Billing chart: Blues highlight medical, benefit policy changes

81120, 81121, 81246

Codes already established:
81218, 81245, 81310, 81450

Payable diagnoses:
C92.60, C92.61, C92.62, C92.A0. C92.A1, C92.A2

Basic benefit and medical policy

Genetic testing for FLT3, NPM1, CEBPA, IDH1 and IDH2 variants in acute myeloid leukemia

Genetic testing for FLT3 internal tandem duplication, or FLT3-ITD; FLT3 tyrosine kinase domain, or FLT3-TKD; NPM1; CEBPA; IDH1 and IDH2 variants may be considered established in cytogenetically normal acute myeloid leukemia (if testing for all variants, panel testing [code *81450] may be appropriate).

Genetic testing for FLT3-ITD, FLT3-TKD, NPM1, CEBPA, IDH1 and IDH2 variants is considered experimental in all other situations.

Genetic testing for FLT3, NPM1 and CEBPA variants to detect minimal residual disease is considered experimental.

Policy updates are effective Sept. 1, 2019.

Payment policy

• Modifiers 26 and TC don’t apply.
• It isn’t payable in an office location or ASF.
• It’s payable to an M.D., D.O. and independent laboratory.

Inclusions:

Genetic testing for cytogenetically normal acute myeloid leukemia is intended to guide management decisions in patients who would receive treatment other than low-dose chemotherapy or best supportive care.

Genetic testing for IDH1 and IDH2 variants is intended for use as diagnostic and prognostic value in hematologic disorders, such as acute myeloid leukemia.

64575, L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688

Not covered:
39599, 0424T 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T

Basic benefit and medical policy

Phrenic nerve stimulation/diaphragm pacing

The safety and effectiveness of phrenic nerve stimulation/diaphragm pacing have been established. It may be a useful therapeutic option when indicated for select patients, using devices that have been granted full pre-market approval from the Food and Drug Administration.

Policy guidelines have been updated effective Nov. 1, 2018.

Inclusions:

Inclusions for FDA-approved device (Avery Mark IV™) are patients with either one of the following:

• Ventilatory failure from a stable, high spinal cord injury
• Central alveolar hypoventilation syndrome

And all the following criteria are met:

• Bilateral clinically acceptable phrenic nerve function (demonstrated with EMG recordings and nerve conduction times)
• Normal chest anatomy, a normal level of consciousness, and the individual has the ability to participate in and complete the training and rehabilitation associated with the use of the device
• Stimulation of the diaphragm (either directly or through the phrenic nerve, visible on fluoroscopy) confirms sufficient muscle activity to accommodate independent breathing without the support of a ventilator for at least four continuous hours a day

Exclusions:

• Individual who is able to breathe spontaneously for four continuous hours or more without use of a ventilator
• Individual with intact and functional phrenic nerve and diaphragm
• Individual whose respiratory insufficiency is temporary
• Motor neuron disease, such as amyotrophic lateral sclerosis (ALS)**
• Treatment of a condition where the phrenic nerve and diaphragm are intact and functional (for example, chronic obstructive lung disease, central sleep apnea, restrictive lung disease, singultus [hiccups])
• Underlying cardiac, pulmonary or chest wall disease which prevents spontaneous breathing for more than four continuous hours, even with the use of a phrenic nerve stimulator or diaphragm pacing system

Humanitarian device exemption

**On Sept. 29, 2011, NeuRx DPS™ RA/4 (diaphragm pacing system) received an HDE for use in patients age 21 and older with amyotrophic lateral sclerosis.

In 2008, NeuRx DPS™ RA/4 received FDA approval through a humanitarian device exemption application for use in patients age 18 or older with stable, high spinal cord injuries. This application is for a medical device intended to benefit patients in the treatment of a disease or condition that affects a relatively small number of individuals in the United States per year. An HDE doesn’t require results of scientifically valid clinical investigations on effectiveness. The FDA only requires sufficient information to determine that the device doesn’t pose unreasonable or significant risk of illness or injury.

81445, 81450

Not covered:
81455, 0037U, 81479

Basic benefit and medical policy

Molecular panel testing

Molecular panel testing may be considered established when guiding the selection of appropriate therapeutic options for specific conditions, effective July 1, 2019. 

Payment policy:

• Modifiers 26 and TC (TOS P and K) don’t apply (aren’t payable) for procedure code 81450.
• Not payable in an office location or ASF.
• Payable to an M.D., D.O. and independent laboratory only.
• Diagnosis restrictions pertaining to the conditions below apply. See Benefit Explainer for current listing.

Inclusions:

Testing for appropriate actionable genomic alterations that influence therapy may be performed through a panel test for the following conditions:

• Non-small cell lung cancer
• Colorectal cancer
• Cutaneous melanoma
• Gastrointestinal stromal tumor
• Glioma
• Acute myeloid leukemia
• Thyroid nodule, to determine a diagnosis of cancer

Exclusions:

Molecular panel testing for conditions other than those listed in the Inclusions section is considered experimental.

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

Keytruda (pembrolizumab) is payable for the following new FDA indications:

Renal cell carcinoma, known as RCC

• In combination with axitinib, for the first-line treatment of patients with advanced RCC

Melanoma

• For the treatment of patients with unresectable or metastatic melanoma.
• For the adjuvant treatment of patients with melanoma with involvement of lymph nodes following complete resection.

 
Urothelial carcinoma

• For the treatment of patients with locally advanced or metastatic urothelial carcinoma who aren’t eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 (Combined Positive Score, or CPS, ≥10) as determined by an FDA-approved test, or in patients who aren’t eligible for any platinum-containing chemotherapy regardless of PD-L1 status.
• For the treatment of patients with locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

Non-small cell lung cancer

• In combination with pemetrexed and platinum chemotherapy, as first-line treatment of patients with metastatic nonsquamous NSCLC, with no EGFR or ALK genomic tumor aberrations.
• In combination with carboplatin and either paclitaxel or paclitaxel protein-bound, as first-line treatment of patients with metastatic squamous NSCLC.
• As a single agent for the first-line treatment of patients with Stage III NSCLC, who aren’t candidates for surgical resection or definitive chemoradiation, or metastatic NSCLC, and whose tumors express PD-L1 [Tumor Proportion Score (TPS) ≥1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations.
• As a single agent for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations before receiving Keytruda.

Dosage information:

• RCC: 200 mg every three weeks with axitinib 5 mg orally twice daily
• Melanoma: 200 mg every three weeks
• Urothelial carcinoma: 200 mg every three weeks
• NSCLC: 200 mg every three weeks

Pharmacy doesn’t require preauthorization of this drug.

The NDCs are 00006-3026-01 and 00006-3026-02.

BCS Automotive Interface Solutions US LLC

BCS Automotive Interface Solutions US LLC, group number 71797, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2020.

Group number: 71797
Alpha prefix: PPO (BZH)
Platform: NASCO Classic

Plans offered:
PPO, medical/surgical
Prescription drug
CDH — HSA, HRA

General Motors

Effective, Jan. 1, 2020, General Motors will offer a new medical plan option for salaried employees in the greater Flint area and their eligible dependents.

This new option is a GM plan, administered by Blue Cross Blue Shield of Michigan, and will be named:

• ConnectedCare: Ascension Genesys

 Note: This plan is not affiliated with a Blue Care Network plan named BCN Advantage^SM ConnectedCare.

GM ConnectedCare: Ascension Genesys is a two-tier plan that’s geographically defined. Eligibility is based on ZIP codes in the greater Flint area.

The member’s ID card will indicate that they are with General Motors and in an Ascension Genesys custom plan.

Group number: 83640
Alpha prefix: DEM
Platform: NASCO
ID card:  Custom Plan (visible on ID Card)

Plans offered:
Medical/surgical
Hearing

Viking Group Inc.

Viking Group Inc., group number 71794, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2020.

Group number: 71794
Alpha prefix: PPO (VKI)
Platform: NASCO and MOS

Plans offered:
Two PPO, medical/surgical
Dental
Two prescription drug plans
Hearing
CDH — HSA
FSA
Vision (MOS platform)