Billing chart: Blues highlight medical, benefit policy changes

94799**

Basic benefit and medical policy

Inhaled nitric oxide
The safety and effectiveness of the use of inhaled nitric oxide, or iNO, have been established. It may be considered a useful therapeutic option for patients meeting specific patient selection criteria.

Updates have been made to the inclusionary criteria, effective Jan. 1, 2019.

Inclusions:
The following patients may be considered appropriate candidates for inhaled nitric oxide therapy:

• When used as a component of treatment of hypoxic respiratory failure in neonates born at more than 34 weeks of gestation. (Hypoxic respiratory failure is defined as an oxygenation index of at least 25 on 2 measurements made at least 15 minutes apart.)
• iNO therapy for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease.
• iNO therapy as a method of assessing pulmonary vaso-reactivity in persons with pulmonary hypertension.

Exclusions:
Other indications for inhaled nitric oxide are experimental including, but not limited to its use in:

• Premature neonates born at less than or equal to 34 weeks of gestation.
• Adults and children with acute respiratory distress syndrome/acute hypoxemic respiratory failure
• Patients with sickle cell disease
• Patients following elective LVAD insertion surgery.
• In lung transplantation, during and/or after graft reperfusion.

For the above conditions, it hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment for these conditions.

Informational guidelines:

• The oxygenation index is calculated as the mean airway pressure times the fraction of inspired oxygen divided by the partial pressure of arterial oxygen times 100. An OI of 25 is associated with a 50 percent risk of requiring extracorporeal membrane oxygenation or dying. An OI of 40 is often used as a criterion to initiate ECMO therapy.
• Prolonged use of iNO beyond one to two weeks hasn’t been shown to improve outcomes. Use of iNO beyond two weeks of treatment is therefore not recommended.

95782, 95783, 95800, 95805-95808, 95810, 95811, E0486, G0398, G0399

Not covered:

Basic benefit and medical policy

Sleep disorders: Diagnosis and medical management

Diagnosis

Polysomnography, known as PSG, is an attended (supervised) sleep study performed in a hospital or freestanding sleep laboratory. The safety and effectiveness of PSG, including a split-night PSG, have been established. It may be considered a useful diagnostic option when indicated.

The safety and effectiveness of an unattended sleep study with a minimum of four recording channels, including oxygen saturation, respiratory movements, airflow and electrocardiogram or heart rate, in a home setting (home sleep study/test) have been established. It may be considered a useful diagnostic option when indicated.

The safety and effectiveness of multiple sleep latency testing, known as MSLT, have been established. It may be a useful tool in diagnosing narcolepsy.

Medical management

The safety and effectiveness of oral appliances to reduce upper airway collapsibility in the treatment of obstructive sleep apnea have been established. Oral appliances may be considered a useful therapeutic option when indicated.

Palate and mandible expansion devices are considered experimental for the treatment of OSA. There is insufficient evidence in the current medical literature to support their efficacy and use in clinical practice.

Nasal expiratory positive airway pressure, known as nasal EPAP, for the treatment of OSA is considered experimental. There is insufficient evidence in the current medical literature to support its efficacy and use in clinical practice.

Oral pressure therapy for the treatment of OSA is considered experimental. There is insufficient medical literature found to support its efficacy.

In the diagnosis of obstructive sleep apnea:

• An unattended (unsupervised) home sleep study is excluded for people with a history of stroke, severe insomnia or chronic opioid use
• Additionally, an adult (ages 18 or older) may have an attended (supervised) sleep study performed in a sleep lab:
• When the initial unattended (unsupervised) study was negative, inadequate, equivocal or non-diagnostic and clinical suspicion for OSA remains

Note: Check member benefits to determine if authorization is required.

• A repeated (attended) sleep study performed in a sleep lab may be considered necessary, if:
• Initial PCG is negative and a clinical suspicion of OSA remains
• To initiate and titrate CPAP in adult patients who have one of the following:
• An AHI or RDI of at least 15 events per hour
• An AHI or RDI of at least five events per hour in a patient with excessive daytime sleepiness or unexplained hypertension.

Medical management using intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered established in adult patients with clinically significant OSA when the below criteria are met:

• OSA as defined by one of the following:
• An AHI, RDI or REI of at least 15 events per hour, OR
• An AHI, RDI or REI of at least five events per hour in a patient with excessive daytime sleepiness or unexplained hypertension, and all the following:
• A trial of CPAP has failed or is contraindicated.
• The device is prescribed by a treating physician.
• The device is custom-fitted by qualified dental personnel.
• There is absence of temporomandibular dysfunction or periodontal disease.

Note: Verify coverage of intraoral appliances under the DME benefit.

The following updates or clarifications have been made to the policy guidelines:

In the diagnosis of OSA in children, an addition was made to the following statement:

Although the definition of severe OSA in children is not well established, an AHI or RDI greater than 1.5 events per hour is considered abnormal (an AHI or RDI of >10 events per hour may be considered severe).

Significant weight change
There is no established threshold for significant change in weight. Studies have reported improvements in OSA with an average weight loss of 20 kilograms or 20 percent of body weight.

Facility and provider requirements
An attended sleep study in a non-hospital-based sleep laboratory must be accredited by the American Academy of Sleep Medicine.

An attended sleep study in a hospital-based sleep testing center must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

To perform and receive reimbursement for in-center and out-of-center sleep testing, a physician must be board certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine. Any M.D. or D.O. may order a sleep test; however, it must be performed and interpreted by a doctor who is board certified in sleep medicine.  Follow our preauthorization program for in-lab sleep testing.

The technician performing the sleep testing must have one of the following certifications:

• American Board of Sleep Medicine, registered technologist
• Board of Registered Polysomnographic Technologists, registered polysomnographic technologist
• National Board for Respiratory Care (any of the following):
• Certified pulmonary function technologist
• Registered pulmonary function technologist
• Certified respiratory therapist
• Registered respiratory therapist

E0830, E0941, E1399**

**Not otherwise classified codes may be used to report service.

Basic benefit and medical policy

Lumbar traction devices for the treatment of low back pain

The use of mechanical, autotraction, gravity-dependent (axial spinal un­­­loading) and pneumatic lumbar traction devices are experimental in any setting, effective Jan. 1, 2019. These devices haven’t been scientifically demonstrated to be safe and effective for the treatment of low back pain, herniated disc or other indications and haven’t been shown to improve patient outcomes.

Exclusions:
Non-established lumbar traction devices include, but are not limited to:

• Pneumatic lumbar traction devices (e.g., Saunders Lumbar HomeTrac, Saunders STx, Orthotrac Pneumatic Vest).
• Autotraction devices (e.g., the Spinalator Spinalign massage intersegmental traction table, the Arthrotonic stabilizer, the Quantum 400 intersegmental traction table and the Anatomotor)
• Axial spinal unloading (gravity-dependent traction) devices (e.g., LTX 3000)
• Conventional lumbar traction using a pelvic harness attached to pulleys and weights, now considered to be obsolete.
• Mechanical traction devices (e.g., Chattanooga New Lumbar Home Traction, Saunders Lumbar Hometrac and the Enshey Traction Bed)

Kalitta Motorsports

Kalitta Motorsports, group number 71783, is joining Blue Cross Blue Shield of Michigan, effective Feb. 1, 2019.

Group number: 71783
Alpha prefix: PPO (KAD)
Platform: NASCO hybrid

Plans offered:
PPO medical/surgical
Vision (VSP)
Prescription drug
Dental
Hearing