Billing chart: Blues highlight medical, benefit policy changes

0466T, 0467T, 0468T

Additional policy codes:

Established:
21120-21123, 21141, 21193, 21196, 21198, 21199, 42140, 42145, 64568

Not covered:
41512, 41530, 42299, S2080

Basic benefit and medical policy

Obstructive sleep apnea — surgical treatment

Certain surgical procedures have been established as safe and effective for the treatment of clinically significant obstructive sleep apnea, known as OSA, when conservative therapies or CPAP have failed. The procedure selected should be based on the patient’s anatomy and the OSA etiology.

Hypoglossal nerve stimulation is considered established when criteria is met, effective May 1, 2019.

Implantable hypoglossal nerve stimulators for those not meeting the inclusion criteria are considered experimental.

Implantable hypoglossal nerve stimulators that aren’t FDA-approved are considered experimental.

Payment policy
Payable in an inpatient, outpatient and ambulatory surgery center location to an M.D. or D.O. (all specialties). Modifiers 26 and TC aren’t applicable.

Inclusions:

• Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty) for the treatment of clinically significant** obstructive sleep apnea syndrome in adult patients who haven’t responded to or don’t tolerate continuous positive airway pressure or failed an adequate trial of an oral appliance
• Hyoid suspension, surgical modification of the tongue, or maxillofacial surgery, including mandibular-maxillary advancement, or MMA, in adult patients with clinically significant** OSA and objective documentation of hypopharyngeal obstruction who haven’t responded to or don’t tolerate CPAP or failed an adequate trial of an oral appliance
• Adenotonsillectomy in pediatric patients with OSA and hypertrophic tonsils and one of the following:
  • Apnea hypopnea index or respiratory disturbance index of at least five per hour
  • AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems or hyperactivity

**Clinically significant OSA is defined as patients who have one of the following:

• AHI or RDI of 15 or more events per hour
• AHI or RDI of five or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke
• Hypoglossal nerve stimulation (all of the following):
  • Member is age 22 or older
  • AHI is 15-65 events per hour
  • Total number of central and mixed apneas are less than 25% of the total AHI
  • Member has a minimum of 30 days of CPAP documentation monitoring that (one of the following):
    • Demonstrates CPAP failure (AHI greater than 15 despite usage of four or more hours per night, five nights per week)
    • Demonstrates CPAP intolerance (usage is less than four hours per night, five nights per week)
  • A drug-induced sleep endoscopy, or DISE, demonstrates absence of complete concentric collapse at the soft palate level
  • Body mass index is less than 32 kg/m2
  • The sleep study used for the AHI is performed within 24 months of the first consultation for the hypoglossal nerve stimulator

Adolescent or young-adult member with Down syndrome (all of the following):

• Member is 10 to 21 years old
• Member had a prior adenotonsillectomy and all of the following:
  • AHI is greater than 10 and less than 50
  • Total number of central and mixed apneas are less than 25% of the total AHI following adenotonsillectomy
• Member has one of the following:
• A tracheostomy
• Ineffective treatment with CPAP due to noncompliance, discomfort, undesirable side effects, persistent symptom despite compliant use or refusal to use the device
• BMI at the 95th percentile or lower for age
• A drug-induced sleep endoscopy demonstrates absence of complete concentric collapse at the soft palate level

Exclusions:

• Laser-assisted palatoplasty, or LAUP
• Midline glossectomy, or MLG
• Palatal stiffening procedures (e.g., cautery-assisted and injection snoreplasty)
• Palatal implants
• Radiofrequency volumetric tissue reduction, or RVTR, of the tongue
• Radiofrequency reduction of the palatal tissues (e.g., somnoplasty)
• Tongue base suspension (e.g., repose system)
• All other minimally invasive surgical procedures not described above
• All interventions for the treatment of snoring in the absence of documented OSA; snoring alone not considered a medical condition

Exclusions for hypoglossal nerve stimulator:

• Any anatomical finding that would compromise the performance of the device
• Any condition or procedure that has compromised neurological control of the upper airway
• Members who are unable or don’t have the necessary assistance to operate the sleep remote
• Members who are pregnant or plan to become pregnant
• Members who are known to require magnetic resonance imaging (this doesn’t apply to the 3028 model, which is MR compatible)
• Members with an implantable device that may be susceptible to unintended interaction with the device

Implantable hypoglossal nerve stimulators for those not meeting the inclusion criteria are considered experimental.

Implantable hypoglossal nerve stimulators that aren’t FDA-approved are considered experimental.

J3590

Basic benefit and medical policy

Cablivi (caplacizumab-yhdp)

Starting Feb. 6, 2019, Cablivi (caplacizumab-yhdp) is payable for its FDA-approved indications. Cablivi (caplacizumab-yhdp) should be reported with NOC code J3590 and NDC 58468-0227-01 until a permanent code is established.

Cablivi (caplacizumab-yhdp) is FDA approved for the treatment of adult patients with acquired thrombotic thrombocytopenic purpura, known as a TTP, in combination with plasma exchange and immunosuppressive therapy.

Note: The first dose is given as an inpatient.

URMBT groups are excluded from coverage of this drug.

Medical Drug Management doesn’t require prior authorization for this drug.

22899

Basic benefit and medical policy

Growing rods for scoliosis (e.g., MAGEC spinal bracing and distraction system)

The safety and effectiveness of FDA-approved growing rods in the treatment of early onset scoliosis have been established. It may be considered a useful therapeutic option when indicated.

This policy is effective July 1, 2019.

Payment policy Code *22899 requires supportive documentation.

Inclusions:
Use of FDA-approved growing rods in the treatment of early onset scoliosis may be a therapeutic option for:

• For skeletally immature patients younger than 10 years of age
• For severe progressive spinal abnormalities (e.g., Cobb angle of 30 degrees or more)
• For thoracic spine height less than 22 cm
• When associated with or at risk of thoracic insufficiency syndrome, known as TIS**

**TIS is defined as the inability of the thorax to support normal respiration or lung growth.

Exclusions:
When the above criteria aren’t met

96000
96001
96002
96003
96004

Basic benefit and medical policy

Comprehensive gait analysis

The safety and effectiveness of comprehensive gait analysis (the use of sophisticated quantitative and video capture devices) have been established. It may be considered a useful diagnostic option in specified situations.

The exclusionary criteria have been updated, effected July 1, 2019.

Inclusions:

• As an aid in surgical planning in patients with gait disorders associated with cerebral palsy

Exclusions:

• Surgical planning for conditions other than gait disorders associated with cerebral palsy.
• Postoperative evaluation of surgical outcomes.
• Rehabilitation evaluation or planning for all conditions.
• Gait analysis that isn’t comprehensive.

Revenue code 0128

Basic benefit and medical policy

Residential freestanding substance abuse facilities

Residential freestanding substance abuse facilities will reject when billed with revenue code 0128, type of bill 86X and taxonomy value 261QR0405X.

64640

Basic benefit and medical policy

Radiofrequency ablation of peripheral nerves to treat pain, including Coolief Cooled RF

Radiofrequency ablation of peripheral nerves to treat pain (e.g., plantar fasciitis, occipital neuralgia, cervicogenic headache, osteoarthritis, etc.), including Coolief Cooled RF, is experimental.

It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

This policy is effective July 1, 2019.

DTE Energy Company

Starting Aug. 1, 2019, DTE Energy Company is adding the following group numbers:

• DTE Electric — 71785
• DTE Merc — 71786
• DTE Gas — 71787
• DTE Citizens Gas — 71788
• DTE LLC — 71789
• DTE Non-regulated Affiliates — 71790

Alpha prefixes — PPO (DTI)
Benefits platform — NASCO hybrid
Membership platform — Members Edge

Plans offered:
PPO, medical/surgical
Vision (VSP)