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October 2019

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:

  • Log in to web-DENIS.
  • 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

81521

Basic benefit and medical policy

Genetic testing in prognosis of breast cancer

The safety and effectiveness of the use of the 21-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay (Oncotype DX®), the EndoPredict®, the Breast Cancer IndexSM, MammaPrint and Prosigna™ tests to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy have been established. They’re useful diagnostic tests for determining the likelihood of distant cancer recurrence in women for patients who meet the inclusionary guidelines.

Other genetic testing for determining the likelihood of distant cancer recurrence in women is experimental (refer to exclusions below).

Inclusionary criteria have been expanded, effective July 1, 2019.

Payment policy
Procedure *81521 isn’t payable in an office or ambulatory surgery center location. Payable to M.D., D.O. and independent laboratories. Modifiers 26 and TC don’t apply.

Inclusions (must meet all):
The use of Oncotype Dx®, the EndoPredict®, the Breast Cancer IndexSM, MammaPrint and Prosigna™ tests to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy may be considered established in women with breast cancer meeting all the following characteristics:

  • Unilateral tumor
  • Hormone receptor-positive (that is, estrogen-receptor [ER] positive or progesterone-receptor [PR]-positive)
  • Human epidermal growth factor receptor (HER) 2-negative
  • Tumor size 0.6-1 cm with moderate/poor differentiation or unfavorable features or tumor size larger than 1 cm
  • Node negative (lymph nodes with micrometastases [less than 2 mm in size] are considered node negative for this policy).
  • They’ll be treated with adjuvant endocrine therapy (tamoxifen or aromatase inhibitors)
  • When the test result will aid the patient in making the decision regarding chemotherapy (when chemotherapy is a therapeutic option)
  • When ordered within six months after diagnosis, since the value of the test for making decisions regarding delayed chemotherapy is unknown.

Use of multigene assay to assess prognosis and determine chemotherapy benefit for node-positive, ER+, HER2- breast cancer with pN1mi (≤2 mm axillary node metastasis) or N1 (<4 nodes) is established.

These tests should only be ordered on a tissue specimen obtained during surgical removal of the tumor and after subsequent pathology examination of the tumor has been completed and determined to meet the above criteria (the test should not be ordered on a preliminary core biopsy). The test should be ordered in the context of a physician-patient discussion regarding risk preferences when the test result will aid in making decisions regarding chemotherapy.

For patients who otherwise meet the above characteristics but who have multiple ipsilateral primary tumors, a specimen from the tumor with the most aggressive histological characteristics should be submitted for testing. It’s not necessary to conduct testing on each tumor; treatment is based on the most aggressive lesion.

Exclusions:

  • Gene expression assays when used in tandem with other similar assays is considered investigational, only a single assay should be used. (Oncotype DX and MammaPrint shouldn’t be ordered on the same patient.)
  • Use of a subset of genes from the 21-gene RT-PCR assay for predicting recurrence risk in patients with noninvasive ductal carcinoma in situ (DCIS) (Oncotype DX® DCIS) to inform treatment planning following excisional surgery is considered experimental.
  • The use of other gene expression assays (Mammostrat® Breast Cancer Test, the BreastOncPx™, NexCourse® Breast IHC4, BreastPRS™, etc.) for any indication is experimental.
  • The use of gene expression assays in men with breast cancer is considered experimental.
  • The use of gene expression assays to molecularly subclassify breast cancer (BluePrint®) is considered experimental.
  • The use of gene expression assays for quantitative assessment of ER, PR and HER2 overexpression (TargetPrint®) is considered experimental.
POLICY CLARIFICATIONS

Revenue code 0128

Basic benefit and medical policy

Michigan hospital based and freestanding substance abuse facilities

Michigan hospital-based and freestanding substance abuse facilities for facility code range 20000 through 21999 will reject as “not a benefit” when reported with type of bill 11X or revenue code 0128.

J0490

Basic benefit and medical policy

Benlysta (belimumab)

Starting April 26, 2019, Benlysta (belimumab) is covered for the following updated FDA-approved indications:

Benlysta (belimumab) is a B-lymphocyte stimulator (BLyS)-specific inhibitor indicated for the treatment of patients aged 5 years and older with active, autoantibodypositive, systemic lupus erythematosus who are receiving standard therapy.

Limitations of use

The efficacy of Benlysta (belimumab) hasn’t been evaluated in patients with severe active lupus nephritis or severe active central nervous system lupus. Benlysta (belimumab) hasn’t been studied in combination with other biologics or intravenous cyclophosphamide. Use of Benlysta (belimumab) isn’t recommended in these situations.

J3490
J3590
C9399

Basic benefit and medical policy

Zolgensma (onasemnogene abeparvovec-xioi)

Zolgensma (onasemnogene abeparvovec-xioi) is considered established starting May 24, 2019.

Zolgensma (onasemnogene abeparvovec-xioi) is considered covered when the following criteria are met:

Zolgensma (onasemnogene abeparvovec-xioi) is an adeno-associated virus vector-based gene therapy indicated for the treatment of pediatric patients younger than age 2 with spinal muscular atrophy, known as SMA, with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene.

Limitation of use:

  • The safety and effectiveness of repeat administration of Zolgensma (onasemnogene abeparvovec-xioi) haven’t been evaluated.
  • The use of Zolgensma (onasemnogene abeparvovec-xioi) in patients with advanced SMA (complete paralysis of limbs, permanent ventilator dependence) hasn’t been evaluated.

Dosing information:

Zolgensma (onasemnogene abeparvovec-xioi) is for single-dose intravenous infusion only.

  • The recommended dosage of Zolgensma (onasemnogene abeparvovec-xioi) is 1.1 × 1014 vector genomes (vg) per kg of body weight.
  • Administer Zolgensma (onasemnogene abeparvovec-xioi) as an intravenous infusion over 60 minutes
  • Starting one day prior to Zolgensma (onasemnogene abeparvovec-xioi) infusion, administer systemic corticosteroids equivalent to oral prednisolone at 1 mg/kg of body weight per day for a total of 30 days. At the end of the 30-day period of systemic corticosteroid treatment, check liver function by clinical examination and by laboratory testing. For patients with unremarkable findings, taper the corticosteroid dose over the next 28 days. If liver function abnormalities persist, continue systemic corticosteroids (equivalent to oral prednisolone at 1 mg/kg/day) until findings become unremarkable, and then taper the corticosteroid dose over the next 28 days. Consult experts if patients don’t respond adequately to the equivalent of 1 mg/kg/day oral prednisolone.

Pharmacy requires preauthorization of this drug.

This drug isn’t a benefit for URMBT. 

NDCs: 71894-0120-02, 71894-0122-03, 71894-0125-04, 71894-0123-03, 71894-0128-05, 71894-0131-06, 71894-0126-04, 71894-0134-07, 71894-0137-08, 71894-0129-05, 71894-0140-09, 71894-0132-06, 71894-0135-07, 71894-0138-08, 71894-0141-09, 71894-0121-03, 71894-0124-04, 71894-0127-05, 71894-0130-06, 71894-0133-07, 71894-0136-08, 71894-0139-09.
GROUP BENEFIT CHANGES

Coalition of Public Safety Employees Health Trust

Coalition of Public Safety Employees Health Trust,
group number 71792, is joining Blue Cross Blue Shield of Michigan starting Oct. 1, 2019.

Group number: 71792
Alpha prefix: PPO (SEE)
Platform: NASCO Flexlink

Plans offered:
PPO medical/surgical

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.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.