Billing chart: Blues highlight medical, benefit policy changes

19296, 19297, 19298, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77316, 77317, 77318, 77778

Basic benefit and medical policy

Accelerated breast irradiation after breast-conserving surgery for early stage breast cancer and breast brachytherapy as boost with whole-breast irradiation

Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation, and interstitial or balloon brachytherapy may be considered established for patients who meet inclusionary guidelines. These procedures are useful therapeutic options for patients meeting selection criteria.
• Accelerated whole breast irradiation is considered experimental in all other situations involving treatment of early stage breast cancer after breast-conserving surgery.
• Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in those who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.
• Accelerated partial breast irradiation, including interstitial accelerated partial breast irradiation, balloon accelerated partial breast irradiation, external beam accelerated partial breast irradiation, noninvasive brachytherapy using Accuboost^®, and intra-operative accelerated partial breast irradiation, is considered experimental.
• Noninvasive brachytherapy using Accuboost for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy is considered experimental.

Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision is considered experimental. There is a lack of published data to validate the efficacy of brachytherapy without surgical excision of the tumor.

The coverage criteria has been updated, effective Sept. 1, 2017.

Inclusions:
Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation for patients who meet the following conditions:
• Invasive carcinoma of the breast
• Tumors >5 centimeters in diameter
• Negative lymph nodes
• Technically clear surgical margins, for example, no ink on tumor on invasive carcinoma or ductal carcinoma in situ
• Age at least 50 years old
• Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.

Exclusions:

• Accelerated whole breast irradiation for patients not meeting the above inclusions.
• Accelerated partial breast irradiation, including interstitial accelerated partial breast irradiation, balloon accelerated partial breast irradiation, external beam accelerated partial breast irradiation, noninvasive brachytherapy using Accuboost, and intra-operative accelerated partial breast irradiation.
• Interstitial or balloon brachytherapy in all other situations not specified under the inclusions.
• Noninvasive brachytherapy using Accuboost for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy.
• Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision.

97124

Basic benefit and medical policy

Therapeutic massage

The criteria has been updated for the therapeutic massage policy. This policy was effective May 1, 2017.

The safety and effectiveness of manual therapeutic massage, code *97124, as part of an overall physical therapy/medicine treatment plan has been established. It may be considered established and medically necessary when the following criteria are met:

• It’s provided as part of a formal course of physical therapy/medicine in addition to other therapeutic interventions on the same date of service.
• Massage therapy is provided in the early, acute phase of therapy of a musculoskeletal problem and is generally limited to two weeks of treatment.
• Massage therapy alone, either as a one-time service or as a series of massages over time, isn’t a covered benefit.
• All Blue Cross Blue Shield of Michigan requirements related to the identification and qualifications of approved providers of physical therapy or physical medicine, apply to the providers of massage therapy.
• Blue Cross rules regarding orders and documentation of rehabilitation services apply to the provision of massage therapy.
• All Blue Cross rules and requirements related to “incident to” billing for physical therapy or physical medicine apply.

Blue Cross reimburses providers for physical medicine services “incident to” physician or nonphysician practitioner services in the outpatient setting when such services are performed by the physician, nurse practitioner or a licensed physical therapist.

Physicians, nurse practitioners, independent physical therapists, OPT facilities and outpatient hospitals can bill for the services of physical therapist assistants and athletic trainers when such services are directly supervised by a licensed physical therapist.

As of August 1, 2015, chiropractors may perform therapeutic massage therapy when provided as part of a complete physical medicine service plan. They’re not allowed to supervise other provider types in the performance of therapeutic massage.

No provider type can supervise therapeutic massage (procedure code *97124) or delegate therapeutic massage to any individual not eligible to perform therapeutic massage including, but not limited to,  massage therapists, therapy aides, exercise physiologists or kinesiotherapists. Medically necessary therapeutic massage may be delivered by participating providers, when such massage is within their scope of practice. This rule applies to all provider types. Self-insured groups may elect a different benefit design that isn’t consistent with these rules.

33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, and 33369

Basic benefit and medical policy

Transcathreter aortic valve implantation aortic stenosis

The criteria have been updated for the transcatheter aortic valve implantation for aortic stenosis policy. This policy is effective, Sept. 1, 2017.

Inclusions:
Transcatheter aortic valve replacement with a device approved by the U.S. Food and Drug Administration and performed via an approach consistent with the device’s FDA-approved labeling is established for patients with aortic stenosis when all of the following conditions are present:

• One of the following:
• Severe aortic stenosis with a calcified aortic annulus
• Failed (stenosed, insufficient or combined) of a surgical bioprosthetic aortic valve
• New York Heart Association heart failure class II, III or IV symptoms
• Left ventricular ejection fraction greater than 20 percent
• One of the following:
• Patient isn’t an operable candidate for open surgery, as judged by at least two cardiovascular specialists including a cardiac surgeon
• Patient is an operable candidate but is at high risk for open surgery (for example, Society of Thoracic Surgeons operative risk score > 8 percent or at a > 15 percent risk of mortality at 30 days).
• Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien XT transcatheter heart valve, see below)

Edwards SAPIEN XT Transcatheter Heart Valve:

1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
• An aortic valve area of > 1.0 cm² or aortic valve area index < 0.6 cm2/m2
• A mean aortic valve gradient > 40 mmHg
• A peak aortic-jet velocity > 4.0 m/sec
• Native anatomy appropriate for the 23, 26, or 29 mm valve system (between 18 and 28 mm)
2. New York Heart Association heart failure Class II, III or IV symptoms
3. Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac  surgeon, or to be at high or greater risk for open surgical therapy (for example, Society of Thoracic Surgeons operative risk score > 8 percent or at a > 15 percent risk of mortality at 30 days).
4. Patient is at intermediate surgical risk for open aortic valve replacement (for example, predicted risk of surgical mortality > 3 percent at 30 days based on the Society of Thoracic Surgeons Risk Score and other clinical comorbidities unmeasured by the STS Risk Calculator).

Medtronic CoreValve™ (Evolut) system:

1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
• An aortic valve area of < 1.0 cm² or aortic valve area index < 0.6 cm2/m2
• A mean aortic valve gradient > 40 mmHg
• A peak aortic-jet velocity > 4.0 m/sec
• Native aortic annulus diameters between 23 and 31 mm
2. New York Heart Association heart failure Class II, III or IV symptoms
3. Patient is judged by a heart team, including a cardiac surgeon, to be at extreme risk or inoperable for open surgical therapy (predicted risk of operative mortality and/or serious irreversible morbidity > 15 percent at 30 days).

Exclusions:
Transcatheter aortic valve replacement is considered experimental for all other indications, including but not limited to:

• The individual is an appropriate candidate for the standard, open surgical approach but has refused
• Hypersensitivity or contraindication to an anticoagulation/antiplatelet regimen
• Presence of active bacterial endocarditis or other active infections
• Non-FDA approved systems

Relative contraindications:
In some cases, the benefits of transcatheter aortic valve implantation may exceed potential risks. In such instances, the cardiologist should provide an attestation indicating that a relative contraindication exists and that the patient fully understands all risks. While the items below aren’t absolute exclusions, the safety and effectiveness of transcatheter aortic valve implantation haven’t been evaluated in patients with the following characteristics or co-morbidities:

• Patients without aortic stenosis
• Untreated, clinically significant coronary artery disease requiring revascularization
• Cardiogenic shock manifested by low cardiac output, vasopressor dependence or mechanical hemodynamic support
• Transarterial access not able to accommodate an 18-Fr sheath
• Sinus of valsalva anatomy that would prevent adequate coronary perfusion
• End-stage renal disease requiring chronic dialysis or creatinine clearance <20 cc/min
• Symptomatic carotid or vertebral artery disease
• Safety, effectiveness and durability haven’t been established for valve-in-valve procedures
• Non-calcified aortic annulus
• Severe ventricular dysfunction with ejection fraction < 20 percent
• Congenital unicuspid or congenital bicuspid aortic valve
• Mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation > 3+)
• Prosthetic ring in any position
• Severe mitral annular calcification, severe mitral insufficiency, moderate to severe mitral or tricuspid regurgitation or Gorlin syndrome
• Moderate to severe mitral stenosis
• Blood dyscrasias defined as: leukopenia, acute anemia (Hb < 9 g/dL), thrombocytopenia, history of bleeding diathesis or coagulopathy, or hypercoagulable states
• Hypertrophic cardiomyopathy with or without obstruction
• Echocardiographic evidence of intracardiac mass, thrombus or vegetation
• Excessive calcification of vessel at access site
• Bulky calcified aortic valve leaflets in close proximity to coronary ostia
• The safety and effectiveness of the Medtronic CoreValve™ system haven’t been evaluated in the pediatric population

81161 and 81408

Basic benefit and medical policy

Genetic testing for Duchenne and Becker muscular dystrophy

The criteria have been updated for the genetic testing for Duchenne and Becker muscular dystrophy policy. This policy is effective Sept. 1, 2017.

Inclusions:

• For a male or female with signs and symptoms of a dystrophinopathy in order to confirm the diagnosis and direct treatment (See testing strategy of a male suspected of dystrophinopathy below.)
• For at-risk female relatives (See testing strategy for carrier testing in at-risk female relatives below.)
• At-risk females include:
• Sisters, daughters, mother and maternal female relatives of an affected male
• First–degree relatives of a known carrier female
• For at-risk male offspring (see definition of at-risk male offspring below)
• To confirm or exclude the need for medical and cardiac surveillance

Testing strategy of a male or female suspected of dystrophinopathy

To establish the diagnosis of a male with clinical findings that suggests Duchenne muscular dystrophy or Becker muscular dystrophy:

• Perform Duchenne muscular dystrophy genetic testing for deletion/duplication analysis first.
• If a mutation isn’t identified, perform sequence analysis for a point mutation.
• If a disease-causing Duchenne muscular dystrophy mutation is identified, the diagnosis of a dystrophinopathy is established.
• In cases where a distinction between Duchenne muscular dystrophy and Becker muscular dystrophy is difficult, the reading frame rule states that the type of deletion/duplication (those that alter the reading frame [out of frame], which correlates with the more severe phenotype of Duchenne muscular dystrophy versus those that don’t alter the reading frame [in-frame] that correlate with the milder Becker muscular dystrophy phenotype) can distinguish the Duchenne muscular dystrophy and Becker muscular dystrophy phenotypes with 91-92 percent accuracy.
• If no disease-causing Duchenne muscular dystrophy mutation is identified, skeletal muscle biopsy is warranted for western blot and immunohistochemistry studies of dystrophin.

Testing strategy for carrier testing in at-risk female relatives:

• When there is a known Duchenne muscular dystrophy mutation, test for that deletion/duplication or point mutation using appropriate testing method.
• When an affected male isn’t available for testing, perform testing by deletion/duplication first and if no mutation is identified, by sequence analysis.

At-risk male
An at-risk male is defined as an asymptomatic male offspring of a female carrier or an asymptomatic male sibling of a patient with a Duchenne muscular dystrophy-associated dystrophinopathy.

Exclusions:
All other indications

Established
92537, 92538, 92540, 92541, 92542
92544, 92545, 92546 and 92547

Experimental
92700

Basic benefit and medical policy

Vestibular function testing

Vestibular function testing has been established. It’s a useful diagnostic option in specified situations. This policy is effective Sept. 1, 2017.

Inclusions:
Vestibular function testing using an electronystagmography and videonystagmography testing batteries, caloric testing or rotational chair testing may be considered medically necessary when the following conditions have been met:

• The patient has symptoms of vestibular disorder (for example, dizziness, vertigo, imbalance).
• A clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has failed to identify the cause of the symptoms.

The ENG/VNG testing batteries may include caloric testing, positional tests and oculomotor evaluation (in other words, spontaneous nystagmus including gaze-evoked nystagmus, positional nystagmus, optokinetic nystagmus, smooth pursuit tracking, saccade test).

Exclusions:
Vestibular function testing for:

• Assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically
• Repeat testing when treatment resolves symptoms
• In all other situations not listed in inclusions

Vestibular evoked myogenic potential tests

All other laboratory-based vestibular function tests not described above.

0423T

Basic benefit and medical policy

Secretory Type II Phospholipase A2, or sPLA2-IIA, testing to predict susceptibility to coronary artery disease

Measurement of sPLA2-IIA biomarker levels is experimental. While measurement of sPLA2-IIA biomarker levels may be used to assess the patient’s potential risk for further cardiovascular disease, there is currently no pharmacological treatment for reducing sPLA2-IIA biomarker levels. Additional well-designed clinical trials are necessary to establish the clinical utility of sPLA2-IIA testing for cardiovascular risk assessment.

This policy is effective Sept. 1, 2017.

J2504

Basic benefit and medical policy

Additional code added as payable to ambulatory infusion center

The following code is now payable to an ambulatory infusion center:

J2504, Injection, pegademase bovine, 25 IU

Letica Corporation

Letica Corporation, group number 75412, added the following plans, effective July 1, 2017.

Group number: 75412
Alpha prefix: NLA (PPO)
NKK (CMM)
NLC (CMM/MED)
Platform: NASCO

Plans offered:
Two PPO plans
HSA
Three prescription drug plans