Billing chart: Blues highlight medical, benefit policy changes

19318

Basic benefit and medical policy

Reduction Mammaplasty for Breast-related Symptoms Policy

The safety and effectiveness of reduction mammoplasty have been established. It may be considered a useful therapeutic option (and not considered cosmetic) when one of the following guidelines is met:

• The patient meets specified patient selection guidelines.
• When performed in conjunction with medically necessary breast reconstruction for the purposes of attaining breast symmetry.

Criteria have been updated for this policy. The policy effective date is Sept. 1, 2020.

Inclusionary and exclusionary guidelines

Inclusions (must meet A, or must meet both B and C):

1. Must meet both 1 and 2:
   1. Patient’s breasts are fully grown (i.e., breast size stable for approximately one year)
   2. Removal of more than 500 grams of tissue from each breast
2. One of the following (1, 2 or 3) must be met:
   1. Pain (both of the following must be met)
      1. Documented pain in the neck or shoulders or postural backache, which must be of long-standing duration
      2. Failure of conservative therapy (e.g., an appropriate support bra, exercises, heat and cold treatments, non-steroidal anti-inflammatory agents or muscle relaxants)
   2. Shoulder grooving
   3. Recurrent intertrigo between the breasts and the chest wall
3. Both of the following criteria must be met:
   1. Patient’s breasts are fully grown (i.e., breast size stable for approximately one year)
   2. The amount of tissue to be removed from each breast must be greater than or equal to the 22nd percentile on the Schnur Scale.**

**If one breast meets the tissue amount based on the Schnur Scale, even if the other breast does not, this criterion is met.

If one breast meets the Schnur scale criteria, and all other criteria for breast reduction are met, breast tissue may be removed from the other breast in order to achieve symmetry.

Exclusions:

Breast reduction isn’t covered for either of the following indications because it’s considered cosmetic in nature and not medically necessary:

• Surgery is being performed to treat psychological symptomatology or psychosocial complaints in the absence of significant physical, objective signs.
• Surgery is being performed for the sole purpose of improving appearance.

38204, 38205, 38207-38215, 38230, 38240, 38242, 38243, 81265-81268, 81370-81383, 86812, 86813, 86816, 86817, 86821, 86822 S2140, S2142, S2150

Basic benefit and medical policy

Bone Marrow Transplant  ̶  Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms, Allogeneic Policy

The safety and effectiveness of allogeneic HCT or reduced-intensity conditioning allogeneic HCT have been established as a treatment of myelodysplastic syndromes or myeloproliferative neoplasms. It’s a useful therapeutic option for patients meeting selection criteria. The policy effective date is Sept. 1, 2020.

Inclusions:

Allogeneic HCT may be considered established as a treatment of one of the following:

• Myelodysplastic syndromes
• Myeloproliferative neoplasms

Reduced-intensity conditioning allogeneic HCT may be considered established as a treatment of one of the following:

• Myelodysplastic syndromes
• Myeloproliferative neoplasms in patients who are at high-risk** of intolerance of a myeloablative conditioning regimen.

**Includes both age and comorbidities

Exclusions:

Patients not meeting the above diagnostic criteria.

J3490
J3590

Basic benefit and medical policy

Triferic AVNU (ferric pyrophosphate citrate)

Triferic AVNU (ferric pyrophosphate citrate) is payable when billed for FDA-approved indications, effective March 27, 2020. Triferic AVNU (ferric pyrophosphate citrate) 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. 

Triferic AVNU (ferric pyrophosphate citrate) is an iron replacement product indicated for the replacement of iron to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease, or HDD-CKD.

Dosage and administration:

6.75 mg iron (III) intravenously over three to four hours at each hemodialysis session via pre-dialyzer infusion line, post-dialyzer infusion line or a separate connection to the venous blood line.

J9999

Basic benefit and medical policy

Jelmyto (mitomycin)

Jelmyto (mitomycin) is payable when billed for FDA-approved indications, effective April 15, 2020. Jelmyto (mitomycin) should be reported with procedure code J9999 and the appropriate national drug code until a permanent code is established.

URMBT groups are excluded from coverage of this drug. 

Jelmyto (mitomycin) is for pyelocalyceal use only and not for intravenous use, topical use or oral administration.

Administer 1.3 g of sodium bicarbonate orally the evening prior to, the morning of and 30 minutes prior to instillation procedure (total of 3.9 g).

The dose of Jelmyto to be instilled is 4 mg per mL via ureteral catheter or ephrostomy tube, with total instillation volume based on volumetric measurements using pyelography, not to exceed 15 mL (60 mg of mitomycin).

Instill Jelmyto once weekly for six weeks. For patients with a complete response three months after Jelmyto initiation, Jelmyto instillations may be administered once a month for a maximum of 11 additional instillations.

40806, 40819, 41010, 41115, 41520

Basic benefit and medical policy

Frenum Surgery (Frenulum Surgery, Frenyumectomy, Frenectomy, Frenotomy) Policy

The safety and effectiveness of surgery to the lingual (under the tongue) frenulum have been established. It may be considered a useful therapeutic option when the patient selection criteria are met.

The safety and effectiveness of surgery to the maxillary anterior labial (class III or IV) frenulum in the infant have been established. It may be considered a useful therapeutic option when the patient selection criteria are met.

The policy effective date is Sept. 1, 2020.

Inclusions:

Indications for ankyloglossia surgery (must meet one):

• There is documentation of an infant’s inability to adequately breast or bottle feed due to ineffective latch.
• Physical examination of a child (may be as young as 9 months of age) by a qualified medical provider confirms the presence of “tongue tie,” causing difficulty in the child’s speech due to the inability to manipulate the tongue. For example, the child may be unable to protrude his tongue past his lips, which would impair his speech.
• Speech therapy evaluation confirms expressive language difficulties as a result of tongue immobility.

Indications for midline maxillary labial frenum surgery (must meet one):

• An infant with a history of not gaining weight
• There is documentation of an infant’s inability to adequately breast or bottle feed due to ineffective latch
• A mother experiencing painful breastfeeding
• Class III lip-tie: frenum inserts between the areas where the maxillary incisors erupt
• Class IV lip-tie: the frenum wraps into the hard palate and into the anterior papilla

Exclusions:

• Services that are dental in nature
• Routine frenulum (clipping) surgery at the time of delivery of the newborn

43499**

**Unlisted code used to report service

Basic benefit and medical policy

POEM for Esophageal Achalasia or Gastroparesis Policy

Peroral endoscopic myotomy, known as POEM, as a treatment for pediatric and adult esophageal achalasia or gastroparesis is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment, effective Sept. 1, 2020.

81210, 81235, 81275, 81276, 81404, 81405, 81406, 81479 

Basic benefit and medical policy

Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy) Policy

The effectiveness and clinical utility of circulating tumor DNA for management of non-small-cell lung cancer (liquid biopsy) has been established. It may be considered a useful therapeutic option when indicated.

Inclusions:

Analyzing cell-free/circulating tumor DNA, or ctDNA, alterations in the ALK, EGFR, BRAF V600E, KRAS, ROS1, NTRK, MET exon14 skipping and RET gene when all the following apply:

• Advanced stage III or IV non-small-cell lung cancer
• Clinical circumstances reflect one of the following:
  • Patient is medically unfit for invasive tissue sampling
  • Following pathologic confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis 
• Follow-up tissue-based analysis is planned for all patients in which an oncogenic driver isn’t identified
• Used to detect ctDNA for targeted therapy benefit or to identify patients who won’t benefit from further molecular testing

Exclusions:  

• Use of circulating tumor DNA for any indications not mentioned above

This policy is effective Sept. 1, 2020.

99183, G0277   

Not covered (experimental):
A4575, E0446

Basic benefit and medical policy

Hyperbaric Oxygen Therapy Policy

The safety and effectiveness of systemic hyperbaric oxygen therapy have been established for some conditions. It may be considered a useful therapeutic option when indicated for specified conditions.

Topical hyperbaric oxygen therapy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes. 

The policy has been updated, effective Sept. 1, 2020.

Inclusions:

Note: For some contracts, hyperbaric oxygen therapy may be excluded when performed in the office setting. Check with carrier for location restrictions.

The following conditions are effectively treated by systemic hyperbaric oxygen therapy:

• Acute peripheral arterial insufficiency
• Acute traumatic peripheral ischemia: HBOT is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb or life is threatened
• Carbon monoxide poisoning/intoxication, acute
• Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
• Crush injuries and suturing of severed limbs as an adjunctive treatment when loss of function, limb or life is threatened
• Cyanide poisoning, acute
• Decompression illness
• Diabetic wounds of the lower extremities in patients who meet all the following criteria:
  • A diagnosis of Type 1 or Type 2 diabetes with a lower extremity wound that is due to diabetes
  • A wound classified as Wagner grade 3 or higher
    • The Wagner classification system of wounds is defined as follows:
      • Grade 0  —  No open lesion
      • Grade 1  —  Superficial ulcer without penetration to deeper layers
      • Grade 2  —  Ulcer penetrates to tendon, bone, or joint
      • Grade 3  —  Lesion has penetrated deeper than grade 2 and there is abscess, osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths
      • Grade 4  —  Wet or dry gangrene in the toes or forefoot
      • Grade 5  —  Gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation (at least at the below the knee level) is indicated.)
  • The patient has failed an adequate course of standard wound therapy. Standard wound care in patients with diabetic wounds includes all the following:
    • The assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible
    • The optimization of nutritional status
    • Optimization of glucose control
    • Debridement by any means to remove devitalized tissue
    • Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings
    • Appropriate off-loading
    • Necessary treatment to resolve any infection that might be present.
• Gas embolism, acute
• Gas gangrene (i.e., clostridial myonecrosis)
• Non-diabetic wounds:
  • There is no measurable sign of healing for at least 30 consecutive days or when there is failure to respond to standard wound care.
    • Wounds must be evaluated at least every 30 days during administration of HBOT for measurable signs of improvement. (See exclusion criteria)
• Osteoradionecrosis as an adjunct to conventional treatment
• Pre and post treatment for patients undergoing dental surgery (non-implant related) of an irradiated jaw
• Preparation and preservation of compromised skin grafts (not for primary management of wounds)
• Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed
• Progressive necrotizing infections
• Refractory mycoses: mucormycosis, actinomycosis, Conidiobolus coronata only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment**
• Soft-tissue radiation necrosis (e.g., radiation enteritis, cystitis, proctitis) as an adjunct to conventional treatment

**For several of the indications included, there is little published evidence to support the effectiveness of hyperbaric oxygen therapy. However, there is little likelihood of RCTs being done for such relatively rare indications. Generally, these patients present with clinically severe situations where therapeutic options are limited. Subject matter expert experience and limited available evidence support that hyperbaric oxygen treatment may offer therapeutic benefit in these cases.

Wounds, including diabetic wounds, being treated with hyperbaric oxygen therapy must be reviewed using clinical documentation that identifies measurable signs of healing, e.g., width, depth and length of the wound.

Exclusions:

• Topical hyperbaric oxygen therapy
• Hyperbaric oxygen pressurization is considered experimental in the treatment of the following conditions (this list may not be all-inclusive):
  • Acute coronary syndromes and as an adjunct to coronary interventions, including but not limited to percutaneous coronary interventions and cardiopulmonary bypass
  • Acute or chronic cerebral vascular insufficiency
  • Acute ischemic stroke
  • Acute osteomyelitis, refractory to standard medical management
  • Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
  • Acute surgical and traumatic wounds
  • Arthritic diseases
  • Autism spectrum disorders
  • Bell palsy
  • Bisphosphonate-related osteonecrosis of the jaw
  • Bone grafts
  • Brown recluse spider bites
  • Carbon tetrachloride poisoning, acute
  • Cardiogenic shock
  • Cerebral edema; acute
  • Cerebral palsy
  • Cerebrovascular disease, acute (thrombotic or embolic) or chronic
  • Chronic arm lymphedema following radiotherapy for cancer
  • Chronic peripheral vascular insufficiency
  • Chronic wounds, other than those situations under the inclusions
  • Cosmetic use
  • Delayed onset muscle soreness
  • Demyelinating diseases, e.g., multiple sclerosis, amyotrophic lateral sclerosis
  • Fibromyalgia
  • Fracture healing
  • Hepatic necrosis
  • Herpes zoster
  • Hydrogen sulfide poisoning
  • Idiopathic femoral neck necrosis
  • Idiopathic sudden sensorineural hearing loss
  • Inflammatory bowel disease (Crohn disease or ulcerative colitis)
  • Intra-abdominal and intracranial abscesses
  • In vitro fertilization
  • Lepromatous leprosy
  • Meningitis
  • Mental illness (i.e., posttraumatic stress disorder, generalized anxiety disorder or depression)
  • Migraine
  • Motor dysfunction associated with stroke
  • Multiple sclerosis
  • Myocardial infarction
  • Non-diabetic wounds
    • Continued treatment should be discontinued when there are no measurable signs of healing within any 30-day period of treatment. (See inclusions.)
  • Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease, Korsakoff’s disease)
  • Organ storage
  • Organ transplantation
  • Pseudomembranous colitis (antimicrobial agent-induced colitis)
  • Pulmonary emphysema
  • Pyoderma gangrenosum
  • Radiation-induced injury in the head and neck, except as noted under the inclusions
  • Retinal artery insufficiency, acute
  • Retinopathy, adjunct to scleral buckling procedures in patients with sickle cell peripheral retinopathy and retinal detachment
  • Senility
  • Septicemia, aerobic
  • Septicemia (anaerobic) and infection other than clostridial
  • Severe or refractory Crohn’s disease
  • Sickle cell crisis and/or hematuria
  • Skin burns (thermal), acute
  • Spinal cord injury
  • Tetanus
  • Traumatic brain injury
  • Tumor sensitization for cancer treatments, including but not limited to, radiotherapy or chemotherapy
  • Vascular dementia

J3490
J3590

Basic benefit and medical policy

Lyumjev (insulin lispro-aabc)

Lyumjev (insulin lispro-aabc) is considered established, effective June 15, 2020.

Lyumjev is a rapid-acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus.

Dosage and administration (See full prescribing information for important administration instructions)

• Subcutaneous injection:
  • Administer Lyumjev at the start of a meal or within 20 minutes after starting a meal subcutaneously into the abdomen, upper arm, thigh or buttocks.
  • Rotate injection sites within the same region to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
  • Should generally be used in regimens with an intermediate or long-acting insulin.
• Intravenous infusion:
  • Administer Lyumjev U-100 intravenously only under medical supervision.
  • Dilute Lyumjev U-100 to a concentration of 1 unit/mL.
  • Individualize and adjust the dosage of Lyumjev based on the patient’s metabolic needs, glucose monitoring results and glycemic control goal.
  • Dose adjustments may be needed when switching from another insulin, with changes in physical activity, changes in concomitant medications, changes in meal patterns (i.e., amount and type of food, timing of food intake), changes in renal or hepatic function, or during acute illness.

This drug isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Sevenfact (factor VIIa)

Effective April 1, 2020, Sevenfact (factor VIIa) is covered for the following FDA-approved indications:

Sevenfact (coagulation factor VIIa [recombinant]-jncw) is a coagulation factor VIIa concentrate indicated for the treatment and control of bleeding episodes occurring in adults and adolescents (ages 12 and older) with hemophilia A or B with inhibitors.

Type of bleeding                              

Dosing regimen recommendation for mild or moderate bleeds, one of the following:

• 75 mcg/kg repeated every three hours until hemostasis is achieved
• Initial dose of 225 mcg/kg. If hemostasis isn’t achieved within nine hours, additional 75 mcg/kg doses may be administered every three hours as need to achieve hemostasis 

For severe bleeds dosing regimen recommendation:                       

• 225 mcg/kg, followed, if necessary, six hours later with 75 mcg/kg every two hours

Dosage forms and strengths

Sevenfact is available as a lyophilized powder in single-use vials containing 1 or 5 mg of coagulation factor VIIa (recombinant)-jncw. After reconstitution with a specified volume of sterile water for injection, each mL contains 1 mg (1,000 mcg) of coagulation factor VIIa (recombinant)-jncw.

This drug isn’t a benefit for URMBT.

J9022

Basic benefit and medical policy

Tecentriq (atezolizumab)

Effective May 18, 2020, Tecentriq (atezolizumab) is payable for the following updated indications:

Non-small-cell lung cancer, or NSCLC

• For the first-line treatment of adult patients with metastatic NSCLC whose tumors have high PD -L1 expression (PD-L1 stained ≥ 50% of tumor cells [TC ≥ 50%] or PD-L1 stained tumor-infiltrating immune cells [IC] covering ≥ 10% of the tumor area [IC ≥ 10%]), as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations

Hepatocellular carcinoma

• Administer Tecentriq 1,200 mg, followed by 15 mg/kg bevacizumab on the same day every three weeks
• If bevacizumab is discontinued, administer Tecentriq as:
  • 840 mg every two weeks, 1,200 mg every three weeks or 1,680 mg every four weeks

J9999

Basic benefit and medical policy

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)

Effective June 29, 2020, Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) is covered for the following FDA-approved indications:

Phesgo is a combination of pertuzumab and trastuzumab, HER2/neu receptor antagonists, and hyaluronidase, an endoglycosidase, indicated for:

• Use in combination with chemotherapy as:
  • Neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer.
  • Adjuvant treatment of patients with HER2-positive early breast cancer at high risk of recurrence.
• Use in combination with docetaxel for treatment of patients with HER2positive metastatic breast cancer, or MBC, who haven’t received prior anti-HER2 therapy or chemotherapy for metastatic disease.

Dosage and administration:

• For subcutaneous use in the thigh only.
• Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) has different dosage and administration instructions than intravenous pertuzumab and trastuzumab products.
• Don’t administer intravenously.
• Perform HER2 testing using FDA-approved tests by laboratories with demonstrated proficiency.
• The initial dose of Phesgo is 1,200 mg pertuzumab, 600 mg trastuzumab and 30,000 units hyaluronidase administered subcutaneously over approximately eight minutes, followed every three weeks by a dose of 600 mg pertuzumab, 600 mg trastuzumab and 20,000 units hyaluronidase administered subcutaneously over approximately five minutes. 
• Neoadjuvant: Administer Phesgo by subcutaneous injection every three weeks and chemotherapy by intravenous infusion preoperatively for 3 to 6 cycles.
• Adjuvant: Administer Phesgo by subcutaneous injection every three weeks and chemotherapy by intravenous infusion postoperatively for a total of one year (up to 18 cycles).
• MBC: Administer Phesgo by subcutaneous injection and docetaxel by intravenous infusion every three weeks.

This drug isn’t a benefit for URMBT.

J9999

Basic benefit and medical policy

Zepzelca (lurpinectedin)

Effective June 15, 2020, Zepzelca (lurpinectedin) is covered for the following FDA-approved indications:

Zepzelca is an alkylating drug indicated for the treatment of adult patients with metastatic small cell lung cancer with disease progression on or after platinum-based chemotherapy.

T1015
T1019

Basic benefit and medical policy

Starting Dec. 1, we’ll no longer pay for T1015, T1019

Effective Dec. 1, 2020, we’ll no longer be paying for procedure codes T1015 and T1019. In 2006, we began paying for these procedure codes as an introduction to achieve consistent delivery of evidence-based recommendations in caring for patients with chronic illness. Since Provider Delivered Care Management is payable for most of our groups and we don’t want to double pay for such services, the T codes are no longer needed.