Billing chart: Blues highlight medical, benefit policy changes

Condition code 87

Basic benefit and medical policy

Condition code 87 is approved

The National Uniform Billing Committee approved the new condition code 87, effective July 1, 2017. Blue Cross Blue Shield of Michigan will also accept this code as of July 1, 2017.

Established:
93797
93798

Non-established:
S9472

Basic benefit and medical policy

Outpatient cardiac rehabilitation

The criteria have been updated for the cardiac rehabilitation outpatient policy. This policy is effective Nov. 1, 2017.

Inclusions (all must be met):

• Phase II cardiac rehabilitation.
• Member must be medically stable and able to tolerate exercise for 20-40 minutes. 
• Must have a least one diagnosis (documented within the last 12 months) listed below:
• Acute myocardial infarction
• Coronary artery bypass graft surgery
• Current stable angina pectoris
• Percutaneous transluminal coronary angioplasty or coronary stenting
• Heart valve surgery
• Heart or heart-lung transplant
• Compensated heart failure

Exclusions:

• Phase III cardiac rehabilitation
• Phase IV cardiac rehabilitation
• Doesn’t meet diagnostic criteria

Repeat participation in a cardiac rehabilitation program in the absence of another qualifying cardiac event

32701, 61781-61783, 61796- 61800, 63620-63621, 77261, 77332- 77334, 77370- 77373, 77402, 77407, 77412, 77432, 77435, G0339, G0340, G6003- G6006

Basic benefit and medical policy

Stereotactic radiosurgery and stereotactic body radiotherapy

The safety and effectiveness of stereotactic radiosurgery and stereotactic body radiotherapy using gamma-ray or linear-accelerator units are established and are considered useful therapeutic options when indicated.

Inclusionary guidelines have been updated, effective Nov. 1, 2017.

Inclusions:
Stereotactic radiosurgery (intracranial) using a gamma-ray or linear-accelerator unit is considered established for the following indications:

• Arteriovenous malformation
• Acoustic neuromas
• Pituitary adenomas
• Non-resectable, residual or recurrent meningiomas
• Craniopharyngiomas
• Glomus jugulare tumors
• Solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission)
• Primary malignancies of the central nervous system (CNS) including, but not limited to, high-grade gliomas (initial treatment or treatment of recurrence)
• Trigeminal neuralgia refractory to medical management

Stereotactic body radiotherapy (extracranial) is considered established for the following indications:

• Members with stage T1 or T2a non-small cell lung cancer (not larger than five centimeters) showing no nodal or distant disease and who aren’t candidates for surgical resection
• Spinal or vertebral body tumors that include:
• Metastatic or primary
• Irradiated or unirradiated
• Spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma)
• In the treatment of primary and metastatic liver malignancies
• Low- or intermediate-risk localized prostate cancer

Stereotactic radiosurgery or stereotactic body radiotherapy using fractionation is considered established when used for indications listed above.

Note:

• Fractionated SRS refers to SRS or SBRT performed more than once on a specific site.
• SBRT is commonly delivered over three to five fractions.
• SRS is most often single-fraction treatment; however multiple fractions may be necessary when lesions are near critical structures.

Exclusions:
Stereotactic body radiotherapy is considered experimental for all other diagnoses not specified in this policy, including malignant neoplasms of the following:

• Pancreas
• Kidney
• Adrenal glands

Stereotactic radiosurgery is considered experimental for the treatment of seizures and functional disorders, other than trigeminal neuralgia, including chronic pain, tremor and uveal melanoma.

81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 82195, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81401, 81403, 81406, 81435, 81436

Basic benefit and medical policy

Genetic testing for Lynch syndrome and other inherited colon cancer syndromes

The safety and effectiveness of genetic testing for polyposis and non-polyposis cancer syndromes have been established. They may be considered useful diagnostic options for individuals who meet clinical criteria for increased risk of hereditary colorectal cancer.

Inclusionary guidelines have been updated, effective Nov. 1, 2017.

Inclusions:
These guidelines refer to the different types of genetic tests available for colorectal cancer.

Genetic testing of the adenosis polyposis coli, also known as APC, gene is established in the following:

• At-risk relatives** (i.e., siblings, parents and offspring) of patients with familial adenomatous polyposis or AFAP or a known APC mutation; or
• Patients with a differential diagnosis of attenuated FAP versus MUTYH-associated polyposis, also known as MAP, versus Lynch syndrome. Whether testing begins with APC mutations or screening for MMR mutations depends on clinical presentation.

**Due to the high lifetime risk of cancer of the majority of the genetic syndromes discussed in this policy, “at-risk relatives” primarily refers to first-degree relatives. However, some judgment must be allowed, for example, in the case of a small family pedigree, when extended family members may need to be included in the testing strategy.

**It’s recommended that, when possible, initial genetic testing for FAP or Lynch syndrome be performed in an affected family member so that testing in unaffected family members can focus on the mutation found in the affected family member.

Genetic testing for MUTYH gene mutations is established in all of the following:

• Patients with a differential diagnosis of attenuated familial adenomatous polyposis vs. MUTYH-associated polyposis vs. Lynch syndrome
• Negative result for APC gene mutations
• Negative family history of no parents or children with FAP is consistent with autosomal recessive MAP

In many cases, genetic testing for MUTYH gene mutations should first target the specific mutations Y165C and G382D, which account for more than 80 percent of mutations in white populations, and subsequently proceed to sequencing only as necessary. In other ethnic populations, however, proceeding directly to sequencing is appropriate.

Genetic testing for MMR gene mutations to determine the carrier status of Lynch syndrome (HNPCC) is established in any of the following:

• Patients with colorectal cancer to test for the diagnosis of Lynch syndrome
• Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer, for the diagnosis of Lynch syndrome
• At-risk relatives of patients with Lynch syndrome with a known MMR mutation
• Patients with a differential diagnosis of attenuated FAP versus MAP versus Lynch syndrome. Whether testing begins with APC mutations or screening for MMR mutations depends on clinical presentation
• Patients without colorectal cancer but with a family history meeting the Amsterdam or Revised Bethesda criteria when no affected family members have been tested for MMR mutations

For patients with colorectal cancer being evaluated for Lynch syndrome, either the microsatellite instability, or MSI, test, or the immunohistochemical, or IHC, test with or without BRAF gene mutation testing, should be used as an initial evaluation of tumor tissue before MMR gene analysis. Both tests are not necessary. Proceeding to MMR gene sequencing would depend on results of MSI or IHC testing. IHC testing in particular may help direct which MMR gene likely contains a mutation, if any, and may also provide additional information if MMR genetic testing is inconclusive.

When indicated, genetic sequencing for MMR gene mutations should begin with MLH1 and MSH2 genes,
unless otherwise directed by the results of IHC testing. Standard sequencing methods will not detect large deletions or duplications; when MMR gene mutations are expected based on IHC or MSI studies but none are found by standard sequencing, additional testing for large deletions or duplications is appropriate.

Genetic testing for EPCAM mutations is established when any one of the following three major criteria (solid bullets) is met:

• Patients with colorectal cancer, for the diagnosis of Lynch syndrome when:
• Tumor tissue shows a high level of microsatellite instability.
• Tumor tissue shows lack of MSH2 expression by immunohistochemistry patient is negative for a germline mutation in MSH2, MLH1, PMS2, and MSH6.
• At-risk relatives of patients with Lynch syndrome with a known EPCAM mutation
• Patients without colorectal cancer but with a family history meeting the Amsterdam or Revised Bethesda criteria
• When no affected family members have been tested for MMR mutations.
• When sequencing for MMR mutations is negative.

The Amsterdam II Clinical Criteria (all criteria must be fulfilled) are the most stringent criteria for defining families at high risk for Lynch syndrome (Vasen et al., 1999):

• Three or more relatives with an associated cancer (colorectal cancer, or cancer of the endometrium, small intestine, ureter, or renal pelvis)
• One should be a first-degree relative of the other two
• Two or more successive generations affected
• One or more relatives diagnosed before the age of 50 years
• Familial adenomatous polyposis should be excluded in cases of colorectal carcinoma;
• Tumors should be verified by pathologic examination.

Modifications:

• Either very small families, which can’t be further expanded, can be considered to have hereditary nonpolyposis colorectal cancer, known as HNPCC, with only two colorectal cancers in first-degree relatives if at least two generations have the cancer and at least one case of colorectal cancer was diagnosed by the age of 55 years; or
• In families with two first-degree relatives affected by colorectal cancer, the presence of a third relative with an unusual early-onset neoplasm or endometrial cancer is sufficient.

The Revised Bethesda Guidelines (fulfillment of any criterion meets guidelines) are less strict than the Amsterdam criteria and are intended to increase the sensitivity of identifying at-risk families (Umar et al., 2004). The Bethesda guidelines are also considered more useful in identifying which patients with colorectal cancer should have their tumors tested for microsatellite instability or immunohistochemistry:

• Colorectal carcinoma, known as CRC, diagnosed in a patient who is less than 50 years old
• Presence of synchronous or metachronous CRC or other HNPCC-associated tumors,** regardless of age
• CRC with high microsatellite instability histology diagnosed in a patient less than 60 years old
• CRC diagnosed in one or more first-degree relatives with a Lynch syndrome-associated tumor, with one of the cancers being diagnosed at younger than 50 years of age
• CRC diagnosed in two or more first or second-degree relatives with HNPCC-related tumors,** regardless of age

** HNPCC-related tumors include colorectal, endometrial, stomach, ovarian, pancreas, ureter and renal pelvis, biliary tract, brain (usually glioblastoma as seen in Turcot syndrome), sebaceous bland adenomas and keratoacanthomas in Muir-Torre syndrome and carcinoma of the small bowel.

Genetic testing for BRAF V600E mutations or MLH1 promoter methylation are established to exclude a diagnosis of Lynch syndrome when:

• MLH1 protein isn’t expressed in a colorectal cancer on immunohistochemical analysis.

Pre- and post-test genetic counseling is established as an adjunct to genetic testing.

Genetic counseling is primarily aimed at patients who are at risk for inherited disorders, and experts recommend formal genetic counseling in most cases when genetic testing for an inherited condition is considered. The interpretation of the results of genetic tests and the understanding of risk factors can be very difficult and complex. Therefore, genetic counseling will assist individuals in understanding the possible benefits and harms of genetic testing, including the possible affect of the information on the individual’s family. Genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing. Genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Exclusions:
Genetic testing for APC gene mutations is considered investigational for colorectal cancer patients with classical FAP for confirmation of the FAP diagnosis.

Genetic testing for all other gene variants for Lynch syndrome or colorectal cancer is considered experimental. The peer reviewed medical literature hasn’t demonstrated the clinical utility of testing for other gene variants for Lynch syndrome.

0002U

Basic benefit and medical policy

Polymetabolite urine testing for adenomatous polyps

The peer reviewed medical literature hasn’t demonstrated the clinical utility of triple-quad mass spectrometry to measure the levels of three metabolites in patient’s urine: ascorbic acid, succinic acid and carnitine, for the detection of adenomatous polyps. Therefore, this service is experimental, effective Nov. 1, 2017.

0469T

Basic benefit and medical policy

Retinal polarization scan (retinal birefringence scanning)

The bilateral retinal polarization scan, ocular screening with on-site automated results is experimental. It hasn’t been scientifically demonstrated to improve long-term patient clinical outcomes.

This policy is effective Nov. 1, 2017