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September 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
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| UPDATES TO PAYABLE PROCEDURES |
J3490
J3590
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Basic benefit and medical policy
Fetroja (cefiderocol)
Fetroja (cefiderocol) is payable when billed for FDA-approved indications, effective Nov. 14, 2019. Fetroja (cefiderocol) 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.
Fetroja (cefiderocol) is a cephalosporin antibacterial indicated in patients 18 years of age or older who have limited or no alternative treatment options for the treatment of complicated urinary tract infections, including pyelonephritis caused by susceptible gram-negative microorganisms.
Dosage and administration:
Administer 2 grams of Fetroja (cefiderocol) for injection every eight hours by intravenous infusion over three hours in patients with creatinine clearance (CLcr) 60 to 119 mL/min.
Dose adjustments are required for patients with CLcr less than 60 mL/min and for patients with CLcr 120 mL/min or greater. |
J3490
J3590 |
Basic benefit and medical policy
Vyepti (eptinezumab-jjmr)
Vyepti (eptinezumab-jjmr) is payable when billed for FDA-approved indications, effective Feb. 21, 2020. Vyepti (eptinezumab-jjmr) 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.
Vyepti (eptinezumab-jjmr) is a calcitonin gene-related peptide antagonist indicated for the preventive treatment of migraine in adults.
Dosage and administration:
Must dilute before use. For intravenous infusion only.
Recommended dosage is 100 mg as an intravenous infusion over approximately 30 minutes every three months. Some patients may benefit from a dosage of 300 mg.
Dilute only in 100 mL of 0.9% sodium chloride injection, USP dose up to 10 mg/kg or treatment as often as every four weeks. |
J9999 |
Basic benefit and medical policy
Trodelvy (sacituzumab govitecan HZIY)
Effective April 21, 2020, Trodelvy (sacituzumab govitecan HZIY) is payable for its FDA-approved indications. Trodelvy (sacituzumab govitecan HZIY) should be reported with not-otherwise-classified code J9999 and the appropriate national drug code until a permanent code is established.
Trodelvy (sacituzumab govitecan HZIY) is a Trop-2-directed antibody and topoisomerase inhibitor conjugate indicated for the treatment of adult patients with metastatic triple-negative breast cancer, or mTNBC, who have received at least two prior therapies for metastatic disease. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.
URMBT groups are excluded from coverage of this drug.
Medical Drug Management doesn’t require prior authorization for this drug. |
Q5104 |
Basic benefit and medical policy
Renflexis (infliximab-abda)
Renflexis (infliximab-abda), procedure code Q5104, is payable for the updated FDA-approved indications, effective June 26, 2019. Indications have been updated to include the treatment of pediatric ulcerative colitis by reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. |
| POLICY CLARIFICATIONS |
Established
81445 and 81450
Experimental
81455, 0037U and 81479
|
Basic benefit and medical policy
Genetic testing: NGS testing of multiple genes through a panel to identify targeted cancer therapy
Tumor location, grade, stage and the patient’s underlying physical condition have traditionally been used in clinical oncology to determine the therapeutic approach to a specific cancer.
However, this traditional approach to cancer treatment doesn’t reflect the wide diversity of cancer at the molecular level. Some individual genetic markers and variants have established utility, and there are medical policies addressing their utility.
This policy addresses expanded panels of 5-50 genes for potential variants.
Next-generation sequence testing of certain multiple, clinically useful genes (through a panel) may be considered established when guiding the selection of appropriate therapeutic options for specific conditions.
This policy is effective July 1, 2020.
Inclusions:
Next-generation sequence testing of certain multiple genes (panel) for appropriate actionable genomic alterations that influence therapy may be performed for the following conditions:
- Non-small-cell lung cancer
- Colorectal cancer
- Cutaneous melanoma
- Gastrointestinal stromal tumor
- Glioma
- Acute myeloid leukemia
- Thyroid nodule, to determine a diagnosis of cancer
- Myelodysplastic syndrome
- Myeloproliferative disease
- Urothelial cancer
Exclusions:
- Next-generation sequence testing of multiple genes (panel) for conditions other than those listed in the Inclusions section.
Next-generation sequence testing of any molecular panel that includes over 50 genes is considered experimental. |
96130
96131
96138
96139
|
Basic benefit and medical policy
Payable codes
Effective Jan. 1, 2019, these codes are payable at 80% of the physician fee schedule for professional services billed with modifier HO. These codes replaced 96102, which was end-dated Dec. 31, 2018. |
J0185 |
Basic benefit and medical policy
Cinvanti (aprepitant)
Cinvanti (aprepitant) is payable for the following new FDA-approved indication:
- Nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy, or MEC, as a three-day regimen.
Limitations of use:
Cinvanti (aprepitant) hasn’t been studied for treatment of established nausea and vomiting.
Dosage information:
- MEC (three-day regimen)
- The recommended dosage in adults is 100 mg on Day 1. Aprepitant capsules (80 mg) are given orally on days 2 and 3.
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J3490
J3590
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Basic benefit and medical policy
Anjeso (meloxicam)
Anjeso (meloxicam) is considered established, effective Feb. 20, 2020.
Anjeso (meloxicam) is an NSAID indicated for use in adults for the management of moderate-to-severe pain, alone or in combination with non-NSAID analgesics.
Limitation of use:
Because of delayed onset of analgesia, Anjeso (meloxicam) alone isn’t recommended for use when rapid onset of analgesia is required.
Dosage and administration:
- Use for the shortest duration consistent with individual patient treatment goals.
- 30 mg once daily, administered by intravenous bolus injection over 15 seconds.
- Monitor patient analgesic response and administer a short-acting, non-NSAID, immediate-release analgesic if response is inadequate.
- Patients must be well hydrated before ANJESO administration.
This drug isn’t a benefit for URMBT. |
J3490
J3590
|
Basic benefit and medical policy
Artesunate (artesunate)
Effective May 27, 2020, Artesunate (artesunate) is covered for the following FDA-approved indications:
Artesunate for injection is an antimalarial indicated for the initial treatment of severe malaria in adult and pediatric patients. Blue Cross Blue Shield of Michigan considers it an established treatment. |
J3490
J3590
|
Basic benefit and medical policy
Durysta (bimatoprost)
Durysta (bimatoprost) is considered established, effective March 4, 2020.
Durysta (bimatoprost) is a prostaglandin analog indicated for the reduction of intraocular pressure in patients with open angle glaucoma or ocular hypertension.
Dosage and administration:
- For ophthalmic intracameral administration.
- The intracameral administration should be carried out under standard aseptic conditions.
This drug isn’t a benefit for URMBT. |
J3490
J3590
|
Basic benefit and medical policy
Fensolvi (leuprolide acetate)
Fensolvi (leuprolide acetate) is a gonadotropin-releasing hormone, or GnRH, agonist indicated for the treatment of pediatric patients age 2 years and older with central precocious puberty.
Dosage and administration:
- Must be administered by a health care professional.
- The dose of Fensolvi is 45 mg administered by subcutaneous injection once every six months.
- Monitor response to Fensolvi with a GnRH agonist stimulation test, basal serum luteinizing hormone, or LH, levels or serum concentration of sex steroid levels at one to two months following initiation of therapy and as needed to confirm adequate suppression of pituitary gonadotropins, sex steroids and progression of secondary sexual characteristics.
- Measure height every three to six months and monitor bone age periodically.
- See full prescribing information for reconstitution and administration instructions.
This drug isn’t a benefit for URMBT. |
J3490
J3590
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Basic benefit and medical policy
Givlaari (givosiran)
Givlaari (givosiran) is considered established, effective Nov. 20, 2019.
Givlaari (givosiran) is an aminolevulinate synthase 1-directed small interfering RNA indicated for the treatment of adults with acute hepatic porphyria.
Dosage and administration:
The recommended dose of Givlaari (givosiran) is 2.5 mg/kg once monthly by subcutaneous injection.
This drug isn’t a benefit for URMBT. |
J3490
J3590
|
Basic benefit and medical policy
MenQuadfi (meningococcal vaccine)
Effective April 1, 2020, MenQuadfi (meningococcal vaccine) is covered for the following FDA-approved indications:
MenQuadfi is a vaccine indicated for active immunization for the prevention of invasive meningococcal disease caused by Neisseria meningitidis serogroups A, C, W and Y. MenQuadfi vaccine is approved for use in individuals ages 2 years and older. MenQuadfi doesn’t prevent N. meningitidis serogroup B disease.
Dosage and administration:
- 0.5 mL dose for intramuscular injection
Primary vaccination:
- Individuals ages 2 years and older: a single dose.
Booster vaccination:
- A single dose of MenQuadfi may be administered to individuals age 15 and older who are at continued risk for meningococcal disease if at least four years have elapsed since a prior dose of meningococcal (groups A, C, W, Y) conjugate vaccine.
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J3490
J3590
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Basic benefit and medical policy
Reblozyl (luspatercept-aamt)
Effective April 3, 2020, Reblozyl (luspatercept-aamt) is payable for the following updated FDA-approved indications:
Anemia failing an erythropoiesis stimulating agent and requiring two or more RBC units over eight weeks in adult patients with very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts, or MDS-RS, or with myelodysplastic/myeloproliferative
neoplasm with ring sideroblasts and thrombocytosis, or MDS/MPN-RS-T.
Limitations of use:
Reblozyl isn’t indicated for use as a substitute for RBC transfusions in patients who require immediate correction of anemia.
Dosage and administration:
- The recommended starting dose is 1 mg/kg once every three weeks by subcutaneous injection.
- Review hemoglobin, or Hgb, results before each administration.
This drug isn’t a benefit for URMBT. |
J9173 |
Basic benefit and medical policy
Imfinzi (durvalumab)
Effective March 27, 2020, Imfinzi (durvalumab) is payable for the following updated FDA-approved indications:
In combination with etoposide and either carboplatin or cisplatin, as first-line treatment of adult patients with extensive-stage small-cell lung cancer, or ES-SCLC.
Dosage and administration:
- Administer Imfinzi (durvalumab) as an intravenous infusion over 60 minutes.
- ES-SCLC: When administered with etoposide and either carboplatin or cisplatin, administer IMFINZI 1500 mg every three weeks before chemotherapy and then every four weeks as a single agent.
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J9271 |
Basic benefit and medical policy
Keytruda (pembrolizumab)
Keytruda (pembrolizumab) is payable for the
following new FDA-approved indications:
- Urothelial carcinoma
- For the treatment of patients with Bacillus Calmette-Guerin-unresponsive, high-risk, non-muscle invasive bladder cancer with carcinoma in situ with or without papillary tumors who are ineligible for or have elected not to undergo cystectomy
Dosing information:
- Urothelial carcinoma: 200 mg every three weeks
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J9999 |
Basic benefit and medical policy
Darzalex Faspro (daratumumab and hyaluronidase-fihj)
Effective May 1, 2020, Darzalex Faspro (daratumumab and hyaluronidase-fihj) is covered for the following FDA-approved indications:
Darzalex Faspro (daratumumab and hyaluronidase-fihj), a combination of daratumumab, a CD38-directed cytolytic antibody, and hyaluronidase, an endoglycosidase, for the treatment of adult patients with multiple myeloma:
- In combination with bortezomib, melphalan and prednisone in newly diagnosed patients who are ineligible for autologous stem cell transplant
- In combination with lenalidomide and dexamethasone in newly diagnosed patients who are ineligible for autologous stem cell transplant and in patients with relapsed or refractory multiple myeloma who have received at least one prior therapy
- In combination with bortezomib and dexamethasone in patients who have received at least one prior therapy
- As monotherapy, in patients who have received at least three prior lines of therapy, including a proteasome inhibitor, or PI, and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent
Dosage and administration
For subcutaneous use only.
- Pre-medicate with a corticosteroid, acetaminophen and a histamine-1 receptor antagonist.
- The recommended dosage of Darzalex Faspro (daratumumab and hyaluronidase-fihj) is (1,800 mg daratumumab and 30,000 units hyaluronidase) administered subcutaneously into the abdomen over approximately 3 to 5 minutes, according to recommended schedule.
- Administer post-medications as recommended.
This drug isn’t a benefit for URMBT. |
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