suspected to be or is a known carrier.

And all of the following 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.
• The disease has high penetrance.
• 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.

If the above criteria for molecular analysis for single-gene disorders aren’t met, invasive diagnostic prenatal (fetal) testing is considered experimental.

Next-generation sequencing
The use of next-generation sequencing in the setting of invasive prenatal testing is considered experimental.

Payable Procedures
L6715, L6880, L6026, L6881, L6882,
L6920, L6925, L6930, L6935, L6940,
L6945, L6950, L6955, L6965, L6975,
L7007, L7008, L7009, L7045, L7170, L7180, L7181, L7185, L7186, L7190,
L7191, L7259

Basic benefit and medical policy

Myoelectric prosthetic components for the upper limb

The safety and effectiveness of myoelectronic prostheses have been established. They may be considered useful therapeutic options for carefully selected candidates.

The safety and effectiveness of myoelectronic prosthesis with whole hand individually powered digits have been established. They may be considered useful therapeutic options for carefully selected candidates.

A partial hand prosthesis with individually powered digits is considered investigational. This policy was effective Nov. 1, 2016.

Note:  Procedure code L6715 is applicable as a “replacement” for a bad digit on an existing L6880 hand and not a covered benefit when applied as an “initial issue” or for amputations below the wrist.

Inclusions
Myoelectric upper-limb prosthetic components may be considered established when all of the following conditions are met:

• The patient has an amputation or missing limb at the wrist or above (forearm, elbow, etc.).
• Standard body-powered prosthetic devices can’t be used or are insufficient to meet the functional needs of the individual in performing activities of daily living.
• The remaining musculature of the arm or arms contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device.
• The patient has demonstrated sufficient neurologic and cognitive function to operate the prosthesis effectively.
• The patient is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.).
• Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (e.g., gripping, releasing, holding, coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the patient’s needs for control, durability (maintenance), function (speed, work capability) and usability.

Children age 2 and older who have shown at least six months successful use of a passive prosthetic device and have a minimum EMG signal of 6μV threshold.

Myoelectric upper-limb whole prosthetic hands with independent articulating digits (L6880) may be considered established when all of the following conditions are met:

• Must meet the above criteria for a myoelectric upper limb prosthetic.
• The patient has an amputation or missing limb at the wrist or above (forearm, elbow, etc.).
• A standard myoelectric prosthesis has been used for one year or more and found insufficient to meet the functional needs of the individual in performing activities of daily living.

Exclusions

• A partial hand prosthesis with independent articulating digits
• Whose ADLs require frequent lifting of heavy objects (12 pounds or greater)
• Whose environments involve frequent contact with dirt, dust, grease, water and solvent
• Whose neuromas or phantom limb pain are exacerbated with the use of the prosthesis

Myoelectric upper-limb prosthetic components are considered not medically necessary under all other conditions.

0310T

Basic benefit and medical policy

Navigated transcranial magnetic stimulation, or nTMS

The medical policy has been updated for the navigated transcranial magnetic stimulation, or nTMS. This policy is effective March 1, 2017.

Navigated transcranial magnetic stimulation is considered experimental for all purposes including, but not limited to, the preoperative evaluation of patients being considered for brain surgery, when localization of eloquent areas of the brain (e.g., controlling verbal or motor function) is an important consideration in surgical planning.

90750

Basic benefit and medical policy

Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted

The U.S. FDA has not approved the Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular injection; therefore, this vaccine is experimental, effective Jan. 1, 2017.

Grede Holdings LLC

Grede Holdings LLC, group number 71743, joined Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.

Group 71743
Alpha Prefix – PPO (NUO)
Platform – NASCO

Plans offered:
PPO
Medical/surgical
Prescription drugs relates only to Brillion Retirees (Wisconsin)