The Record - Billing chart: Blues highlight medical, benefit policy changes

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

Click on BCBSM Provider Publications & Resources.

Click on Benefit Policy for a Code.

Click on Topic.

Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.

Enter the procedure code.

Click on Finish.

Click on Search.

Code*

BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines

NEW PAYABLE PROCEDURES

0501T, 0502T, 0503T, 0504T, 75574**

**Covered starting Jan. 1, 2010

Noninvasive fractional flow reserve

The use of noninvasive fractional flow reserve to guide decisions about the use of invasive coronary angiography in select patients has been established. It’s a useful diagnostic option when indicated, effective Jan. 1, 2019.

Payment policy
Modifiers 26 and TC don’t apply to procedure codes 0501T, 0502T, 0503T and 0504T. They also aren’t subject to the Radiology Management Program, although 75574 is. Procedure codes 0501T and 0504T aren’t covered in a facility location.

Inclusions:
Patients must meet both criteria:

Have stable chest pain
Have intermediate risk of coronary artery disease (e.g., suspected or presumed stable ischemic heart disease)

And meet one of the following:

Diagnosis of congestive heart failure/cardiomyopathy/left ventricular dysfunction when all the following are met:
- Left ventricular ejection fraction < 55%
- Low to moderate coronary heart disease risk^a
- Coronary artery disease hasn’t been excluded as the etiology of the cardiomyopathy
Symptomatic^b or asymptomatic patients undergoing non‑coronary surgery (including open and percutaneous valvular procedures or ascending aortic surgery)
- All the pre-operative information can be obtained using cardiac CT, and
- Moderate coronary heart disease risk^a
Symptomatic^b patients who are suspected of having coronary artery disease and meet one of the following:

During a planned outpatient exercise stress test (without imaging), all the following apply:

Performed within the past 60 days
Patient is symptomaticb
During the test, one of the following occurred:

Exercise-induced chest pain
ST segment change
Abnormal blood pressure response
Complex ventricular arrhythmias

Have undergone either myocardial perfusion imaging or a stress echocardiogram within the past 60 days and imaging is one of the following:

Neither normal or abnormal
Abnormal

No coronary artery disease imaging (e.g., myocardial perfusion imaging, cardiac PET scan, stress echo or coronary angiogram) has been performed within the preceding 60 days.

Symptomatic^b patient with abnormal resting EKG

Exercise stress test (without imaging) would be uninterpretable related to one of the following:

Left bundle branch block
Paced ventricular rhythm
Left ventricular hypertrophy with repolarization abnormalities
Resting ST segment depression

≥ 1 mm

Digoxin effects as evidence by one of the following:

ST depression in a concave shape
Flattened, inverted or biphasic T waves
Shortened QT interval

Pre-excitation syndrome (e.g., Lown-Ganong-Levine syndrome, Wolff-Parkinson-White syndrome)

Short PR interval (< 0.12 sec)

Note: Fractional flow reserve using coronary tomography angiography requires at least a 64-slice coronary computed tomography angiography and can’t be calculated when images lack sufficient quality.

^a Risk factor is determined using standard assessment methods (e.g., SCORE, or Systematic Coronary Risk Evaluation, chart)
^b Symptomatic is defined by one or more of the following:

Chest pain with low probability of coronary artery disease, but high risk
Moderate to high risk of coronary artery disease and one of the following:

Chest, jaw, neck, shoulder, arm, hand, epigastric or back pain
Diaphoresis
Syncope
Shortness of breath

High risk of coronary artery disease and one of the following:

Palpitations
Lightheadedness
Near syncope
Nausea or vomiting
Anxiety
Weakness
Fatigue

Patients with any cardiac symptom who have any of the following diseases associated with coronary artery disease:

Abdominal aortic aneurysm
Chronic renal insufficiency or renal failure
Diabetes mellitus
Established and symptomatic peripheral vascular disease
History of:

Cerebrovascular accident
Transient ischemic attack
Carotid endarterectomy
High-grade carotid stenosis (>70%)

Exclusions:

Assessment of coronary arteries for suspected congenital anomalies
Patients who have:

Body mass index > 35% kg/m2
Presence of uncontrolled rapid heart rate or arrhythmia
Suspicion of acute coronary syndrome when acute myocardial infarction or unstable angina hasn’t been ruled out.
History of:

Myocardial infarction within the last 30 days
Coronary artery bypass graft surgery
Presence of dense arterial calcification or intracoronary stent
Evidence of clinical instability (e.g., unstable blood pressure – systolic < 90 mmHg, severe congestive heart failure, acute pulmonary edema, cardiogenic shock)

Patients who require emergent procedures
Patients not meeting inclusionary guidelines

J3490
J3590

Basic benefit and medical policy

Tegsedi (inotersen)

Tegsedi (inotersen) is considered established, effective Oct. 5, 2018.

Tegsedi (inotersen) is covered when all the following criteria are met:

Age 18 or older
Must have a diagnosis of peripheral nerve disease caused by hereditary transthyretin-mediated amyloidosis, or hTTR, with documented transthyretin, or TTR, mutation
Documentation of clinical signs and symptoms of peripheral neuropathy or autonomic neuropathy
Must have polyneuropathy disability, or PND, score ≤ IIIb
Must have baseline FAP Stage 1 or 2
Must not be on concomitant treatment with Tegsedi and Onpattro

Quantity limit: FDA-approved dosing
Initial authorization period: One year

FDA approved indication and diagnosis:
For treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis (hATTR) in adults

Dosing and administration
Dosing: 284 mg administered subcutaneously once weekly.

Tegsedi (inotersen) isn’t a benefit for URMBT.

Prior authorization is required for this drug.

NDCs: 71860-0007-01, 71860-0007-02

J9999

Basic benefit and medical policy

Libtayo (cemiplimab-rwlc)

Effective Sept. 28, 2018, Libtayo (cemiplimab-rwlc) is payable for its FDA-approved indications. Libtayo (cemiplimab-rwlc) should be reported with not otherwise classified, or NOC, code J9999 and national drug code, or NDC, 61755-0008-01 until a permanent code is established.

Libtayo is approved for the treatment of patients with metastatic cutaneous squamous cell carcinoma, known as CSCC, or locally advanced CSCC who aren’t candidates for curative surgery or curative radiation. The recommended dosage of Libtayo is 350 mg as an intravenous infusion over 30 minutes every three weeks.

URMBT groups are excluded from coverage of this drug.

Medical drug management doesn’t require prior authorization for this drug.

Established
Q4131, Q4132, Q4133, Q4151**
Q4154**

Investigational
Q4100, Q4137, Q4138, Q4139, Q4140, Q4145, Q4148, Q4150, Q4153, Q4155, Q4156, Q4157, Q4159, Q4160, Q4162, Q4163, Q4168, Q4169, Q4170, Q4170, Q4171, Q4173, and Q4174

**New payable procedures

Basic benefit and medical policy

Amniotic membrane and amniotic fluid

The safety and effectiveness of select human amniotic membrane products have been established. They may be useful therapeutic options when indicated.

Injection of amniotic fluid is investigational for all indications. The safety, effectiveness and improvement in health outcomes haven’t been scientifically demonstrated.

This policy is effective March 1, 2019.

Inclusions:
Diabetic lower extremity ulcers

Treatment of nonhealing** diabetic lower-extremity ulcers using the following human amniotic membrane products (AmnioBand^® Membrane, Biovance^®, Epifix^®, Grafix™)

**Nonhealing is defined as less than a 20% decrease in wound area with standard wound care for at least two weeks.

Ophthalmic conditions
Sutured human amniotic membrane grafts may be considered medically necessary for the treatment of any of the following indications:

Neurotrophic keratitis
Corneal ulcers and melts
Pterygium repair
Stevens-Johnson syndrome
Persistent epithelial defects when one of the following are met:

Failed to close completely after five days of conservative^∧ treatment
Failed to demonstrate a decrease in size after two days of conservative^∧ treatment

^∧Conservative treatment is defined as the use of topical lubricants or topical antibiotics or therapeutic contact lens or patching.

Exclusions:

Ophthalmic conditions
Sutured human amniotic membrane grafts for the treatment of all other ophthalmic conditions, including, but not limited to:

Dry eye syndrome
Burns
Corneal perforation
Bullous keratopathy
Limbus stem cell deficiency and
After photorefractive keratectomy

Other conditions
All other human amniotic membrane products and indications not listed under inclusions, including, but not limited to:

Treatment of lower-extremity ulcers due to venous insufficiency
Human amniotic membrane without suture (e.g., Prokera^®, AmbioDisk™) for ophthalmic indications
Injection of micronized or particulated human amniotic membrane for all indications, including but not limited to treatment of:

Osteoarthritis and plantar fasciitis

Injection of human amniotic fluid for all indications

UPDATES TO PAYABLE PROCEDURES

B4157, B4162

Basic benefit and medical policy

Medical formula for inborn errors of metabolism

The safety and effectiveness of oral medical formula for individuals with inborn errors of metabolism have been established. Oral medical formula is considered an established treatment option when policy criteria are met, effective Jan. 1, 2019.

Payment policy
Submit codes with BO modifier. Payable to durable medical equipment suppliers only. A maximum 30-day supply (per 25 days with a five-day grace period) is allowed.

Inclusions:
Oral medical formula (medical formula for consumption by mouth) for individuals of any age is considered established when all the following are met:

The individual has a diagnosis of an inborn error of metabolism.**
The oral medical formula is labeled and used for nutritional management of an IEM that interferes with the metabolism of specific nutrients (e.g., phenylketonuria, homocystinuria, maple syrup urine disease, etc.).
The oral medical formula nutrition is ordered by a clinical or medical biochemical geneticist.

** See appendix in medical policy for list of applicable diagnoses.

Exclusions:

Formula for any condition other than an inborn error of metabolism (e.g., diabetes, hypercholesterolemia, etc.)
Formula that doesn’t require a physician order for purchase
Formula not specifically used for the nutrition of an individual with IEM.
Medical food product that isn’t formula (e.g., food modified to be low in protein [meat or cheese substitutes, pasta, etc.])
Nutrition via tube feeding (refer to the Enteral Nutrition policy for guidelines)

J3590

Basic benefit and medical policy

JIVI (antihemophilic factor [recombinant] Pegylated-aucl)

JIVI^® (antihemophilic factor [recombinant] Pegylated-aucl) is payable for its FDA-approved indications, effective Aug. 30, 2018.

JIVI, antihemophilic factor (recombinant), PEGylated-aucl, is a recombinant DNA-derived, Factor VIII concentrate indicated for use in previously treated adults and adolescents 12 years of age and older with hemophilia A (congenital Factor VIII deficiency) for on-demand treatment and control of bleeding episodes, perioperative management of bleeding and routine prophylaxis to reduce the frequency of bleeding episodes.

JIVI (antihemophilic factor [recombinant] Pegylated-aucl) should be reported with procedure code J7199 and NDC 00026-3942-25, 00026-3944-25, 00026-3946-25 or 00026-3948-25.

URMBT groups are excluded from coverage.

Pharmacy doesn’t require preauthorization for this drug.

J9171

Basic benefit and medical policy

Docefrez (docetaxel)

Docefrez (docetaxel) is established for the new FDA-approved indication for the treatment of castration-resistant prostate cancer, with prednisone in metastatic castration-resistant prostate cancer, effective Jan. 8, 2019.

POLICY CLARIFICATIONS

90649

Basic benefit and medical policy

Gardasil 9 (human papillomavirus 9-valent vaccine, recombinant)

Effective Oct. 5, 2018, Gardasil 9 (human papillomavirus 9-valent vaccine, recombinant) is covered through age 45 for the following FDA-approved indications:

Gardasil 9 (human papillomavirus 9-valent vaccine, recombinant) is a vaccine indicated in girls and women ages 9 through 45 for the prevention of the following diseases:

Cervical, vulvar, vaginal and anal cancer caused by human papillomavirus types 16, 18, 31, 33, 45, 52 and 58
Genital warts (condyloma acuminata) caused by HPV types 6 and 11

And the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58:

Cervical intraepithelial neoplasia, or CIN, grade 2/3 and cervical adenocarcinoma in situ, or AIS.
Cervical intraepithelial neoplasia grade 1
Vulvar intraepithelial neoplasia, or VIN, grade 2 and grade 3
Vaginal intraepithelial neoplasia, or VaIN, grade 2 and grade 3
Anal intraepithelial neoplasia, or AIN, grades 1, 2 and 3

Gardasil 9 (human papillomavirus 9-valent vaccine, recombinant) is indicated in boys and men ages 9 through 45 for the prevention of the following diseases:

Anal cancer caused by HPV types 16, 18, 31, 33, 45, 52 and 58
Genital warts (condyloma acuminata) caused by HPV types 6 and 11

And the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58:

Anal intraepithelial neoplasia grades 1, 2, and 3

Dosing information:
Ages 9 through 14 years:

Regimen: Two-dose schedule: 0, 6 to 12 months**
Regimen: Three-dose schedule: 0, 2, 6 months

Age 15 through 45 years:

Regimen: Three-dose schedule: 0, 2, 6 months

**If the second dose is administered earlier than five months after the first dose, administer a third dose at least four months after the second dose.

Pharmacy doesn’t require prior authorization of this drug.

NDCs: 00006-4119-01, 00006-4119-03, 00006-4121-01, 00006-4121-02

J0583

Basic benefit and medical policy

Angiomax (bivalirudin)

Effective Dec. 21, 2018, Angiomax (bivalirudin) is covered for the following updated FDA-approved indications:

Angiomax (bivalirudin) is indicated for use as an anticoagulant in patients undergoing percutaneous coronary intervention, known as PCI, including patients with heparin-induced thrombocytopenia, known as HIT, or heparin-induced thrombocytopenia and thrombosis syndrome, known as HITTS.

Dosing information:

The recommended dosage is a 0.75 mg/kg intravenous bolus dose followed immediately by a 1.75 mg/kg/h intravenous infusion for the duration of the procedure. Five minutes after the bolus dose has been administered, an activated clotting time should be performed and an additional bolus dose of 0.3 mg/kg should be given if needed.
Extending duration of infusion post-procedure up to four hours should be considered in patients with ST segment elevation MI, known as STEMI.

Pharmacy doesn’t require preauthorization of this drug.

NDC: 65293-0001-01

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

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

Hepatocellular carcinoma, known as HCC: For the treatment of patients with HCC who have been previously treated with sorafenib.
Merkel cell carcinoma, known as MCC: For the treatment of adult and pediatric patients with recurrent locally advanced or metastatic Merkel cell carcinoma. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.
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 [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

Dosage information:

Hepatocellular carcinoma: 200 mg every three weeks
Merkel cell carcinoma: 200 mg every three weeks for adults; 2 mg/kg (up to 200 mg) every three weeks for pediatrics
Urothelial carcinoma: 200 mg every three weeks

Pharmacy doesn’t require preauthorization of this drug.

NDCs: 00006-3026-01, 00006-3026-02

GROUP BENEFIT CHANGES

Lear Corporation

A company formerly called IMA has been acquired by Lear. Their group number is 71427. The group joins Blue Cross Blue Shield of Michigan, effective July 1, 2019.

Group number: 71427
Alpha prefix: PPO LRP and LPQ
Platform: NASCO hybrid

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

Note: The Federal Employee Program^® follows its own criteria related to procedure codes J3490, J3590, J9271 and J9305.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.