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June 2020
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 |
0523T |
Basic benefit and medical policy
*0523T is payable
Code *0523T is payable effective Jan. 1, 2019.
Payment policy:
Modifiers 26 and TC don’t apply, and it isn’t payable as a stand-alone service. |
Value code 86
Value code 87
Value code 90 |
Basic benefit and medical policy
Changes for value codes
Value code 86 is discontinued, effective March 31, 2020.
Value codes 87 and 90 are effective April 1, 2020. |
| UPDATES TO PAYABLE PROCEDURES |
| J0695 |
Basic benefit and medical policy
Zerbaxa
Zerbaxa, procedure code J0695, is payable for the new FDA-approved indications. The indications have been updated to include the following treatments:
- Hospital-acquired bacterial pneumonia
- Ventilator-associated bacterial pneumonia
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J3490
J3590 |
Basic benefit and medical policy
Tepezza (teprotumumab-trbw)
Tepezza (teprotumumab-trbw) is payable when billed for FDA-approved indications, effective Jan. 21, 2020. Tepezza (teprotumumab-trbw) should be reported with procedure code J3490 or J3590 and the appropriate National Drug Code until a permanent code is established.
URMBT groups are excluded from coverage of this drug.
Tepezza (teprotumumab-trbw) is an insulin-like growth factor-1 receptor inhibitor indicated for the treatment of thyroid eye disease.
Dosage and administration:
- Initiate dosing with 10 mg/kg for first infusion, followed by 20 mg/kg every three weeks for seven additional infusions
- Administer Tepezza by intravenous infusion over 60 to 90 minutes
Dosage forms and strengths:
For injection: 500 mg lyophilized powder in a single-dose vial for reconstitution |
J3490
J3590 |
Basic benefit and medical policy
Quzyttir (cetirizine)
Quzyttir (cetirizine) is payable when billed for FDA-approved indications, effective Oct. 1, 2019. Quzyttir (cetirizine) should be reported with procedure code J3490 or J3590 and the appropriate National Drug Code until a permanent code is established.
URMBT groups are excluded from coverage of this drug.
Quzyttir (cetirizine) is a histamine-1 (H1) receptor antagonist indicated for the treatment of acute urticaria in adults and children ages 6 months and older.
Limitations of use:
Not recommended in pediatric patients less than 6 years of age with impaired renal or hepatic function.
Dosage and administration:
For intravenous administration only
Recommended dosages:
- Adults and adolescents ages 12 and older: 10 mg
- Children ages 6 to 11 years old: 5 mg or 10 mg
- Children ages 6 months to 5 years: 2.5 mg
|
J7297 |
Basic benefit and medical policy
Liletta
Liletta (levonorgestrel-releasing intrauterine system), procedure code J7297, is payable for the new FDA‑approved indications. The indications have been updated to include prevention of pregnancy for up to six years. |
| POLICY CLARIFICATIONS |
| 94799 |
Basic benefit and medical policy
Inhaled Nitric Oxide policy
The criteria have been updated for the Inhaled Nitric Oxide policy. This policy is effective Nov. 1, 2019.
The safety and effectiveness of the use of inhaled nitric oxide have been established. It may be considered a useful therapeutic option for patients meeting specific patient selection criteria.
Inclusions:
The following patients may be considered appropriate candidates for inhaled nitric oxide, or iNO, therapy:
- When used as a component of treatment of hypoxic respiratory failure in neonates born at more than 34 weeks of gestation. (Hypoxic respiratory failure is defined as an oxygenation index of at least 25 on two measurements made at least 15 minutes apart.)
- iNO therapy for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease.
- iNO therapy as a method of assessing pulmonary vaso-reactivity in people with pulmonary hypertension.
Exclusions:
Other indications for inhaled nitric oxide are experimental including, but not limited to, its use in:
- Premature neonates born at less than or equal to 34 weeks of gestation
- Adults and children with acute respiratory distress syndrome or acute hypoxemic respiratory failure
- Patients with sickle cell disease
- Patients following elective LVAD insertion surgery
- In lung transplantation, during or after graft reperfusion
For the above conditions, it hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment for these conditions.
Informational guidelines:
- The oxygenation index, or OI, is calculated as the mean airway pressure times the fraction of inspired oxygen divided by the partial pressure of arterial oxygen times 100. An OI of 25 is associated with a 50% risk of requiring extracorporeal membrane oxygenation, or ECMO, or dying. An OI of 40 is often used as a criterion to initiate ECMO therapy.
- Prolonged use of iNO (inhaled NO) beyond one to two weeks hasn’t been shown to improve outcomes. Use of iNO beyond two weeks of treatment is therefore not recommended.
- If ECMO is initiated in near-term neonates who qualify for and are receiving treatment with iNO, the iNO should be discontinued as there is no benefit to combined treatment.
|
J0202 |
Basic benefit and medical policy
Lemtrada (alemtuzumab)
Effective Oct. 29, 2019, Lemtrada (alemtuzumab) is payable for the following updated indications:
Lemtrada (alemtuzumab) is a CD52-directed cytolytic monoclonal antibody indicated for the treatment of relapsing forms of multiple sclerosis, to include relapsing-remitting disease and active secondary progressive disease, in adults. Because of its safety profile, the use of Lemtrada (alemtuzumab) should generally be reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.
Limitations of use:
Lemtrada (alemtuzumab) isn’t recommended for use in patients with clinically isolated syndrome because of its safety profile.
Dosage and administration:
- Baseline laboratory tests are required before treatment.
- Administer Lemtrada (alemtuzumab) by intravenous infusion over four hours for two or more treatment courses:
- Initial treatment of two courses:
- First course: 12 mg/day on five consecutive days.
- Second course: 12 mg/day on three consecutive days 12 months after first treatment course.
- Subsequent treatment courses of 12 mg per day on three consecutive days (36 mg total dose) may be administered, as needed, at least 12 months after the last dose of any prior treatment course.
- Premedicate with corticosteroids prior to Lemtrada (alemtuzumab) infusion for the first three days of each treatment course.
- Administer antiviral agents for herpetic prophylaxis starting on the first day of Lemtrada (alemtuzumab) dosing and continuing for a minimum of two months after completion of Lemtrada (alemtuzumab) dosing or until CD4+ lymphocyte count is more than 200 cells per microliter, whichever occurs later.
- It must be diluted before administration.
|
J0584 |
Basic benefit and medical policy
Crysvita (burosumab-twza)
Effective Sept. 17, 2019, Crysvita (burosumab-twza) is payable for pediatric patients ages 6 months and older.
FDA-approved indication/diagnosis: X-linked hypophosphatemia, or XLH, in adult and pediatric patients ages 6 months and older
Coverage of Crysvita (burosumab-twza) is provided when all the following are met:
- FDA-approved age
- Diagnosis of X-linked hypophosphatemia confirmed by one of the following:
- Genetic testing
- Elevated serum fibroblast growth factor 23 (FGF23) level > 30 pg/mL
- Prescribed by endocrinologist
- Serum phosphorus < 2.5 mg/dL
- Presence of clinical signs and symptoms of the disease (e.g., rickets, growth retardation, musculoskeletal pain, bone fractures)
- Measurable bone/joint pain (≥ 4 BPI-Q3 Worst Pain)
- Trial and failure of the preferred products as specified in the Blue Cross Blue Shield of Michigan and Blue Care Network utilization management medical drug list
Crysvita (burosumab-twza) is considered experimental when used for all other conditions including, but not limited to, tumor induced osteomalacia.
Dosing:
Pediatric XLH: Starting dose regimen is 0.8 mg/kg of body weight rounded to the nearest 10 mg, administered every two weeks. The minimum starting dose is 10 mg up to a maximum dose of 90 mg. Dose may be increased up to approximately 2 mg/kg (maximum 90 mg), administered every two weeks to achieve normal serum phosphorus.
Adult XLH: Dose regimen is 1 mg/kg body weight rounded to the nearest 10 mg up to a maximum dose of 90 mg administered every four weeks. |
J2323 |
Basic benefit and medical policy
Tysabri (natalizumab)
Effective Aug. 5, 2019, Tysabri (natalizumab) is payable for the following updated indications for multiple sclerosis:
Tysabri (natalizumab) is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease in adults.
Dosage:
- 300 mg infused intravenously over one hour, every four weeks
Pharmacy requires prior authorization of this drug. |
| J2796 |
Basic benefit and medical policy
Nplate (romiplostim)
Effective Oct. 17, 2019, Nplate (Romiplostim) is payable for the updated indications.
Nplate is a thrombopoietin receptor agonist indicated for the treatment of thrombocytopenia in:
- Adult patients with immune thrombocytopenia, known as ITP, who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.
- Pediatric patients ages 1 and older with ITP for at least six months who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.
Limitations of use:
- Nplate isn’t indicated for the treatment of thrombocytopenia due to myelodysplastic syndrome, or MDS, or any cause of thrombocytopenia other than chronic ITP.
- Nplate should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increases the risk for bleeding.
- Nplate shouldn’t be used in an attempt to normalize platelet counts.
|
J3490
J3590 |
Basic benefit and medical policy
Beovu (brolucizumab)
Beovu (brolucizumab) is considered established, effective Oct. 8, 2019.
Beovu (brolucizumab) is a human vascular endothelial growth factor, or VEGF, inhibitor indicated for the treatment of neovascular (wet) age-related macular degeneration, or AMD.
Dosing information:
Beovu (brolucizumab) is administered by intravitreal injection. The recommended dose for Beovu (brolucizumab) is 6 mg (0.05 mL of 120 mg/mL solution) monthly (approximately every 25-31 days) for the first three doses, followed by one dose of 6 mg (0.05 mL) every eight to 12 weeks.
Pharmacy requires preauthorization of this drug.
This drug isn’t a benefit for URMBT.
The National Drug Code is 00078-0827-61. |
J3490
J3590 |
Basic benefit and medical policy
Reblozyl (luspatercept-aamt)
Reblozyl (luspatercept-aamt) is considered established, effective Nov. 8, 2019.
Reblozyl (luspatercept-aamt) is an erythroid maturation agent indicated for the treatment of anemia in:
- Adult patients with beta thalassemia who require regular red blood cell transfusions.
Dosage and administration:
- The recommended starting dose is 1 mg/kg once every three weeks by subcutaneous injection.
- Review hemoglobin results before each administration.
This drug isn’t a benefit for URMBT.
The National Drug Codes are:
- 59572-0711-01
- 59572-0775-01
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J3490 |
Basic benefit and medical policy
XENLETA (lefamulin)
XENLETA (lefamulin) is a pleuromutilin antibacterial indicated for the treatment of adults with community-acquired bacterial pneumonia, known as CABP, caused by susceptible microorganisms.
To reduce the development of drug resistant bacteria and maintain the effectiveness of XENLETA (lefamulin) and other antibacterial drugs, XENLETA (lefamulin) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
Dosing information:
For treatment of adults with CABP, the recommended dosage of XENLETA is as follows:
- For the duration, 150 mg every 12 hours by intravenous infusion over 60 minutes** for five to seven days
- 600 mg orally every 12 hours for five days
**With option to switch to XENLETA Tablets 600 mg every 12 hours to complete the treatment course
- Patients with hepatic impairment: Reduce the dosage of XENLETA injection to 150 mg infused over 60 minutes every 24 hours in patients with severe hepatic impairment (Child-Pugh Class C). XENLETA tablets haven’t been studied in and aren’t recommended for patients with moderate (Child-Pugh Class B) or severe hepatic impairment.
- Administration instruction for XENLETA tablets: Take at least one hour before a meal or two hours after a meal. Swallow XENLETA tablets whole with water (six to eight ounces).
- Administration instruction for XENLETA injection: Infuse over 60 minutes.
See full prescribing information for additional details on the administration and preparation of XENLETA tablets and injection.
Pharmacy doesn’t require preauthorization of this drug.
This drug isn’t a benefit for URMBT.
The National Drug Codes are:
- 72000-0120-01
- 72000-0120-06
- 72000-0110-30
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J3490
J3590 |
Basic benefit and medical policy
Ziextenzo (pegfilgrastim-bmez)
Ziextenzo (pegfilgrastim-bmez) is considered established, effective Nov. 4, 2019.
Ziextenzo (pegfilgrastim-bmez) is a leukocyte growth factor indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.
Limitations of use:
Ziextenzo (pegfilgrastim-bmez) isn’t indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.
Dosage and administration:
Patients with cancer receiving myelosuppressive chemotherapy:
- 6 mg administered subcutaneously once per chemotherapy cycle.
- Don’t administer between 14 days before and 24 hours after administration of cytotoxic chemotherapy.
- Use weight-based dosing for pediatric patients weighing less than 45 kg.
This drug isn’t a benefit for URMBT.
The NDC is 61314-0866-01. |
J7185 |
Basic benefit and medical policy
Xyntha antihemophilic factor (recombinant)
Effective Oct. 17, 2019, Xyntha antihemophilic factor (recombinant) is payable for the updated indications.
Xyntha is a recombinant antihemophilic factor indicated in adults and children with hemophilia A for on-demand treatment and control of bleeding episodes and for perioperative management.
Xyntha isn’t indicated in patients with von Willebrand's disease.
Pharmacy doesn’t require prior authorization of this drug. |
Q9950 |
Basic benefit and medical policy
Lumason (sulfur hexafluoride lipid-type A microspheres)
Blue Cross Blue Shield of Michigan has adopted the revised FDA-approved indications for Lumason (sulfur hexafluoride lipid-type A microspheres), the ultrasound contrast agent indicated for use in:
- Echocardiography to opacify the left ventricular chamber and to improve the delineation of the left ventricular endocardial border in adult and pediatric patients with suboptimal echocardiograms
- Ultrasonography of the liver for characterization of focal liver lesions in adult and pediatric patients
- Ultrasonography of the urinary tract for the evaluation of suspected or known vesicoureteral reflux in pediatric patients
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Condition code A7 |
Basic benefit and medical policy
Condition code A7
The National Uniform Billing Committee approved new condition code A7, effective April 1, 2020. |
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