Billing chart: Blues highlight medical, benefit policy changes

Established codes:
19303, 19304, 19318, 19350, 54520, 55970, 55980, 56805, 57291, 57292, 57335, 58150, 58152, 58180, 58260, 58262, 58275, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554

Note: Code 17380 may be considered established when performed to prepare tissues before genital surgery when billed with 55970, 55980, 57291, 57292 or 57335 — see inclusions.

Investigational, not medically necessary, etc.:
11950, 11951, 11952, 11954,15820, 15821, 15822, 15823, 15824,15825, 15826, 15828, 15830, 15832,15833, 15834, 15835, 15836, 15837,15838, 15839, 15876, 15877, 15878, 15879, 17380, 21120, 21121, 21122, 21123 21125, 21127, 30400, 30410, 30420, 30430, 30435, 30450

Basic benefit and medical policy

Transgender services

The criteria have been updated for the transgender services policy. This policy is effective May 1, 2019.

Assessment, diagnosis and treatment should be provided through a multidisciplinary gender services clinic or program affiliated with a major medical center. If this level of service is unavailable, there should be documentation that reflects a coordinated approach to care by specialists involved (mental health specialists, physicians, surgeons, etc.).

Puberty suppression**

Puberty suppression hormones for adolescents may be indicated for members who meet all the following inclusionary criteria:

• Onset of puberty to at least Tanner Stage 2.
• The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed).
• Gender dysphoria emerged or worsened with the onset of puberty.
• Any coexisting psychological, medical or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment.
• The adolescent has given informed consent and, particularly when the adolescent hasn’t reached the age of medical consent, the parents or other legally authorized caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
• The absence of contraindications to therapy in the judgment of the managing physician.

**Medications for puberty suppression may be managed under the member’s pharmacy benefit.

Hormone therapy**

Hormone therapy may be indicated for members who meet all the following inclusionary criteria:

• Persistent, well-documented gender dysphoria
• Capacity to make a fully informed decision and to consent for treatments
• Eighteen years of age or older (age of majority)
• If significant medical or mental health concerns are present, they must be reasonably well-controlled.
• The absence of contraindications to therapy in the judgment of the managing physician

**Medications for hormone therapy may be managed under the member’s pharmacy benefit.

Gender reassignment surgery

Gender reassignment surgery may be indicated for members who meet all the following inclusionary criteria:

• Persistent, well-documented gender dysphoria
• The provider must supply documentation that supports the member meets criteria for gender reassignment surgery. This includes detailed psychological assessments by two mental health providers:
• Psychiatrist
• Ph.D. prepared clinical psychologist
• Master’s level clinicians who are licensed to practice independently in their state
• Eighteen years of age or older
• Capacity to make a fully informed decision and to consent for treatment
• If significant medical or mental health concerns are present, they must be controlled.
• Twelve continuous months of hormone therapy** as appropriate to the patient’s gender role (unless there is a contraindication to hormonal therapy):
• **Hormonal therapy is not required before a mastectomy in biological female-to-male patients.
• The aim of hormone therapy before gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.
• Twelve continuous months of living in a gender role that is congruent with their gender identity:
• Living in a gender role congruent with gender identity for 12 continuous months is not required before a mastectomy in biological female-to-male patients.

Electrolysis

• If gender reassignment surgery is approved for a biological male transitioning to female, permanent hair removal (by electrolysis) may be considered established following medical review. Permanent hair removal is considered established only when the scrotal and surrounding tissues are used in the surgical construction of the vagina.
• If gender reassignment surgery is approved for a biological female transitioning to male, permanent hair removal (by electrolysis) may be considered established following medical review. Permanent hair removal is considered established only when free flap or other donor tissues are used for phalloplasty that’s performed in conjunction with vaginectomy and full-length urethroplasty.

Some patients receiving transgender services may require and benefit from ongoing behavioral health services, including psychotherapy.

Exclusions:

• Transgender services aren’t covered if contract or certificate language contains specific exclusion of these services.
• Reversal of transgender surgical procedures.
• All surgical procedures that are primarily cosmetic and not medically necessary, including but not limited to:
• Abdominoplasty
• Blepharoplasty
• Breast enhancements
• Brow lift
• Calf implants
• Cheek/malar implants
• Chin/nose implants
• Chondrolaryngoplasty (Adam’s apple reduction)
• Collagen injections
• Drugs for hair loss or growth
• Forehead lift
• Hair removal (for exception: see inclusions, electrolysis)
• Hair transplantation
• Lip reduction
• Liposuction
• Mastopexy
• Neck tightening
• Pectoral implants
• Removal of redundant skin
• Rhinoplasty
• Speech-language therapy
• Non-covered services

J9351

Basic benefit and medical policy

Hycamtin (topotecan)

Effective Sept. 5, 2018, Hycamtin (topotecan) is covered for the following updated FDA-approved indications:

Hycamtin (topotecan) for injection is a topoisomerase inhibitor indicated for treatment of:

• Patients with metastatic ovarian cancer after disease progression on or after initial or subsequent chemotherapy, as a single agent
• Patients with small cell lung cancer platinum-sensitive disease who progressed at least 60 days after initiation of first-line chemotherapy, as a single agent
• Patients with Stage IV-B, recurrent or persistent cervical cancer that isn’t amenable to curative treatment, in combination with cisplatin

Dosing information:

• Ovarian cancer and small cell lung cancer: 1.5 mg/m2 by intravenous infusion over 30 minutes daily for five consecutive days, starting on Day 1 of a 21-day cycle
• Cervical cancer: 0.75 mg/m2 by intravenous infusion over 30 minutes on Days 1, 2 and 3, with cisplatin 50 mg/m2 on Day 1 of a 21-day cycle
• Renal impairment: Reduce dose if creatinine clearance (CLcr) 20 to 39 mL/min

Pharmacy doesn’t require preauthorization of this drug.

NDC: 00078-0674-61

81479, 81599

Basic benefit and medical policy

Gene genetic testing using single nucleotide variants to predict risk of nonfamilial breast cancer

Regarding the policy titled Genetic Testing (Single Nucleotide Variants) To Predict Risk of Nonfamiliar Breast Center, the effectiveness and clinical utility of genetic testing using single nucleotide variants to predict future risk of breast cancer is considered experimental. There is insufficient scientific evidence on the analytical and clinical validity as well as clinical utility of these tests on patient management and outcomes.

This policy is effective March 1, 2019.

83698, 0423T

Basic benefit and medical policy

Fluad measurement of Lp-PLA2 and sPLA-IIA in cardiovascular risk

The measurement of lipoprotein-associated Phospholipase A2 (Lp-PLA2) in the assessment of cardiovascular risk is considered experimental. While this service may be safe, its usefulness in the clinical management of atherosclerosis hasn’t been established.

Measurement of secretory type II Phospholipase A2 (sPLA2-IIA) to determine risk of cardiovascular disease is considered experimental. Current medical literature doesn’t support a causal relationship between sPLA2-IIA and cardiovascular disease.

This policy has been updated, effective May 1, 2019.

B4105

Basic benefit and medical policy

Relizorb

Relizorb^® is considered experimental. There is insufficient scientific evidence to indicate that this technology is beneficial.

This policy is effective May 1, 2019.