Billing chart: Blues highlight medical, benefit policy changes

90867, 90868, 90869

Basic benefit and medical policy

Transcranial magnetic stimulation of the brain

Transcranial magnetic stimulation of the brain has been established. It may be a useful treatment option in specified situations.

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

Inclusions:

Transcranial magnetic stimulation must be administered by an approved FDA-cleared device for the treatment of major depressive disorder, according to specified stimulation parameters, five days a week for six weeks (total of 30 sessions), followed by a three-week tapering of three TMS treatments in one week, two TMS treatments the next week and one TMS treatment in the last week.

Must meet all these criteria:

1. The member is 18 to 70 years of age (includes ages 18 and 70).
2. A drug screen is obtained if indicated by history, current clinical evaluation or a high degree of clinical suspicion.
3. A confirmed diagnosis of severe major depressive disorder (single or recurrent episode), measured by evidence-based scales such as Beck Depression Inventory (score 30-63), Zung Self-Rating Depression Scale (>70), PHQ-9 (>20), Hamilton Depression Rating Scale (>20) or Montgomery-Asberg Depression Rating Scale (MADRS) (score >34).
4. At least one of the following:
   • Current depressive episode treatment: Medication treatment resistance, as evidenced by:
     • Lack of a clinically significant response to four trials of psychopharmacologic agents:
       • Two single-agent trials of antidepressants from at least two different agent classes
       • Two augmentation trials with different classes of augmenting agents, utilizing either (or both) of the agents used in the single-agent trials
         
         Notes: Each agent in the treatment trial must have been administered at an adequate course of mono- or poly-drug therapy. Also, trial criteria is six weeks of maximal FDA-recommended dosing or maximal tolerated dose of medication, with objectively measured evaluation at initiation and during the trial, showing no evidence of response (i.e., < 50% reduction of symptoms or scale improvement).
   • The patient is unable to tolerate a therapeutic dose of medications.
   • Intolerance is defined as severe somatic or psychological symptoms that can’t be modulated by any means, including, but not limited to, additional medications to ameliorate side effects. Examples of somatic side effects: persistent electrolyte imbalance, pancytopenia, severe weight loss, poorly controlled metabolic syndrome or diabetes.
   • Examples of psychological side effects: suicidal-homicidal thinking/attempts, impulse dyscontrol.
     
     Note: A trial of less than one week of a medication is not be considered a qualifying trial to establish intolerance.
   • The patient has a history of response to rTMS in a previous depressive episode (and it has been at least three months since the prior episode).
   • The patient is a candidate for electroconvulsive therapy; further, electroconvulsive therapy would not be clinically superior to transcranial magnetic stimulation (e.g., in cases with psychosis, acute suicidal risk, catatonia or life‑threatening inanition rTMS should not be utilized).
5. The patient failed a trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms, as documented by standardized rating scales that reliably measure depressive symptoms (e.g., Becks Depression Inventory, Zung Self-Rating Depression Scale, PHQ-9, Hamilton Depression Rating Scale or MADRS).
6. Conditions that must be met during the entire rTMS treatment:
   • A board-certified psychiatrist, trained in this therapy, must deliver the treatment.
   • An attendant trained in BCLS, the management of complications (such as seizures) and the use of the equipment must be present.
   • Adequate resuscitation equipment must be available (e.g., suction and oxygen).
   • The facility must maintain awareness of response times of emergency services (either fire/ambulance or “code team”), which should be available within five minutes. These relationships are reviewed on at least a one-year basis and include mock drills.

Exclusions:

• All other behavioral health, neuropsychiatric or medical conditions (e.g., anxiety disorders, mood disorders, schizophrenia, Alzheimer’s, dysphagia, seizures)
• Pregnancy
• Maintenance treatment
• Presence of psychosis in the current episode
• Seizure disorder or any history of seizure, except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence
• Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 centimeters from the TMS magnetic coil or other implanted metal items, including, but not limited to, a cochlear implant, implanted cardioverter defibrillator, pacemaker, vagus nerve stimulator or metal aneurysm clips or coils, staples or stents

  Note: Dental amalgam fillings aren’t affected by the magnetic field and are acceptable for use with TMS.

• If the patient (or, when indicated, the legal guardian) is unable to understand the risk and benefits of rTMS and provide informed consent
• Presence of a medical or co-morbid psychiatric contraindication to rTMS
• Patient lacks a suitable environmental or social and/or professional support system for post-treatment recovery
• There isn’t a reasonable expectation that the patient will be able to adhere to post-procedure recommendations
  

  Note: Caution should be exercised in any situation where the patient’s seizure threshold may be decreased. Examples include:

• Presence in the bloodstream of a variety of agents, including, but not limited to, tricyclic antidepressants, clozapine, antivirals, theophylline, amphetamines, PCP, MDMA, alcohol and cocaine as these present a significant risk
• Presence of the following agents, including, but not limited to, SSRIs, SNRIs, bupropion, some antipsychotics, chloroquine, some antibiotics and some chemotherapeutic agents as they present a relative risk and should be considered when making risk-benefit assessments
• Withdrawal from alcohol, benzodiazepines, barbiturates and chloral hydrate also present a strong relative hazard

J0742

Basic benefit and medical policy

Recarbrio (imipenem, cilastatin and relebactam)

Effective June 4, 2020, Recarbrio (imipenem, cilastatin and relebactam) is payable for the following updated FDA‑approved indications:

• Hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia
• Complicated urinary tract infections, including pyelonephritis, in patients who have limited or no alternative treatment options
• Complicated intra-abdominal infections in patients who have limited or no alternative treatment options.

Dosage and administration

• Administer Recarbrio 1.25 grams (imipenem 500 mg, cilastatin 500 mg, relebactam 250 mg) by intravenous infusion over 30 minutes every six hours in patients age 18 and older with creatinine clearance 90 mL/min or greater.
• Dosage adjustment in patients with renal impairment.

0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, C1823

Basic benefit and medical policy

Phrenic Nerve Stimulation – CSA Policy

The use of phrenic nerve stimulation for the treatment of central sleep apnea is considered experimental. There is insufficient evidence in the current medical literature that this technology improves health outcomes. This policy is effective Nov. 1, 2020.