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February 2020

Professional

We’re announcing HEDIS quality measure changes

In October, the National Committee for Quality Assurance released value set changes for the following HEDIS^® quality measures:

Comprehensive Diabetes Care, or CDC: HbA1c control
Comprehensive Diabetes Care, or CDC: Retinal eye exam
Controlling High Blood Pressure, or CBP

Important changes

CDC: HbA1c: Two new procedure codes (*3051F and *3052F) were added to better capture HbA1c levels. Code *3045F (HbA1c level 7.0-9.0%) should no longer be used. When conducting an HbA1c test in your office, submit the distinct numeric results on the HbA1c claim with the appropriate procedure code:

Procedure code* Most recent HbA1c level

3044F <7%

3046F >9%

3051F >7% and <8%

3052F >8% and <9%

CDC: Retinal eye exam: One new procedure code (*2023F) was added to capture negative eye exam results, which result in two years of compliance for HEDIS^®. The code descriptor for *2022F was also revised to indicate its use for a positive eye exam. When results are received from an eye care professional, submit the results on a $0.01 claim with the appropriate procedure code:

Procedure code*	Retinal eye exam findings
2022F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy
2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy
3072F	Low risk for retinopathy (no evidence of retinopathy in the prior year)

CBP: The measure has been revised to allow for administrative closure through claims. Submit blood pressure procedure codes for each office visit:

Procedure code* Most recent systolic blood pressure

3074F <130 mm Hg

3075F 130-139 mm Hg

3077F ≥ 140 mm Hg

Procedure code* Most recent diastolic blood pressure

3078F <80 mm Hg

3079F 80-89 mm Hg

3080F ≥ 90 mm Hg

Learn more about the CDC and CBP measures, including information about who’s included in the measures, exclusions and useful tips, by accessing the following tip sheets:

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

HEDIS medical record reviews begin in February

Each year from February through May, Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set, or HEDIS^®, medical record reviews for members who live in Michigan. This year, Blue Cross HEDIS clinical consultants will conduct HEDIS reviews for members with Blue Cross’ PPO plans (including commercial, Medicare Plus Blue^SM and individual products) who had services in 2019.

Effective Jan. 1, 2020, to support HEDIS and government-required programs, the Blue Cross and Blue Shield Association has mandated who can retrieve medical records for patients living in Michigan but enrolled in another state’s Blue plan. Blue Cross Blue Shield of Michigan is authorized to retrieve medical records for patients enrolled in a Blue Medicare Advantage PPO plan in another state.

Inovalon, an independent data and analytics firm, is authorized to retrieve medical records for patients enrolled in all Blue Cross PPO plans, as well as Blue Medicare Advantage PFFS and HMO plans.

For the HEDIS reviews, Blue Cross looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results, colorectal screenings and body mass index. This information helps us improve health care quality reporting for our members.

Blue Cross HEDIS clinical consultants will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. The HEDIS review also requires proof of service documentation for data collected from a medical record.

If you have questions or concerns, contact Laurie Latvis at llatvis@bcbsm.com.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Sign up for additional training webinars

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

Here is a list of upcoming webinars. Simply click on the name of the training webinar to register:

Webinar name	Date and time
Learning to use the new features of e-referral	Tuesday, Feb. 4, 10 to 10:30 a.m.
Learning to use the new features of e-referral	Thursday, Feb. 6, 1 to 1:30 p.m.
Hyaluronic acid knee injections — preferred vs. non-preferred	Tuesday, Feb. 11, 1 to 1:30 p.m.
Hyaluronic acid knee injections — preferred vs. non-preferred	Tuesday, Feb. 18, 10 to 10:30 a.m.

We’ve also posted recordings of webinars previously delivered in the summer and fall of 2019, including the November Patient Portals session. You can find them on the Learning opportunities and Provider Training pages. Here’s how to find the links:

For Blue Cross:

Log in to Provider Secured Services.
Go to BCBSM Newsletters and Resources.
Click on Provider Training under Popular links.

For BCN:

Log in to Provider Secured Services.
Go to BCN Provider Publications and Resources.
Click on Learning opportunities under Other Resources.

As additional training webinars become available, we’ll keep you up to date with web-DENIS messages or articles in The Record and BCN Provider News.

Take our Blues Brief survey

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how satisfied you are with the monthly (professional), quarterly (facility) and specialty versions of Blues Brief, our two-page provider newsletter. Let us know by completing a short survey. The survey closes March 31, 2020. Your responses will improve the future Blues Brief publications.

Blues Brief can be found at bcbsm.com/providers/newsletters.html and on web-DENIS under BCBSM Newsletters and Resources or BCN Provider Publications and Resources. The newsletter includes brief summaries of select articles in The Record and BCN Provider News. It’s not intended to replace either publication.

Learn more about health concerns addressed in Medicare Health Outcomes Survey

According to the National Committee for Quality Assurance:

Falls are the leading cause of death by injury in people age 65 and older; each year, 1 in 4 older adults falls.
Urinary incontinence is significantly underreported and underdiagnosed.
Any amount of physical activity reduces the risk of developing certain chronic conditions and increases quality of life.

The Medicare Health Outcomes Survey, or HOS, measures patient-reported outcomes to help address these serious health concerns. The survey runs from April to July and asks Medicare Advantage members about how their health care providers talk to them about these important topics:

Fall risk management
Management of urinary incontinence in older adults
Physical activity in older adults

Review the HOS tip sheet to see sample survey questions and learn how you can address care opportunities with patients.

Starting May 1, additional radiology procedures for our commercial, Medicare Plus Blue members will require prior authorization

Beginning May 1, 2020, the PPO Radiology Management Program, administered by AIM Specialty Health^®, will require prior authorization for additional radiology procedures. This change will apply to Blue Cross Blue Shield of Michigan commercial members, Blue Care Network commercial members and Medicare Plus Blue^SM members.

Here are the procedure codes that will require prior authorization for both office settings and hospital outpatient locations:

Myocardial perfusion imaging, or MPI, and positron emission tomography, or PET, scan:

*78429
*78430
*78431
*78432
*78433

A list of these codes will be available at aimspecialtyhealth.com** in April 2020. You can also refer to Blue Cross’ online provider manuals.

Providers can get authorization through Provider Secured Services at bcbsm.com/providers or by contacting AIM at 1-800-728-8008.

Reminder: Keep in mind that not all of our members require prior authorization through AIM. Benefit Explainer will let you know if a service requires authorization when you enter the patient’s contract number and the procedure code for a service.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Reminder: UAW International and UAW Retiree Health Care Trust don’t require AIM prior authorization

There continues to be some confusion about which UAW-related groups require preauthorization from AIM Specialty Health^®. While UAW Retiree Medical Benefits Trust, or URMBT, members require prior authorization for select outpatient medical diagnostic services, the following UAW groups do not require prior authorization:

UAW Retiree Health Care Trust (group number 70605)
UAW International Union (group number 71714)

Keep in mind that you should always check Benefit Explainer for information about eligibility and benefits for your patients. Benefit Explainer will let you know if a service requires authorization after you enter the patient's contract number and service procedure code.

Update: Blue Cross, BCN support providers who offer comprehensive opioid treatment

In the December 2019 Record, we published an article on this topic. We have updated the article with some additional information and clarifications. Please use the following as your reference for information about the Centers for Medicare & Medicaid Services program that encourages providers to offer the comprehensive range of opioid treatment services that many patients need.

Blue Cross Blue Shield of Michigan and Blue Care Network have implemented the CMS program that encourages providers to offer the comprehensive range of opioid treatment services that many patients need. You can view the CMS final rule on this program, which was published in the Federal Register.**

What this means
Starting Jan. 1, 2020, Medicare Plus Blue^SM and BCN Advantage^SM are using bundled rates to reimburse providers who offer certified opioid treatment programs, or OTPs. The bundled payment includes both drug and non-drug components and may allow for intensity add-on codes to be used when needed.

Only providers who are certified through the Substance Abuse and Mental Health Services Administration, or SAMHSA, to provide OTP services are eligible to receive bundled reimbursement.

Additional information you need to know

This applies to Medicare Plus Blue and BCN Advantage members only — not to our commercial members (BCN HMO^SM and Blue Cross’ PPO).
Member cost sharing applies for these services.
The bundled OTP reimbursement is for professional services only:

For Medicare Plus Blue, payment is based on the Medicare physician fee schedule.
For BCN Advantage, payment is based on the flat rates for non-drug costs released in December 2019 by CMS in Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet** (MLN 8296732).
HCPCS codes G2067 through G2080 must be billed with place of service 58.

The reimbursement doesn’t include drug costs. You’ll need to bill these as pharmaceutical services using standard billing practices.

What’s an OTP?
OTPs provide medication-assisted treatment along with counseling and other services for people diagnosed with an opioid use disorder. The treatment of opioid dependence with medications is governed by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations 8. This regulation created a system to accredit and certify opioid treatment programs.

SAMHSA’s Division of Pharmacologic Therapies is responsible for overseeing the certification of OTPs.

For information on how to obtain OTP certification, visit SAMHSA’s Certification of Opioid Treatment Programs** webpage.

About the CMS program
Section 2005 of the SUPPORT for Patients and Communities Act*** established a new Medicare Part B benefit for opioid use disorder treatment services. The opioid use disorder treatment services include medications for medication-assisted treatment furnished by opioid treatment programs.

To meet this statutory requirement, CMS has finalized the following:

Definitions of OTP and opioid use disorder treatment services.
Enrollment policies for OTPs.
Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat opioid use disorder and service intensity, and by full and partial weeks.
Adjustments to the bundled payment rates for geography and annual updates.
Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate.
Zero beneficiary copayment for a time-limited duration.

Blue Cross and BCN implemented this program beginning Jan. 1, 2020, as required by the SUPPORT for Patients and Communities Act. However, for Blue Cross and BCN members, applicable member cost-sharing amounts apply.

What’s next?
In the future, we may offer bundled rates to reimburse OTP services for our commercial members, in addition to our Medicare Advantage members.

Look for updates on this and on related topics in future issues of The Record and BCN Provider News, as well as web-DENIS messages and news items on our ereferrals.bcsbm.com website.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
***SUPPORT stands for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Additional free waiver training opportunities offered

We’ve added information on some new training sessions since we communicated about this topic in the January Record.

The Michigan Center for Clinical Systems Improvement, known as Mi-CCSI, and Blue Cross Blue Shield of Michigan are hosting the American Society of Addiction Medicine Treatment of Opioid Use Disorder course at various Michigan locations this year. Each course will provide the required eight educational hours to obtain the medication-assisted treatment waiver to prescribe buprenorphine in an office setting for patients with opioid use disorder.

The first two sessions, both hosted by Mi-CCSI, include a financial incentive. They’re flagged with two asterisks after the date and time, with an associated footnote at the bottom of the article.

Date and time	Location and registration link
Feb. 7 from 8 a.m. to 5 p.m.**	Delta Hotels by Marriott 2747 S. 11th St. Kalamazoo To register, click on the following: https://elearning.asam.org/p/MICCSI272020
March 2 from 8 a.m. to 5 p.m.**	Muskegon Community College Stevenson Center, Room 2318 221 S. Quarterline Road Muskegon To register, click on the following: https://elearning.asam.org/p/MICCSI322020
April 27 from 8 a.m. to 5 p.m.	Hagerty Center 715 E. Front St. Room A and B Traverse City To register, click on the following: https://elearning.asam.org/p/MOC427
May 28 from 8 a.m. to 5 p.m.	Upper Peninsula Health Group Conference Room 853 W. Washington St. Marquette To register, click on the following: https://elearning.asam.org/p/MOC528
June 5 from 8 a.m. to 5 p.m.	Thunder Bay National Marine Sanctuary 500 W Fletcher St. Alpena To register, click on the following: https://elearning.asam.org/p/MOC652020
Sept. 21 from 8 a.m. to 5 p.m.	Kent County Health Department 700 Fuller Ave. NE. Grand Rapids To register, click on the following: https://elearning.asam.org/p/MICCSI92120

These courses fill up quickly, so we encourage you to register early.

**The first 15 providers attending the full eight hours will be paid for the day as follows:

Physicians (M.D.s and D.O.s) — $500
Advanced practice providers (nurse practitioners and physician assistants) — $250

This incentive is only for the Feb. 7 and March 2 sessions.

Medicare Part B medical specialty drug prior authorization list changing in March

We’re adding medications to the Medicare Plus Blue^SM and BCN Advantage^SM Part B medical specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician’s office, an outpatient facility or a member’s home.

For dates of service on or after March 16, 2020, you’ll need to request authorization for the following medications through the system specified below.

NovoLogix:

J3590 Adakveo^®
J3490 Scenesse^®
J3490 Reblozyl^®

AIM Specialty Health^® ProviderPortal^SM:

J9309 Polivy^™
J9036 Belrapzo^™
J9118 Asparlas^™
J9313 Lumoxiti^™
J9356 Herceptin Hylecta^™
Q5116 Trazimera^™
Q5117 Kanjiti^™
Q5118 Zirabev^™

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care and when you bill these medications as a professional service or as an outpatient facility service:

Electronically through 837P or on a professional CMS-1500 claim form
Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

AIM authorization requests
You can submit authorizations through the AIM ProviderPortal or by calling 1-844-377-1278. For information about accessing the AIM ProviderPortal, see the Frequently Asked Questions page on the AIM website.**

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Clarification: Prolia and Xgeva drug authorization

The Part B specialty drugs Prolia^® and Xgeva^® require authorization for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These drugs have specific instructions for authorization because they have the same generic name, denosumab, and the same HCPCS code, J0897.

Authorization systems are unique for each drug:

If you’re administering Prolia, used to treat osteoporosis, request the authorization through the NovoLogix^® online tool.
If you’re administering Xgeva, primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortal^SM.

Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal to ensure AIM knows which medication you’re ordering. Using the generic name, denosumab, can cause delays in the prior authorization process.

How to bill
To ensure appropriate and timely reimbursement, enter the following National Drug Code numbers and HCPCS code on the claim:

Prolia — Enter NDC 55513071001 and HCPCS code J0897
Xgeva — Enter NDC 55513073001 and HCPCS code J0897

We require authorization for these medications for all outpatient sites of care. When you bill the medications as a professional service or as an outpatient facility service for Medicare Plus Blue and BCN Advantage, bill one of the following ways:

Electronically through an 837P transaction or on a professional CMS-1500 claim form
Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Facility

Sign up for additional training webinars

Here is a list of upcoming webinars. Simply click on the name of the training webinar to register:

Webinar name	Date and time
Learning to use the new features of e-referral	Tuesday, Feb. 4, 10 to 10:30 a.m.
Learning to use the new features of e-referral	Thursday, Feb. 6, 1 to 1:30 p.m.
Hyaluronic acid knee injections — preferred vs. non-preferred	Tuesday, Feb. 11, 1 to 1:30 p.m.
Hyaluronic acid knee injections — preferred vs. non-preferred	Tuesday, Feb. 18, 10 to 10:30 a.m.

For Blue Cross:

Log in to Provider Secured Services.
Go to BCBSM Newsletters and Resources.
Click on Provider Training under Popular links.

For BCN:

Log in to Provider Secured Services.
Go to BCN Provider Publications and Resources.
Click on Learning opportunities under Other Resources.

As additional training webinars become available, we’ll keep you up to date with web-DENIS messages or articles in The Record and BCN Provider News.

Take our Blues Brief survey

Reminder: UAW International and UAW Retiree Health Care Trust don’t require AIM prior authorization

UAW Retiree Health Care Trust (group number 70605)
UAW International Union (group number 71714)

Update: Blue Cross, BCN support providers who offer comprehensive opioid treatment

Only providers who are certified through the Substance Abuse and Mental Health Services Administration, or SAMHSA, to provide OTP services are eligible to receive bundled reimbursement.

Additional information you need to know

This applies to Medicare Plus Blue and BCN Advantage members only — not to our commercial members (BCN HMO^SM and Blue Cross’ PPO).
Member cost sharing applies for these services.
The bundled OTP reimbursement is for professional services only:

For Medicare Plus Blue, payment is based on the Medicare physician fee schedule.
For BCN Advantage, payment is based on the flat rates for non-drug costs released in December 2019 by CMS in Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet** (MLN 8296732).
HCPCS codes G2067 through G2080 must be billed with place of service 58.

The reimbursement doesn’t include drug costs. You’ll need to bill these as pharmaceutical services using standard billing practices.

SAMHSA’s Division of Pharmacologic Therapies is responsible for overseeing the certification of OTPs.

For information on how to obtain OTP certification, visit SAMHSA’s Certification of Opioid Treatment Programs** webpage.

To meet this statutory requirement, CMS has finalized the following:

Definitions of OTP and opioid use disorder treatment services.
Enrollment policies for OTPs.
Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat opioid use disorder and service intensity, and by full and partial weeks.
Adjustments to the bundled payment rates for geography and annual updates.
Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate.
Zero beneficiary copayment for a time-limited duration.

What’s next?
In the future, we may offer bundled rates to reimburse OTP services for our commercial members, in addition to our Medicare Advantage members.

Look for updates on this and on related topics in future issues of The Record and BCN Provider News, as well as web-DENIS messages and news items on our ereferrals.bcsbm.com website.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
***SUPPORT stands for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Medicare Part B medical specialty drug prior authorization list changing in March

J3590 Adakveo^®
J3490 Scenesse^®
J3490 Reblozyl^®

AIM Specialty Health^® ProviderPortal^SM:

J9309 Polivy^™
J9036 Belrapzo^™
J9118 Asparlas^™
J9313 Lumoxiti^™
J9356 Herceptin Hylecta^™
Q5116 Trazimera^™
Q5117 Kanjiti^™
Q5118 Zirabev^™

Electronically through 837P or on a professional CMS-1500 claim form
Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Clarification: Prolia and Xgeva drug authorization

Authorization systems are unique for each drug:

If you’re administering Prolia, used to treat osteoporosis, request the authorization through the NovoLogix^® online tool.
If you’re administering Xgeva, primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortal^SM.

How to bill
To ensure appropriate and timely reimbursement, enter the following National Drug Code numbers and HCPCS code on the claim:

Prolia — Enter NDC 55513071001 and HCPCS code J0897
Xgeva — Enter NDC 55513073001 and HCPCS code J0897

Electronically through an 837P transaction or on a professional CMS-1500 claim form
Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Pharmacy

Medicare Part B medical specialty drug prior authorization list changing in March

J3590 Adakveo^®
J3490 Scenesse^®
J3490 Reblozyl^®

AIM Specialty Health^® ProviderPortal^SM:

J9309 Polivy^™
J9036 Belrapzo^™
J9118 Asparlas^™
J9313 Lumoxiti^™
J9356 Herceptin Hylecta^™
Q5116 Trazimera^™
Q5117 Kanjiti^™
Q5118 Zirabev^™

Electronically through 837P or on a professional CMS-1500 claim form
Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Clarification: Prolia and Xgeva drug authorization

Authorization systems are unique for each drug:

If you’re administering Prolia, used to treat osteoporosis, request the authorization through the NovoLogix^® online tool.
If you’re administering Xgeva, primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortal^SM.

How to bill
To ensure appropriate and timely reimbursement, enter the following National Drug Code numbers and HCPCS code on the claim:

Prolia — Enter NDC 55513071001 and HCPCS code J0897
Xgeva — Enter NDC 55513073001 and HCPCS code J0897

Electronically through an 837P transaction or on a professional CMS-1500 claim form
Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

NovoLogix authorization requests
You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:

For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P” to request access to NovoLogix and fax it to the number provided on the form.
For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application and fax it to the number provided on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

All Providers

Blue Cross and Blue Shield Association gives Blue Distinction Total Care a new name

The Blue Cross and Blue Shield Association recently announced that the national Blue Distinction^® Total Care program is now called Total Care. The association also added a new Total Care+ designation level.

The move is part of an effort to strengthen branding of the national Blue Cross value-based care programs. It’s also intended to minimize any market confusion and avoid including both Specialty Care and Total Care under the Blue Distinction umbrella. (For information about our Blue Distinction^® Specialty Care program, see the article in the January — February issue of Hospital and Physician Update.)

Total Care is the nation’s largest integrated network of value‐based care providers. It gives employers access to similar quality programs when they have employees in multiple states. In Michigan, Patient-Centered Medical Home-designated practices and Organized Systems of Care are designated as Total Care providers. There are no changes to the name or design of the PCMH or OSC programs; only the Total Care and Total Care+ names are changing.

Keep the following in mind:

The name of our national centers of excellence program, Blue Distinction^® Specialty Care, hasn’t changed. This change only affects Total Care.
Providers designated as Total Care and Total Care+ must continue to meet all the local quality and cost outcomes criteria of the PCMH or OSC program. Designated providers will continue to be paid with value-based reimbursement that’s tied to quality and cost outcomes, rather than the traditional fee-for-service model.

For more information about Total Care, click here. For more information about our PCMH and OSC programs, see the About the Physician Group Incentive Program section of bcbsm.com/providers or visit valuepartnerships.com.

Tell your patients about the risks of medication noncompliance

In the United States, 3.8 billion prescriptions are written annually, with only 1 in 5 new prescriptions filled, according to the Centers for Disease Control and Prevention. Among those filled, the CDC estimates that 50% are taken incorrectly because of issues related to timing, dosage, frequency and duration.

As most physicians know, patients often don’t understand the damage or consequences of noncompliance. This is especially true for those who have high blood pressure, high cholesterol, asthma or diabetes.

To encourage your patients to take medication compliance seriously, consider sharing these statistics with them:

Patients with hypertension who aren’t taking high blood pressure medication correctly are 3 to 7 times more likely to suffer a stroke, according to the American College of Cardiology.
More than 12% of adults in the U.S. age 20 and older had total cholesterol higher than 240 mg per dl, the CDC found. But only 55% of adults who could benefit from statin medication are currently taking it.
Of U.S. adults diagnosed with asthma, 61.9% don’t have their asthma controlled and are five times more likely than children to die from asthma, according to the CDC.
Patients with Type 2 diabetes who are noncompliant with their diabetes medication are more likely to be hospitalized or visit the emergency room than patients who are compliant, according to the National Center for Biotechnology Information.

Suggestions
To help ensure your patients take their medication appropriately, suggest they do the following:

Print the American Heart Association’s medicine chart to write down when and how to take medication.
Use pill organizers.
Keep track of medications and when to take them using sticky notes, a white board or a calendar.
Set reminders using a smartphone.

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

81406

Not covered:
81408 (used to report ATM variant),
81479 (used to report CHEK2 variant)

Basic benefit and medical policy

Moderate penetrance variants associated with breast cancer in individuals at high risk

The safety and effectiveness of testing for PALB2 variants for breast cancer risk assessment in adults have been established. It may be considered a useful diagnostic option when indicated, effective Jan. 1, 2020.

Inclusions:
Testing for PALB2 variants for breast cancer risk assessment in adults who meet all the following criteria:

The individual meets criteria for genetic risk evaluation (BRCA testing).
The individual has undergone testing for sequence variants in BRCA1 and BRCA2 with negative results.

Criteria for genetic risk evaluation:
The National Comprehensive Cancer Network, known as NCCN, provides criteria for genetic risk evaluation for individuals with no history of breast cancer and for those with breast cancer. Updated versions of the criteria are available on the NCCN website.**

Exclusions:

Testing for PALB2 sequence variants in individuals who don’t meet the criteria outlined above is considered experimental.
Testing for CHEK2 and ATM variants in the assessment of breast cancer risk is considered experimental.

UPDATES TO PAYABLE PROCEDURES

32701, 61781, 61782, 61783, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77261, 77332, 77333, 77334,
77370, 77371, 77372, 77373, 77402, 77407, 77412, 77432, 77435, G0339, G0340, G6003, G6004, G6005, G6006

Basic benefit and medical policy

Stereotactic radiosurgery and stereotactic body radiotherapy using gamma-ray or linear-accelerator units

The safety and effectiveness of stereotactic radiosurgery and stereotactic body radiotherapy** using gamma-ray or linear-accelerator units are established and considered useful therapeutic options when indicated.

Reference AIM criteria for clinical preference.

**Platforms available for SRS and SBRT are distinguished by their source of radiation; they include gamma radiation from cobalt 60 sources, high-energy photons from LINAC systems and particle beams (e.g., protons). Particle beam (e.g., proton therapy) is not covered in this policy.

Inclusionary criteria have been updated, effective Jan. 1, 2020.

Inclusions:
Stereotactic radiosurgery (intracranial) using a gamma-ray or linear-accelerator unit is considered established for the following indications:

Arteriovenous malformation
Acoustic neuromas
Pituitary adenomas
Non-resectable, residual or recurrent meningiomas
Craniopharyngiomas.
Glomus jugulare tumors
Solitary or multiple brain metastases in patients having good performance status.
Primary or recurrent malignancies of the central nervous system including, but not limited to, high-grade gliomas
Trigeminal neuralgia refractory to medical management

Stereotactic body radiotherapy (extracranial) is considered established for the following indications:

Spinal or vertebral body tumors that include:
- Metastatic or primary
- Irradiated or unirradiated
Spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma).
Members with stage T1 or T2a non-small cell lung cancer (not larger than 5 cm) showing no nodal or distant disease and who aren’t candidates for surgical resection
In the treatment of primary and metastatic liver malignancies
Low- or intermediate-risk localized prostate cancer.***
For local treatment of advanced or recurrent pancreatic adenocarcinoma without evidence of distant metastasis
Uveal melanoma
- For treatment of melanoma of the choroid.
Lung metastatic disease when all the following apply:
- Single metastatic lesion measuring ≤ 5 cm
- Extrapulmonary disease is stable or volume of disease is low with remaining treatment options when one of the following apply:
  - Intent is either curative or palliative (example: lesion is close to a major vessel and standard treatment could lead to hemoptysis or hemorrhage)
  - Treatment of a previously irradiated field
Bone metastatic disease when both of the following apply:
- Treatment of a previously irradiated field
- Re-treatment with external beam radiation therapy would result in significant risk of spinal cord injury.

Stereotactic radiosurgery or stereotactic body radiotherapy using fractionation is considered established when used for indications listed above.

Notes:

Fractionated SRS refers to SRS or SBRT performed more than once on a specific site.
SBRT is commonly delivered over 3 to 5 fractions.
SRS is most often single-fraction treatment; however, multiple fractions may be necessary when lesions are near critical structures.

***SBRT using proton beam therapy is acceptable for low/intermediate prostate cancer.

Exclusions:
Stereotactic radiosurgery is considered experimental for the treatment of seizures and functional disorders (other than trigeminal neuralgia), including chronic pain and tremor.

J9023

Basic benefit and medical policy

Bavencio (avelumab)

Effective May 14, 2019, Bavencio (avelumab) is payable for additional diagnoses C64.1, C64.2 and C64.9.

J9042

Basic benefit and medical policy

Adcetris (Brentuximab vedotin)

Adcetris (Brentuximab vedotin) is payable for additional diagnosis C83.31.

Q4132, Q4133, Q4151, Q4154, Q4186, 65778, 65779

Not covered codes:
Q4100, Q4137-Q4140, Q4145, Q4148, Q4150, Q4153, Q4155- Q4157, Q4159, Q4160, Q4162, Q4163, Q4168-Q4171, Q4173, Q4174, Q4181, Q4183-Q4185, Q4187-Q4192, Q4194, Q4198, Q4201, Q4204-Q4206, Q4208-Q4219, Q4221

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 experimental for all indications. The safety, effectiveness and improvement in health outcomes hasn’t been scientifically demonstrated.

Policy updates are effective Jan. 1, 2020.

Inclusions:
Treatment of nonhealing** diabetic lower-extremity/venous stasis 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.

Human amniotic membrane grafts with or without suture (Prokera, AmbioDisk^™) for the treatment of any of the following ophthalmic indications:

Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy^a
Corneal ulcers and melts that don’t respond to initial conservative therapy^a
Corneal perforation when there is active inflammation after corneal transplant, requiring adjunctive treatment
Bullous keratopathy as a palliative measure in patients who aren’t candidates for curative treatment (e.g., endothelial or penetrating keratoplasty)
Partial limbal stem cell deficiency with extensive diseased tissue where selective removal alone isn’t sufficient
Moderate or severe Stevens-Johnson syndrome
Persistent epithelial defects that don’t respond within two days to conservative therapy^a
Severe dry eye (DEWS 3 or 4)^b with ocular surface damage and inflammation that remains symptomatic after conservative therapy^a
Moderate or severe acute ocular chemical burn

Human amniotic membrane grafts with suture or glue for the treatment of any of the following ophthalmic indications:

Corneal perforation when corneal tissue isn’t immediately available
Pterygium repair when there is insufficient healthy tissue to create a conjunctival autograft

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

^bSee policy guidelines for definition.

Exclusions:
All other human amniotic membrane products and indications not outlined under inclusions, including, but not limited to:

Grafts with or without suture 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
Treatment of lower-extremity ulcers due to venous insufficiency

Policy guidelines:

Dry eye severity level DEWS 3 to 4

Discomfort, severity and frequency — Severe frequent or constant
Visual symptoms — chronic or constant, limiting to disabling
Conjunctival injection — +/- or +/+
Conjunctive staining — moderate to marked
Corneal staining — marked central or severe punctate erosions
Corneal/tear signs — filamentary keratitis, mucus clumping, increase in tear debris
Lid/meibomian glands — frequent
Tear film breakup time — < 5
Schirmer score (mm/5 min) — < 5

Q5115

Basic benefit and medical policy

Additional payable diagnoses for Q5115

Blue Cross Blue Shield of Michigan has approved additional payable diagnoses for HCPCS code Q5115. Diagnosis codes C91.10 and C91.12 are payable when billed with Q5115.

POLICY CLARIFICATIONS

0440T, 0441T, 0442T

Basic benefit and medical policy

Cryoablation for the treatment of peripheral neuropathy is experimental

Cryoablation (i.e., cryoneurolysis, cryoanalgesia) for the treatment of peripheral neuropathy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Cryoablation treatment for peripheral neuropathy includes, but isn’t limited to, the following conditions:

Peripheral neuropathy brought on by diabetes, genetic predisposition (hereditary causes), exposure to toxic chemicals, alcoholism, malnutrition, inflammation (infectious or autoimmune), injury and nerve compression or by taking certain medications such as those used to treat cancer and HIV/AIDS
Peripheral neuromas
Post-thoracotomy/intercostal pain
Total knee arthroplasty and osteoarthritis pain
Chronic headaches (e.g., migraine, tension, cluster, cervicogenic, occipital neuralgia)

The policy exclusions have been updated, effective Jan. 1, 2020.

Revenue codes
0870
0871
0872
0873
0874
0875

Basic benefit and medical policy

New revenue codes

The National Uniform Billing Committee approved the following new revenue codes:

0870
0871
0872
0873
0874
0875

The codes are payable, effective April 1, 2019.

Revenue code
0891

Basic benefit and medical policy

New revenue code

The National Uniform Billing Committee approved new revenue code 0891. The code is payable effective April 1, 2019. This revenue code must be reported with HCPCS code Q2041, Q2042 or Q2043 and requires individual consideration.

29800, 29805, 29830, 29840, 29860, 29870, 29900, 29999

Basic benefit and medical policy

In-office needle arthroscopy

In-office needle arthroscopy (e.g., mi-eye^™ 2, VisionScope^®) is experimental. Its use hasn’t been scientifically demonstrated to improve patient clinical outcomes. This policy is effective Jan. 1, 2020.

Payment policy

Procedures aren’t covered when provided in an office location.

32850, 32853, 32854, 32855, 32856, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147

Basic benefit and medical policy

Combined lung, double lung and liver transplants

Combined double lung and liver transplants have been established as clinically safe and effective for carefully selected patients with end-stage lung and liver disease when transplantation of a single organ is precluded by severe disease in the other organ system, such that the patient’s prognosis after combined transplantation is felt to be better than with sequential transplantation.

This policy is effective Jan. 1, 2020.

Inclusions:
Indications for combined lung-double lung and liver transplant include, but are not limited to, progressive chronic lung/liver disease unresponsive to other medical and surgical therapy. In general, patients are selected for combined lung-liver transplant if one or more of the following apply:

A lung transplant is typically required for irreversible, chronic lung diseases for which there is no further medical or surgical therapy available and survival is limited.
Bilateral lung transplantation is typically required when chronic lung infection disease is present, i.e., associated with cystic fibrosis and bronchiectasis. Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation.
A liver transplant is typically required for irreversibly damaged livers for which there is no further medical or surgical therapy available, prognosis is poor and end stage liver disease (e.g., alcoholic liver disease, viral hepatitis, autoimmune hepatitis, protoporphyria, biliary cirrhosis, vascular disease, trauma or toxic reactions)
End-stage lung disease and end-stage liver disease.

Exclusions:

Patients with coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function
Patients with colonized,highly resistant or highly virulent bacteria, fungi or mycobacteria
Patients with intrahepatic cholangiocarcinoma
Patients with hepatocellular carcinoma that has extended beyond the liver
Patients with ongoing alcohol or drug abuse as defined by the transplant program.

33274
33275

Basic benefit and medical policy

Leadless cardiac pacemakers

The safety and effectiveness of leadless cardiac pacemakers have been established. It may be considered a useful therapeutic option when indicated. This policy is effective Nov. 1, 2019.

Procedure codes 33274 and 33275 have been added as a covered service for members meeting selection criteria, effective Nov. 1, 2019.

Inclusions:
The Micra^® transcatheter pacing system may be considered established in patients when both conditions below are met:

The patient has symptomatic paroxysmal or permanent high-grade arteriovenous block or symptomatic bradycardia-tachycardia syndrome or sinus node dysfunction (sinus bradycardia or sinus pauses).
The patient has a significant contraindication precluding placement of conventional single-chamber ventricular pacemaker leads such as any of the following:
- History of an endovascular or cardiovascular implantable electronic device infection or who are very high risk for infection
- Limited access for transvenous pacing given venous anomaly, occlusion of axillary veins or planned use of such veins for a semi-permanent catheter or current or planned use of an AV fistula for hemodialysis
- Presence of a bioprosthetic tricuspid valve

The micra transcatheter pacing system is considered investigational in all other situations in which the above criteria aren’t met.

Exclusions:

As per the FDA label, the Micra Model MC1VR01 pacemaker is contraindicated for patients who have the following types of devices implanted:
- An implanted device that would interfere with the implant of the Micra device in the judgment of the implanting physician
- An implanted inferior vena cava filter
- A mechanical tricuspid valve
- An implanted cardiac device providing active cardiac therapy that may interfere with the sensing performance of the Micra device
As per the FDA label, the Micra Model MC1VR01 pacemaker is also contraindicated for patients who have the following conditions:
- Femoral venous anatomy unable to accommodate a 7.8 mm (23 French) introducer sheath or implant on the right side of the heart (for example, due to obstructions or severe tortuosity).
- Morbid obesity that prevents the implanted device to obtain telemetry communication within <12.5 cm (4.9 in)
- Known intolerance to titanium, titanium nitride, parylene C, primer for parylene C, polyether ether ketone, siloxane, nitinol, platinum, iridium, liquid silicone rubber, silicone medical adhesive and heparin or sensitivity to contrast medical that can’t be adequately premedicated
As per the FDA label, the Micra Model MC1VR01 pacemaker shouldn’t be used in patients for whom a single dose of 1.0 mg dexamethasone acetate can’t be tolerated because the device contains a molded and cured mixture of dexamethasone acetate with the target dosage of 272 μg dexamethasone acetate. It’s intended to deliver the steroid to reduce inflammation and fibrosis.

Additional documentation guidelines
Payable providers: M.D.s and D.O.s
Payable location: Inpatient only

Established
33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369

Investigational
33999

Basic benefit and medical policy

Transcatheter Aortic Valve Implantation for Aortic Stenosis policy

The criteria have been updated for the Transcatheter Aortic Valve Implantation for Aortic Stenosis policy. This policy is effective Jan. 1, 2020.

Medical policy statement

Transcatheter aortic valve replacement performed with an FDA-approved transcatheter heart valve system, performed via an approach consistent with the device’s FDA-approved labeling, may be indicated for patients with aortic stenosis.

Inclusions:
Transcatheter aortic valve replacement with a device approved by the FDA and performed via an approach consistent with the device’s FDA-approved labeling is established for patients with aortic stenosis when all the following conditions are present:

One of the following:
- Severe aortic stenosis with a calcified aortic annulus
- Failure (stenosed, insufficient or combined) of a surgical bioprosthetic aortic valve
New York Heart Association heart failure class II, III or IV symptoms
Left ventricular ejection fraction greater than 20%
One of the following:
- Patient isn’t an operable candidate for open surgery, as judged by at least two cardiovascular specialists including a cardiac surgeon.
- Patient is an operable candidate but is at high risk for open surgery (i.e., Society of Thoracic Surgeons operative risk score ≥ 8% or at a ≥ 15% risk of mortality at 30 days).
- Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien XT Transcatheter Heart Valve; see below).
- Patient is at low surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien 3, Sapien 3 Ultra, CoreValve Evolut R or CoreValve Evolut PRO).

Edwards SAPIEN XT Transcatheter Heart Valve:

Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
- An aortic valve area of ≤ 1.0 cm² or aortic valve area index ≤ 0.6 cm2/m2
- A mean aortic valve gradient ≥ 40 mmHg
- A peak aortic-jet velocity ≥ 4.0 m/sec
- Native anatomy appropriate for the 23, 26, or 29 mm valve system (between 18 and 28 mm)
New York Heart Association heart failure Class II, III or IV symptoms.
Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon, or is at high or greater risk for open surgical therapy (i.e., Society of Thoracic Surgeons operative risk score ≥ 8% or at a ≥ 15% risk of mortality at 30 days).
Patient is at intermediate surgical risk for open aortic valve replacement (i.e., predicted risk of surgical mortality ≥ 3% at 30 days based on the Society of Thoracic Surgeons [STS] risk score and other clinical comorbidities unmeasured by the STS Risk Calculator).

Edwards SAPIEN and Edwards SAPIEN 3 Ultra Patient with severe aortic valve stenosis who is at low risk for death or major complications associated with open-heart surgery.

LOTUS Edge^™ Valve System

Aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis.
- An aortic valve area of ≤ 1.0 cm2 OR aortic valve area index ≤ 0.6 cm2/m2)
Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon or is at high or greater risk for open surgical therapy (i.e., predicted risk of surgical mortality ≥ 8% at 30 days, based on the Society of Thoracic Surgeons risk score and other clinical comorbidities unmeasured by the STS risk calculator).

Medtronic CoreValve^™ (Evolut) system:

Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
- An aortic valve area of ≤ 1.0 cm² or aortic valve area index ≤ 0.6 cm2/m2
- A mean aortic valve gradient ≥ 40 mmHg.
- A peak aortic-jet velocity ≥ 4.0 m/sec
- Native aortic annulus diameters between 23 and 31 mm
New York Heart Association heart failure Class II, III or IV symptoms
Patient with severe aortic valve stenosis who is at low risk or higher for death or major complications associated with open-heart surgery

Exclusions:
Transcatheter aortic valve replacement is considered experimental for all other indications, including, but not limited to:

The individual is an appropriate candidate for the standard, open surgical approach but has refused.
Hypersensitivity or contraindication to an anticoagulation/antiplatelet regimen
Presence of active bacterial endocarditis or other active infections
Non-FDA approved systems or approaches including:
- Portico and JenaValve systems
- Transcaval approach

33945
50360
50365

Basic benefit and medical policy

Heart-kidney transplant

The safety and effectiveness of a heart-kidney transplant have been established. It may be considered a useful therapeutic option for carefully selected patients with end-stage heart and kidney disease. This policy is effective Jan. 1, 2020.

Inclusions:
Indications for combined heart-kidney transplant include, but are not limited to, progressive chronic heart and kidney disease unresponsive to other medical and surgical therapy. In general, patients are selected for a combined heart-kidney transplant if one or more of the following apply:

End-stage heart and kidney disease
End-stage heart disease and estimated glomerular filtration rate, or eGFR, is 33 mL/minute or less, or preoperative evaluation of the kidney indicates the likelihood that the rate of progression of renal injury or dysfunction after single organ transplant is high.
End-stage heart disease not amenable to any other form of therapy and is associated with a life expectancy of six to 12 months.

Exclusions:

Significant systemic or multisystemic disease (other than cardiorenal failure)
Pulmonary hypertension that is fixed as evidenced by pulmonary vascular resistance, or PVR, greater than 5 Woods units, or trans-pulmonary gradient greater than or equal to 16 mm/Hg
Severe pulmonary disease despite optimal medical therapy, not expected to improve with heart transplantation alone

58674
Experimental:
58578, 58999, 0404T

Basic benefit and medical policy

Laparoscopic ultrasound-guided radiofrequency ablation

Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for the treatment of uterine fibroids is established. It may be considered a useful therapeutic option when indicated.

Laparoscopic and percutaneous techniques of myolysis as a treatment of uterine fibroids other than laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) are considered experimental; this includes Nd: YAG lasers, bipolar electrodes and cryomyolysis. There is insufficient published evidence to assess the safety and effect on health outcomes in the treatment of uterine fibroids.

Transcervical ultrasound-guided radiofrequency ablation (e.g., Sonata^® System) in the treatment of uterine fibroids is experimental. There is insufficient published evidence to assess the effect on health outcomes.

The medical policy exclusions have been updated, effective Jan. 1, 2020.

Inclusions:
Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for the treatment of uterine fibroids may be indicated as an alternative to hysterectomy or myomectomy when the member has one or more of the following:

Severe menorrhagia causing anemia
Bulk-related symptoms (e.g., pelvic pain, pressure or discomfort, urinary symptoms related to compression of the ureter or bladder, or dyspareunia)
Contraindications to general anesthesia
Pre-menopausal state with symptomatic fibroids in members who want to avoid a hysterectomy

Exclusions:

Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for all situations other than those specified above
Transcervical ultrasound-guided radiofrequency ablation (e.g., Sonata^® System) in the treatment of uterine fibroids

67027, 67028, J7311, J7312, J7313, J7314

Basic benefit and medical policy

Intravitreal corticosteroid implants

The safety and effectiveness of dexamethasone intravitreal and fluocinolone acetonide intravitreal implants have been established. They may be considered a useful therapeutic option when indicated.

All other uses of intravitreal implants are considered experimental.

Inclusionary guidelines have been updated, effective Jan. 1, 2020.

Inclusions:

Fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) for the treatment of:
- Chronic non-infectious intermediate, posterior uveitis or panuveitis
Fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq) for the treatment of:
- Chronic non-infectious uveitis affecting the posterior segment of the eye
Fluocinolone acetonide intravitreal implant 0.19 mg (IIuvien^™) for the treatment of both of the following:
- Diabetic macular edema in patients who have been previously treated with a course of corticosteroids
- Didn’t have a clinically significant rise in intraocular pressure
Dexamethasone intravitreal implant 0.7 mg (Ozurdex^®) for the treatment of any of the following:
- Non-infectious ocular inflammation or uveitis, affecting the intermediate or posterior segment of the eye
- Macular edema following branch or central retinal vein occlusion
- Diabetic macular edema

Exclusions:

A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) or 0.19 mg (Iluvien^®) or dexamethasone intravitreal implant 0.7 mg (Ozurdex^™) is considered investigational for the treatment of:
- Birdshot retinochoroidopathy
- Cystoid macular edema related to retinitis pigmentosa
- Idiopathic macular telangiectasia type 1
- Postoperative macular edema
- Circumscribed choroidal hemangiomas
- Proliferative vitreoretinopathy
- Radiation retinopathy
All other uses of a corticosteroid intravitreal implant

81210, 81275, 81276, 81311, 81403, 81404, 88363, 0111U

Experimental procedures:
86152, 86153

Basic benefit and medical policy

KRAS, NRAS and BRAF analyses in metastatic colorectal cancer

The safety and effectiveness of KRAS, NRAS and BRAF mutation analyses have been established and may be considered a useful diagnostic option to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of all patients with metastatic colorectal cancer. It’s a useful therapeutic option when indicated.

KRAS, NRAF and BRAF variant analysis using circulating tumor DNA or circulating tumor cell testing (liquid biopsy) to guide treatment for patients with metastatic colorectal cancer is considered experimental.

Inclusions:

KRAS, NRAS and BRAF mutation analysis in patients with metastatic colorectal cancer to determine their nonresponse to EGFR inhibitor drugs such as Vectibix^® (panitumumab) and Erbitux^® (cetuximab).

83993

Basic benefit and medical policy

Fecal Calprotectin policy

The medical policy statement has been updated for the Fecal Calprotectin policy.

Pediatric patients
The clinical utility of fecal calprotectin testing has been established for pediatric patients. It can be a useful option when used as an adjunctive non-invasive test for confirming a diagnosis or recurrence of inflammatory bowel disease and in determining if an endoscopy may be needed.

Adult patients
Fecal calprotectin testing has been established for the evaluation of patients when the differential diagnosis is inflammatory bowel disease or noninflammatory bowel disease, including irritable bowel syndrome, for whom endoscopy with biopsy is being considered.

Fecal calprotectin testing is considered experimental in the management of inflammatory bowel disease, including the management of active inflammatory bowel disease and surveillance for relapse of disease in remission.

This policy is effective Jan. 1, 2020.

Established
86294, 86386, 88120, 88121

Experimental
0012M, 0013M, 81599

Basic benefit and medical policy

Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance policy

The medical policy statement has been updated for the Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance policy. The policy is effective Jan. 1, 2020.

Medical policy statement

The safety and effectiveness of Food and Drug Administration-approved urinary tumor markers for bladder cancer have been established. It may be considered a useful diagnostic option when used as an adjunct to cytology and cystoscopy.

The use of urinary tumor markers in screening for precancerous colonic polyps is experimental. There is insufficient evidence in the peer-reviewed medical literature to determine the effects of this technology on health outcomes.

Inclusions:
The assessment of FDA-approved urinary tumor markers for bladder cancer, as an adjunct to cytology and cystoscopy, is considered indicated in:

The diagnosis of urinary bladder malignancy in members at very high risk
The follow-up of members with a history of urinary bladder malignancy when the measurements of these markers is deemed essential in making management decisions

Exclusions:

All other indications for bladder cancer not specified under the inclusions

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of Cxbladder^™; therefore, Cxbladder tests are considered experimental.

96900, 96910, 96912, 96913, 96999

Basic benefit and medical policy

Light and Laser Therapy for Vitiligo and Atopic Dermatitis policy

The criteria have been updated for the Light and Laser Therapy for Vitiligo and Atopic Dermatitis policy. This policy will be effective Jan. 1, 2020.

Medical policy statement

Psoralen plus ultraviolet A, or PUVA, narrowband ultraviolet B, or NB-UVB, and targeted phototherapy with excimer laser, with or without the use of oral or topical medications for the treatment of vitiligo, are considered established treatments. They may be useful therapeutic options when indicated.

Inclusions:

Vitiligo that isn’t responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal and tar preparations)
NB-UVB and excimer laser phototherapy in individuals age 3 or older
Topical PUVA can be performed in children age 2 or older when up to 20% of their body surface area
Systemic PUVA or oral PUVA is restricted to children age 12 or older who have widespread vitiligo (20% or greater body surface area)
Treatment of vitiligo is restricted to the face, neck, trunk and extremities.

Exclusions:

Systemic PUVA or oral PUVA is contraindicated in children younger than age 12.
Treatment of vitiligo of the acral areas (fingers, palms, soles of feet)
Laser treatment for atopic dermatitis, contact dermatitis or other eczema

Established
L8699, S0812, 65710, 65767, 65785

Experimental
65760, 65765, 65770, 65771, 65775, S0800, S0810, 66999

Basic benefit and medical policy

Refractive Keratoplasties, Phototherapeutic Keratectomy and Implantation of Intrastromal corneal Ring Segments policy

The criteria have been updated for the Refractive Keratoplasties, Phototherapeutic Keratectomy and Implantation of Intrastromal Corneal Ring Segments policy. The policy is effective Jan. 1, 2020.

Medical policy statement

Epikeratophakia (donor cornea is transplanted onto the anterior surface of the recipient’s cornea) for the treatment of aphakia (absence of the eye lens) is an established procedure. It may be a useful therapeutic option when indicated.

Refractive procedures mentioned in this policy may be considered cosmetic and not medically necessary when used to correct myopia (nearsightedness), hyperopia (farsightedness), astigmatism (imperfection in the curvature of the cornea) or presbyopia (gradual loss of ability to focus on nearby objects, acquired with age). Individual contract language will apply.

Implantation of intrastromal corneal ring segments (Intacs^®) is established for the treatment of keratoconus (cornea thins and begins to bulge into a cone-like shape). It may be a useful therapeutic option when indicated.

Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of myopia (nearsightedness) isn’t medically necessary.

Keratophakia (placement of a donor cornea under the recipient’s cornea) is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment.

Phototherapeutic keratectomy for treatment of recurrent corneal erosions is an established procedure. It may be a therapeutic useful option when indicated.

Inclusions:

Epikeratophakia (donor cornea is transplanted onto the anterior surface of the recipient’s cornea) for the treatment of aphakia (absence of the eye lens).
Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of keratoconus (cornea thins and bulges like a cone) is appropriate when all the following criteria are met:
- The patient has experienced a deterioration in their vision.
- Corneal transplantation is the only alternative to improve their functional vision.
- The patient has a clear central cornea with a corneal thickness of 450 microns or greater at the proposed incision site.
Phototherapeutic keratectomy is an established surgical modality for treatment of recurrent corneal erosions when non-operative methods have failed.

Exclusions:

Refractive keratoplasty procedures for indications not listed above, including those that are cosmetic in nature.
Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of myopia (nearsightedness) and all other conditions not listed above
Keratophakia (placement of a donor cornea under the recipient’s cornea)

Phototherapeutic keratectomy for indications not listed above, including those that are cosmetic in nature

EXPERIMENTAL PROCEDURES

90619

Basic benefit and medical policy

Meningococcal conjugate vaccine

Meningococcal conjugate vaccine serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier, also known as MenACWY-TT, use is experimental, effective Jan. 1, 2020. The FDA hasn’t approved the vaccine for use in the United States.

GROUP BENEFIT CHANGES

Quicken Loans

Effective Jan. 1, 2020, the following group numbers have been added under Quicken Loans:

000071807 — Rock Ventures LLC
000071808 — Xenith LLC
000071809 — Stock X LLC

Alpha prefix: PPO (IQU)
Platform: NASCO

Plans offered:
PPO
Prescription drug
CDH — HSA

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