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May 2017

Billing chart: 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
UPDATES TO PAYABLE PROCEDURES

B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9999

Basic benefit and medical policy

Intradialytic parenteral nutrition

The criteria have been updated for the intradialytic parental nutrition medical policy. This policy is effective May 1, 2017.

Intradialytic parenteral nutrition, or IDPN, as an adjunct to hemodialysis may be considered established when it’s offered as an alternative to a regularly scheduled regimen of total parenteral nutrition, or TPN, only in patients who would be considered candidates for TPN.

IDPN is considered not medically necessary in patients who would be considered a candidate for TPN, but for whom the IDPN isn’t offered as an alternative to TPN, but in addition to regularly scheduled infusions of TPN.

IDPN as an adjunct to hemodialysis is considered experimental in patients who would not otherwise be considered candidates for TPN.

Inclusions:
They include all of the following:

  • Patients who meet the criteria for TPN**
  • Patients are receiving regularly scheduled TPN
  • When it’s given as an alternative to their regularly scheduled TPN

Exclusions:

  • Patients who aren’t candidates for TPN
  • Patients who are receiving or are a candidate for TPN, but for whom the IDPN isn’t offered as an alternative to TPN, but in addition to regularly scheduled infusions to TPN

**Patients who are considered candidates for TPN are those who have a severe pathology of the alimentary tract that doesn’t allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient’s general condition.

This policy only addresses intravenous parenteral nutrition as an adjunct to hemodialysis, not peritoneal dialysis.

Note: Refer to JUMP policy “Total Parenteral Nutrition” for criteria for TPN.

Condition Code 84

Basic benefit and medical policy

Blue Cross Blue Shield of Michigan now recognizes condition code 84.

Condition Code 85

Basic benefit and medical policy

Blue Cross now recognizes condition code 85.

J1745, Q5102

Basic benefit and medical policy

Specialty Pharmacy

Infliximab (excludes biosimilar) and Infliximab (biosimilar) is included in the Specialty Pharmacy prior authorization program, effective April 1, 2017.

J3490, J3590

Basic benefit and medical policy

Specialty Pharmacy

Exondys 51™ is included in the Specialty Pharmacy prior authorization program, effective April 1, 2017.

66820, 66821

Basic benefit and medical policy

Posterior capsulotomy utilizing an Nd:YAG laser

The safety and effectiveness of posterior capsulotomy utilizing an Nd:YAG laser have been  established. It’s a useful therapeutic option when used to correct functional impairment due to opacification after cataract surgery in members meeting selection criteria.
This policy is effective May 1, 2017.

Group variations
This policy applies to all book of business groups, as well as Medicare Advantage plans.

Inclusions:
Note: This policy doesn’t address the need to evaluate or treat posterior segment pathology or improve visualization of the posterior pole in other eye diseases.

For Nd:YAG laser posterior capsulotomy, after
cataract removal in the same eye when all of the following medical necessity criteria have been met:

  • The eye examination confirms that there is posterior capsular opacification.
  • The visual impairment has interfered with the member’s ability to carry out needed or desired activities and is clearly documented in the medical record.
  • Other diseases (e.g., diabetic retinopathy, macular degeneration) have been excluded as the primary cause of the visual impairment.
  • In the physician’s estimation, significant improvement in visual function can be expected as a result of the surgery.

Additionally, the member must have one of the following:

  • A best-corrected visual acuity (BCVA) of 20/50 or worse, at  distance or near
  • A BCVA of 20/40 or better and visual disability fluctuates as a result of symptoms of glare or decreased contrast, such as one of the following:
    • Consensual light testing decreasing acuity of vision by two lines
    • Glare testing decreasing acuity of vision by two lines

Exclusions:

  • Laser capsulotomy performed at the same time as cataract removal surgery
  • Laser capsulotomy performed prophylactically

81599, 84999

Basic benefit and medical policy

Gene expression profiling for uveal melanoma

The safety and effectiveness of gene-expression profiling for uveal melanoma have been established. It may be considered a useful prognostic tool when indicated. This policy is effective May 1, 2017.

Inclusions:

  • Gene expression profiling for uveal melanoma (e.g., DecisionDX-UM) for patients with primary, localized uveal melanoma.
  • The test must be ordered by a specialist with experience in treating uveal melanoma.

Exclusions:

  • Gene expression profiling for uveal melanoma that doesn’t meet the above criteria.
  • Genetic testing for cutaneous melanoma is experimental.
POLICY CLARIFICATIONS

81313, 81539, 81479

Basic benefit and medical policy

Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer

Genetic and protein biomarkers for the diagnosis and cancer risk assessment of prostate cancer are considered experimental. This includes, but is not limited to, the following:

  • Kallikrein markers (e.g., 4Kscore™ Test)
  • Metabolomic profiles (e.g., Prostarix™)
  • PCA3 testing
  • TMPRSS fusion genes
  • Candidate gene panels
  • Mitochondrial DNA mutation testing (e.g., Prostate Core Mitomics Test™)
  • Gene hypermethylation testing (e.g., ConfirmMDx®)
  • Prostate Health Index (phi)
  • MiPS (Mi-ProstateScore)

Single-nucleotide polymorphism testing for cancer risk assessment of prostate cancer is considered experimental.

The policy has been updated, effective May 1, 2017.
EXPERIMENTAL PROCEDURES

E1399**

**Unlisted code used to bill H-wave devices

Basic benefit and medical policy

H-wave stimulation

The use of H-wave stimulation is experimental for all indications including, but not limited to, treatment of pain (including diabetic peripheral neuropathic pain), wound healing and postoperative treatment to improve function or range of motion. Its use hasn’t been scientifically demonstrated to result in improved patient outcomes.

This policy is effective May 1, 2017.

0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T

Basic benefit and medical policy

Extra-aortic counterpulsation ventricular assist system

The extra-aortic counterpulsation ventricular assist system (e.g., C-Pulse Heart Assist) is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment.

This policy is effective May 1, 2017

36473, 36474

Basic benefit and medical policy

Endovenous mechanochemical ablation, or MOCA, for the treatment of varicose veins (e.g., ClariVein®)

Endovenous mechanochemical ablation for the treatment of varicose veins is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment.

This policy is effective May 1, 2017.

55899

Basic benefit and medical policy

Focal treatment for prostate cancer

The use of focal therapy modalities inclusive of laser ablation, high-intensity focused ultrasound, cryoablation, radiofrequency thermal ablation and photodynamic therapy to treat patients with localized prostate cancer is considered experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

This policy is effective May 1, 2017.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.