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September 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
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| UPDATES TO PAYABLE PROCEDURES |
19318
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Basic benefit and medical policy
Reduction mammaplasty
The safety and effectiveness of reduction mammaplasty have been established. It may be considered a useful therapeutic option (and not considered cosmetic) when either:
- The patient meets specified patient selection guidelines.
- When performed in conjunction with medically necessary breast reconstruction for the purposes of attaining breast symmetry.
Inclusionary criteria have been updated, effective Sept. 1, 2019.
Inclusions:
Patients younger than age 18 can’t give legal consent for surgery. The parent or legal guardian must support and authorize a reduction mammaplasty (breast reduction). Emancipated minors may be extended individual consideration.
A. Must meet both criteria 1 and 2:
- Patient’s breasts are fully developed (breast size is stable for approximately one year).
- Removal of more than 500 grams of tissue per breast.
or
Must meet both B and C criteria:
B. Two of the following must be met:
- Pain (both of the following):
- Documented pain in the neck or shoulders or postural backache that must be of long-standing duration
- Failure of conservative therapy (for example, an appropriate support bra, exercises, heat/cold treatments, non-steroidal anti-inflammatory agents or muscle relaxants)
- Shoulder grooving
- Recurrent intertrigo between the breasts and the chest wall
and
C. Must meet both criteria:
- Patient’s breasts are fully grown (breast size stable for approximately one year).
- The amount of tissue to be removed must be greater than or equal to the 22nd percentile on the Schnur scale.
The Schnur sliding scale (see below) is used by doctors to evaluate individuals being considered for breast reduction surgery.
Body surface area, along with average weight of breast tissue removed, is incorporated into the chart. If the individual's body surface area and weight of breast tissue removed fall below the 22nd percentile, then the surgery isn’t considered medically necessary. If the individual's body surface area and weight of breast tissue removed is above the 22nd percentile, then the surgery is considered medically necessary if other applicable criteria are met.
Schnur sliding scale (11)
Body surface area
(in meters squared) |
Lower 22nd percentile
(grams to be removed per breast) |
| 1.35 |
199 |
| 1.40 |
218 |
| 1.45 |
238 |
| 1.50 |
260 |
| 1.55 |
284 |
| 1.60 |
310 |
| 1.65 |
338 |
| 1.70 |
370 |
| 1.75 |
404 |
| 1.80 |
441 |
| 1.85 |
482 |
| 1.90 |
527 |
| 1.95 |
575 |
| 2.00 |
628 |
| 2.05 |
687 |
| 2.10 |
750 |
| 2.15 |
819 |
| 2.20 |
895 |
| 2.25 |
978 |
| 2.30 |
1,068 |
| 2.35 |
1,167 |
| 2.40 |
1,275 |
| 2.45 |
1,393 |
| 2.50 |
1,522 |
| 2.55 |
1,662 |
Calculation of body surface area
Body surface area = the square root of height (cm) times weight (kg) divided by 3,600.
To convert pounds to kilograms, multiply pounds by 0.45.
To convert inches to meters, multiply inches by .0254.
To calculate body surface area, click here.**
Exclusions:
Breast reduction isn’t covered for either of the following indications because it’s considered cosmetic in nature and not medically necessary:
- Surgery is being performed to treat psychological symptomatology or psychosocial complaints, in the absence of significant physical, objective signs.
- Surgery is being performed for the sole purpose of improving appearance.
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
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81445, 81545, 0018U, 0026U, 81479**
**Used to represent an unlisted procedure |
Basic benefit and medical policy
Molecular markers in FNA of thyroid
The use of either Afirma Gene Expression Classifier® or ThyroSeq v3® in fine needle aspirates of thyroid nodules with indeterminate cytologic findings (Bethesda diagnostic category III [atypia/follicular lesion of undetermined significance] or Bethesda diagnostic category IV [follicular neoplasm/suspicion for a follicular neoplasm]) is established in patients who have the following characteristics:
- Thyroid nodules without strong clinical or radiologic findings suggestive of malignancy
- In whom surgical decision-making would be affected by test results
The use of any of the following types of molecular marker testing or gene variant analysis in fine needle aspirates of thyroid nodules with indeterminate findings (Bethesda diagnostic category III [atypia/follicular lesion of undetermined significance] or Bethesda diagnostic category IV [follicular neoplasm/suspicion for a follicular neoplasm]) or suspicious findings (Bethesda diagnostic category V [suspicious for malignancy]) to rule in malignancy to guide surgical planning for initial resection rather than a two-stage surgical biopsy followed by definitive surgery may be considered established:
- ThyroSeq v3®
- ThyraMIR microRNA/ThyGenX®
- Afirma BRAF after Afirma Gene Expression Classifier®
- Afirma MTC® after Afirma Gene Expression Classifier®
Gene expression classifiers, genetic variant analysis and molecular marker testing in fine needle aspirates of the thyroid not meeting criteria outlined above, including but not limited to use of RosettaGX Reveal® and single-gene TERT testing, are considered experimental.
This policy statement has been updated, effective Sept. 1, 2019.
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J3590
J3490
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Basic benefit and medical policy
Avastin (bevacizumab) Blue Cross Blue Shield of Michigan has approved additional diagnoses for the off-label use of Avastin (bevacizumab). When submitted with one of the diagnoses codes listed below manual review isn’t required. Report with not otherwise classified procedure code J3490 or J3590 and the appropriate National Drug Code.
Diagnosis codes
E08.319, E08.3291, E08.3292, E08.3293, E08.3391, E08.3392, E08.3393, E08.3491, E08.3492, E08.3493, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E09.319, E09.3291, E09.3292, E09.3293, E09.3491, E09.3492, E09.3493, E09.3551, E09.3552, E09.3553, E09.3591, E09.3592, E09.3593, E10.319, E10.321, E10.3291, E10.3292, E10.3293, E10.331, E10.3391, E10.3392, E10.3393, E10.341, E10.3491, E10.3492, E10.3493, E10.351, E10.3551, E10.3552
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| POLICY CLARIFICATIONS |
11920, 11921, 11922, 19301, 19302, 19304, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, C1789, L8600, S2066, S2067 and S2068 |
Basic benefit and medical policy
Reconstructive breast surgery, management of breast implants
The safety and effectiveness of breast implant and breast reconstruction procedures have been established. Insertion, removal and reinsertion of silicone gel or saline filled breast implants are established procedures for breast reconstruction and implant surgery when specific clinical criteria are met.
The policy is effective Sept. 1, 2019.
Breast reconstruction
Inclusions:
Breast reconstruction on affected breast or contralateral breast to achieve symmetry (reconstruction may include insertion or re-insertion of implants [silicone or saline], free flap, autologous tissue, latissimus dorsi flap or transverse rectus abdominis myocutaneous flap, nipple tattooing or nipple reconstruction) for any of the conditions listed below:
- Congenital defects, such as breast agenesis
- Mastectomy (including radical, modified radical, subcutaneous, simple and partial) due to current diagnosis of breast cancer
- Mastectomy secondary to family or personal history of cancer of the breast
- Accidental injury or trauma to the breast
Exclusions:
All other conditions
Implants
Inclusions:
Implant removal for documented:
- Baker Class III contractures (only if initial implant was for reconstructive purposes)
- Baker Class IV contracture
- Recurrent infection
- Breast implant-wssociated anaplastic large cell lymphoma, or BIA-ALCL
- Suspected BIA-ALCL (symptoms of pain, swelling, redness or lump in the area of the implant; seroma; asymmetry of the breast). Bilateral removal is covered if requested.
- Extrusion
- Silicone implant rupture
- Surgery for a new diagnosis of breast cancer
- Textured-surface breast implant when the surgeon determines it’s in the best interest of the patient. Reinsertion of an implant won’t be covered.
Exclusions:
The following indications for removal of breast implant aren’t considered medically necessary:
- Patient anxiety
- Pain not related to contractures or rupture
- Baker Class III contractures in patients with implants for cosmetic purposes
- Removal of a ruptured saline breast implant when the original insertion was for a cosmetic purpose
- Systemic symptoms, attributed to connective tissue diseases, autoimmune diseases, etc.
Exclusions:
When the above criteria aren’t met
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81171
81172
81243
81244
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Basic benefit and medical policy
Genetic testing for FMR1 and FMR2 variants, including fragile X and fragile XE syndromes
Genetic testing for FMR1 variants may be considered established in select patient populations.
Genetic testing for FMR2 variants (AFF2 gene) is considered experimental. Medical literature hasn’t demonstrated the clinical utility of this testing.
The policy is effective Sept. 1, 2019.
FMR1 gene testing
Inclusions:
Individuals with characteristics of fragile X syndrome or a fragile X-associated disorder, including:
- Individuals with intellectual disability, developmental delay or autism spectrum disorder
- Women with primary ovarian insufficiency younger than age 40 in whom fragile X-associated primary ovarian insufficiency is suspected
- Women with ovarian failure before the age of 40 prior to in vitro fertilization (refer to member’s specific certificate for coverage of in-vitro services)
- Individuals with neurologic symptoms consistent with fragile X-associated tremor or ataxia syndrome
Individuals who have a personal or family history of fragile X syndrome who are seeking reproductive counseling, including:
- Individuals who have a family history of fragile X syndrome or a family history of undiagnosed intellectual disability
- Affected individuals or relatives of affected individuals who have had a positive cytogenetic fragile X test result who are seeking information on carrier status
- Prenatal testing of fetuses of known carrier mothers
Exclusions:
Genetic testing for FMR1 variants for all other uses not specified under the inclusions
Genetic testing for FMR2 (AFF2) variants is considered experimental.
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81227
81355
G9143
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Basic benefit and medical policy
Genotype-guided warfarin dosing
Genetic testing for warfarin dosing is experimental. The clinical utility of genetic testing to determine cytochrome p450 2C9 (CYP2C9), P450 4F2 (CYP4F2) and vitamin K epoxide reductase subunit C1(VKORC1) genetic polymorphisms and other warfarin responsive testing for the purpose of determining warfarin dosing hasn’t been demonstrated. The peer-reviewed medical literature hasn’t yet shown that this testing has sufficient diagnostic accuracy to provide clinically relevant information for patient management.
The policy is effective Sept. 1, 2019.
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Established
93580
Other codes (investigational, not medically necessary, etc.)
93799
33999
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Basic benefit and medical policy
Closure devices for patent foramen ovale and atrial septal defects
The criteria have been updated for the Closure Devices for Patent Foramen Ovale and Atrial Septal Defects policy, effective July 1, 2019.
Closure of patent foramen ovale, using a percutaneous transcatheter approach may be considered established when specified criteria are met.
Transcatheter closure of secundum atrial septal defects may be considered established when using a device that has been FDA approved for that purpose and used according to the labeled indications.
Inclusions:
Closure of patent foramen ovale using a percutaneous transcatheter approach using AMPLATZERTM PFO Occluder when all the following are met:
- Used to reduce the risk of recurrent ischemic stroke
- Patient is between 18 and 60 years of age
- Echocardiography confirms diagnosis of patent foramen ovale with a right-to-left interatrial shunt
- Documented history of cryptogenic ischemic stroke due to presumed paradoxical embolism as determined by a neurologist and cardiologist:
- Any other identifiable cause of stroke has been excluded including:
- Large vessel atherosclerotic disease
- Small vessel occlusive disease
- None of the following is present:
- Uncontrolled vascular risk factors including:
- Uncontrolled diabetes mellitus
- Uncontrolled hypertension
- Other sources of right-to-left shunts including:
- Atrial septal defect
- Fenestrated septum
- Active endocarditis or other untreated infections
- Inferior vena cava filter
Closure of atrial septal defects with an FDA-approved device when all the following are met:
- There is echocardiographic evidence of ostium secundum atrial septal defect.
- There is evidence of right ventricular volume overload.
Exclusions:
- Stroke due to presumed paradoxical embolism through a patent foramen ovale.
- Patent foramen ovale with recurrent cryptogenic migraine
- Closure of a septal defect when performed using the transmyocardial approach
- Open surgery is needed to repair multiple congenital defects or other cardiac defects
- Multiple cardiac defects that can’t be covered by the device
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J1599
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Basic benefit and medical policy
Cutaquig (immune globulin subcutaneous (human) - hipp)
Cutaquig (immune globulin subcutaneous (human) - hipp) is considered established, effective Dec. 12, 2018.
Cutaquig (immune globulin subcutaneous (human) - hipp) is considered covered when all the following criteria are met:
Cutaquig (Immune Globulin Subcutaneous (human) - hipp) is a 16.5% immune globulin solution for subcutaneous infusion indicated for treatment of primary humoral immunodeficiency in adults.
Dosage information:
Before switching to Cutaquig, obtain the patient’s serum IgG trough level to guide subsequent dose adjustments.
Dose:
- Switching from IGIV to Cutaquig: Calculate the dosing by using a dose conversion factor (1.40); Switching from other IGSC: dosing should be the same as for previous IGSC.
- Weekly: Start Cutaquig one week after last IGIV infusion
Initial weekly dose =
Previous IGIV dose (in grams) x 1.40
Number of weeks between IGIV doses
- Adjust dosing according to patient’s.
- pharmacokinetics and clinical response.
This drug isn’t a benefit for URMBT.
Prior authorization is required for this drug.
NDCs: 68982-0810-01, 68982-0810-02,
68982-0810-03, 68982-0810-04, 68982-0810-05, 68982-0810-06, 68982-0810-81, 68982-0810-82, 68982-0810-83, 68982-0810-84, 68982-0810-85, 68982-0810-86
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J9022 |
Basic benefit and medical policy
Value codes approved
Effective June 1, 2018, the following diagnoses are payable for procedure code J9022:
- C68.1
- C79.10
- C79.11
- C79.19
- C79.89
- C79.9
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Value codes
P1, P2, P3
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Basic benefit and medical policy
Value codes approved Effective July 1, 2019, the National Uniform Billing Committee approved three new value codes.
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