The Record - Billing chart: Blues highlight medical, benefit policy changes

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:

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

UPDATES TO PAYABLE PROCEDURES

J9047

Basic benefit and medical policy

Kyprolis (carfilzomib)

Kyprolis (carfilzomib), procedure code J9047, is payable for U.S. Food and Drug Administration-approved clarified indications. Effective Aug. 1, 2020, These indications have been updated to include treatment of adult patients with relapsed or refractory multiple myeloma who have received one to three lines of therapy in combination with lenalidomide and dexamethasone; or dexamethasone; or daratumumab and dexamethasone.

J9228

Basic benefit and medical policy

Yervoy (ipilimumab)

Yervoy (ipilimumab), procedure code J9228, is payable for the updated FDA-approved indications.

Indications have been updated to include treatment of patients with hepatocellular carcinoma who have been previously treated with sorafenib, in combination with nivolumab. Also, Yervoy has been approved for treatment of adult patients with metastatic non-small cell lung cancer expressing PD-L1 (≥1%) as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, as first-line treatment in combination with nivolumab. In addition to treatment of adult patients with metastatic or recurrent non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations as first-line treatment, in combination with nivolumab and two cycles of platinum doublet chemotherapy.

J9999

Basic benefit and medical policy

Monjuvi (tafasitamab-cxix)

Monjuvi (tafasitamab-cxix) is payable when billed for FDA-approved indications, effective July 31, 2020. Monjuvi (tafasitamab-cxix) 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.

Monjuvi (tafasitamab-cxix) is a CD19-directed cytolytic antibody indicated in combination with lenalidomide for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma, or DLBCL, not otherwise specified, including DLBCL arising from low-grade lymphomawho aren’t eligible for autologous stem cell transplant.

Dosage and administration:

Administer premedications prior to starting Monjuvi
The recommended dosage of Monjuvi is 12 mg/kg as an intravenous infusion according to the following dosing schedule:

Cycle 1: Days 1, 4, 8, 15 and 22 of the 28-day cycle.
Cycles 2 and 3: Days 1, 8, 15 and 22 of each 28-day cycle.
Cycle 4 and beyond: Days 1 and 15 of each 28-day cycle.

Administer Monjuvi in combination with lenalidomide for a maximum of 12 cycles and then continue Monjuvi as monotherapy until disease progression or unacceptable toxicity.

Dosage forms and strengths:

For injection: 200 mg of tafasitamab-cxix as lyophilized powder in single dose vial for reconstitution. Instillation volume based on volumetric measurements using pyelography, not to exceed 15 mL (60 mg of mitomycin).

Condition code 89

Basic benefit and medical policy

Condition code 89 approved

The National Uniform Billing Committee approved new condition code 89. This is effective Jan. 1, 2021.

POLICY CLARIFICATIONS

33215, 33216, 33217, 33218, 33220, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 93260, 93261, 93282, 93283, 93284, 93287, 93289, 93295, 93296

Not covered:

0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0614T

Basic benefit and medical policy

Implantable Cardioverter Defibrillator (ICD), Including Subcutaneous ICDs, policy

The safety and effectiveness of an automatic implantable cardioverter defibrillator, or ICD, and electronic surveillance of the AICD have been established. It may be considered a useful therapeutic option for patients who meet selection criteria.

The safety and effectiveness of a subcutaneous automatic implantable cardioverter defibrillator and electronic surveillance of the AICD have been established. It may be considered a useful therapeutic option for patients who meet selection criteria.

Inclusionary criteria for the indication of cardiac sarcoid have been added, effective Jan. 1, 2021.

Inclusions:

Standard automatic implantable cardioverter defibrillators

I. Adults

The use of the automatic implantable cardioverter defibrillator may be considered established in adults who meet the following criteria:

Primary prevention

Inclusions (one of the following):

Ischemic cardiomyopathy with New York Heart Association, or NYHA, functional Class II or Class III symptoms, a history of myocardial infarction at least 40 days before ICD treatment and left ventricular ejection fraction of 35% or less
Ischemic cardiomyopathy with NYHA functional Class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment and left ventricular ejection fraction of 30% or less
Nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined
Hypertrophic cardiomyopathy, or HCM, with one or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in one or more first-degree relatives younger than 50 years; left ventricular hypertrophy greater than 30 mm; one or more runs of nonsustained ventricular tachycardia at heart rates of 120 beats per minute or greater on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM.
Diagnosis of any one of the following cardiac ion channelopathies and considered to be at high risk for sudden cardiac death:

Congenital long QT syndrome
Brugada syndrome
Short QT syndrome
Catecholaminergic polymorphic ventricular tachycardia

Diagnosis of cardiac sarcoid and considered to be at high risk for sudden cardiac death:

Spontaneous sustained ventricular arrhythmias, including prior cardiac arrest, if meaningful survival of greater than one year is expected;
LVEF 35% or less, despite optimal medical therapy and a period of immunosuppression (if there is active inﬂammation), if meaningful survival of greater than one year is expected;
LVEF greater than 35%, if meaningful survival of greater than one year is expected; and one of the following:
- Syncope or near-syncope, believed to be arrhythmic in etiology
- Evidence of myocardial scar by cardiac MRI or positron emission tomographic scan
- Inducible sustained ventricular arrhythmias (>30 seconds of monomorphic VT orpolymorphic VT) or clinically relevant VF
An indication for permanent pacemaker implantation

Secondary prevention

Inclusions:

Patients with a history of a life-threatening clinical event associated with ventricular arrhythmic events, such as sustained ventricular tachyarrhythmia after reversible causes (e.g., acute ischemia) have been excluded.

II. Pediatrics

Inclusions:

The use of the ICD or SCD may be considered established in children who meet any of the following criteria:

Survivors of cardiac arrest, after reversible causes have been excluded.
Symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation
Congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias
Hypertrophic cardiomyopathy, or HCM, with one or more major risk factors for sudden cardiac death (history or premature HCM-related sudden death in one or more first-degree relatives younger than 50 years; massive left ventricular hypertrophy based on age-specific norms; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM
Diagnosis of any one of the following cardiac ion channelopathies and considered to be at high risk for sudden cardiac death:

Congenital long QT syndrome
Brugada syndrome
Short QT syndrome
Catecholaminergic polymorphic ventricular tachycardia

Subcutaneous automatic implantable cardioverter defibrillators

FDA-approved subcutaneous cardioverter-defibrillators are established for adults who meet patient selection criteria for an implanted cardioverter defibrillator and who don’t need pacing and the placement of a conventional AICD is precluded due to any of the following conditions. These also apply to pediatric patients in addition to those inclusions in the pediatric section:

Poor vascular access secondary to dialysis or other vascular conditions
A high risk for infection, e.g., immunocompromised patients or those with a history of a previous transvenous infection
History of congenital heart disease with anatomic limitations for transvenous placement of the AICD
History of need for explantation of a transvenous ICD due to a complication, with ongoing need for ICD therapy

Exclusions:

The use of the ICD is considered experimental in primary prevention patients who:

Have had an acute myocardial infarction (e.g., less than 40 days before ICD treatment);
Have New York Heart Association class IV congestive heart failure (unless patient is eligible to receive a combination cardiac resynchronization therapy ICD device)
Have had a cardiac revascularization procedure in past three months (coronary artery bypass graft or percutaneous transluminal coronary angioplasty) or are candidates for a cardiac revascularization procedure
Have noncardiac disease that would be associated with life expectancy less than one year

The use of the ICD in secondary prevention is considered experimental for all other indications than those listed above.

The use of the ICD in pediatric patients is considered experimental for all other indications than those listed above.

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

Not covered:
33999**

**Not Otherwise Classified code used to report non-FDA-approved systems

Basic benefit and medical policy

Transcatheter aortic valve replacement

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

Exclusionary criteria have been updated, effective Jan. 1, 2021.

Inclusions:

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

Severe aortic stenosis with a calcified aortic annulus or 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.
Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapiens 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 to be at high or greater risk** for open surgical therapy.
Patient is at intermediate surgical risk** for open aortic valve replacement.

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.

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.

**Definition of predictive risk factor based on the Society of Thoracic Surgeons, known as STS, predicted risk score for major complications and other clinical comorbidities unmeasured by the STS risk calculator for open surgery.

Low risk – predicted operative risk score of less than 3% or 4%
Intermediate risk – predicted operative risk score of 3% to 7%
High risk – predicted operative risk score of 8% or higher; or judged by a heart team, which includes an experienced cardiac surgeon and a cardiologist, to have an expected mortality risk of ≥ 15% within 30 days

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
Presence of unicuspid or bicuspid aortic valve
Non-FDA-approved systems or approaches including:

Portico, and JenaValve systems
Transcaval approach

Relative contraindications:

In some cases, the benefits of transcatheter aortic valve implantation may exceed potential risks. In such instances, the cardiologist should provide an attestation indicating that relative contraindications exist and that the patient fully understands all risks. While the items below aren’t absolute exclusions, the safety and effectiveness of transcatheter aortic valve implantation haven’t been evaluated in patients with the following characteristics or co-morbidities:

Patients without aortic stenosis
Untreated, clinically significant coronary artery disease requiring revascularization
Cardiogenic shock manifested by low cardiac output, vasopressor dependence, or mechanical hemodynamic support
Trans arterial access not able to accommodate an 18-Fr sheath
Sinus of valsalva anatomy that would prevent adequate coronary perfusion
End-stage renal disease requiring chronic dialysis or creatinine clearance <20 cc/min
Symptomatic carotid or vertebral artery disease
Safety, effectiveness and durability haven’t been established for valve-in-valve procedures
Non-calcified aortic annulus
Severe ventricular dysfunction with ejection fraction < 20%
Congenital unicuspid or congenital bicuspid aortic valve
Mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation > 3+)
Prosthetic ring in any position
Severe mitral annular calcification, severe mitral insufficiency, moderate to severe mitral or tricuspid regurgitation, or Gorlin syndrome
Moderate to severe mitral stenosis
Blood dyscrasias defined as: leukopenia, acute anemia (Hb < 9 g/dL), thrombocytopenia, history of bleeding diathesis or coagulopathy, or hypercoagulable states
Hypertrophic cardiomyopathy with or without obstruction
Echocardiographic evidence of intracardiac mass, thrombus, or vegetation
Excessive calcification of vessel at access site
Bulky calcified aortic valve leaflets in close proximity to coronary ostia
The safety and effectiveness of the Medtronic CoreValve™ system haven’t been evaluated in the pediatric population.

81210, 81445

Basic benefit and medical policy

Genetic testing ̶ BRAF mutation in selecting melanoma patients for targeted therapy

The medical policy statement has been updated for the Genetic Testing ̶ BRAF Mutation in Selecting Melanoma Patients for Targeted Therapy policy. The policy effective date is Jan. 1, 2021.

Medical policy statement

Testing for BRAF V600 variants in tumor tissue of patients with unresectable or metastatic melanoma is established to select patients for treatment with FDA-approved BRAF or MEK inhibitors.

Testing for BRAF V600 variants in tumor tissue of patients with resected stage III melanoma is established to select patients for treatment with FDA-approved BRAF or MEK inhibitors.

Testing for BRAF V600 variants for all other patients with melanoma is considered experimental.

Testing for genetic mutations using a panel with 5-50 genes may also be considered appropriate for cutaneous melanoma (Stage 3 and Stage 4).

Testing for BRAF V600 or the above panel with 5-50 genes for all other reasons is experimental.

Inclusions and exclusions:

Refer to the pharmacy policies (Vemurafenib, Trametinib, Cobimetinib) for patient selection.

81420, 81507, 81599,** 81479***

Not covered:
81422, 0060U, 0168U

Payment policy

**Not Otherwise Classified code used to report test of multianalyte assays with algorithmic analysis

***NOC code used if others don’t apply and the test doesn’t involve an algorithmic analysis

Basic benefit and medical policy

Noninvasive prenatal screening

The safety and effectiveness of noninvasive prenatal screening for fetal aneuploidies using cell-free fetal DNA have been established. It may be considered a useful diagnostic option when indicated.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of noninvasive prenatal screening for microdeletions using cell-free fetal DNA. Therefore, this service is considered experimental.

Exclusions regarding twin zygosity and Vanadis^® have been added, effective Jan. 1, 2021.

Inclusions:

Nucleic acid sequencing-based testing of maternal plasma to screen for trisomy 21 in women with singleton pregnancies. (Karyotyping would be necessary to exclude the possibility of a false positive nucleic acid sequencing-based test.)
Concurrent nucleic acid sequencing-based testing of maternal plasma for trisomy 13 or 18 in women who are eligible for and are undergoing nucleic acid sequencing-based testing of maternal plasma for trisomy 21.

Exclusions:

Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 in women with twin or multiple gestation pregnancies
Nucleic acid sequencing-based testing of maternal plasma for trisomy 13 or 18, other than in the situations specified above
Nucleic acid sequencing-based testing of maternal plasma for fetal sex chromosome aneuploidies
Nucleic acid sequencing-based testing of maternal plasma for microdeletions
Nucleic acid sequencing-based testing of maternal plasma for twin zygosity
Vanadis® NIPT of maternal plasma to screen for trisomy 21, 18 and 13

Policy guidelines:

Karyotyping would be necessary to exclude the possibility of a false-positive, nucleic acid sequencing-based test. Before testing, women should be counseled about the risk of a false-positive test. In Committee Opinion No. 640, the American College of Obstetricians and Gynecologists (2015) recommended that all patients receive information on the risks and benefits of various methods of prenatal screening and diagnostic testing for fetal aneuploidies, including the option of no testing.

Studies published to date on noninvasive prenatal screening for fetal aneuploidies have reported rare but occasional false positives. False-positive findings have been found to be associated with factors including placental mosaicism, vanishing twins and maternal malignancies. Diagnostic testing is necessary to confirm positive cell-free fetal DNA tests, and management decisions should not be based solely on the results of cell-free fetal DNA testing. The American College of Obstetricians and Gynecologists further recommended that patients with indeterminate or uninterpretable (i.e., “no call”) cell-free fetal DNA test results be referred for genetic counseling and offered ultrasound evaluation and diagnostic testing because “no call” findings have been associated with an increased risk of aneuploidy.

Cell-free DNA screening doesn’t assess risk of neural tube defects. Patients should continue to be offered ultrasound or maternal serum alpha-fetoprotein screening.

Genetic counseling

Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing; further genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

81479, 81599, 84999

Basic benefit and medical policy

Gene expression profiling for cutaneous melanoma

The medical policy statement has been updated for the Gene Expression Profiling for Cutaneous Melanoma policy.

Medical policy statement

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of gene expression profiling for the diagnosis or prognosis of cutaneous melanoma. Therefore, this service is considered experimental.

Inclusions and exclusions:

Excluded tests include but are not limited to:

Pigmented Lesion Assay
myPath Melanoma
DecisionDx-Melanoma

The policy effective date is Jan. 1, 2021.

Established

86294, 86386, 88120, 88121

Experimental

0012M, 0013M, 81599

Basic benefit and medical policy

Urinary biomarkers for bladder cancer

The safety and effectiveness of FDA-approved urinary tumor marker tests for bladder cancer have been established.

An FDA-approved urinary tumor marker test may be considered a useful diagnostic option when used as an adjunct to cytology and cystoscopy. The policy effective date is Jan. 1, 2021.

Inclusions:

The assessment of FDA-approved urinary tumor markers for bladder cancer, as an adjunct to cytology and cystoscopy, is considered established 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 analytical validity and clinical utility outcomes of Cxbladde™ therefore, Cxbladder tests are considered experimental.

Established

94772, 94774, 94775, 94776, 94777, A4556, A4557, E0619

Experimental

E0618

Basic benefit and medical policy

Home cardiorespiratory monitoring ̶ pediatric

The criteria have been updated for the Home Cardiorespiratory Monitoring ̶ Pediatric policy, effective Jan. 1, 2021.

Inclusions:

Home cardiorespiratory monitoring when initiated in infants younger than 12 months of age in any of the following situations:

Those who have experienced a brief resolved unexplained event (previously known as apparent life-threatening event) and aren’t considered lower risk following clinical evaluation
Those with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise.
Those with neurologic or metabolic disorders affecting respiratory control, including central apnea and apnea of prematurity
Those with chronic lung disease (e.g.., bronchopulmonary dysplasia)

Home cardiorespiratory monitoring in children over 12 months of age in any of the following situations:

Those with home noninvasive ventilator use
Those with home invasive ventilator use
Those with chronic lung disease
Those with cyanotic heart disease

Exclusions:

Home cardiorespiratory monitoring when used as a strategy to reduce the risk of sudden infant death syndrome
Home cardiorespiratory monitoring in all other conditions including, but not limited to, the diagnosis of obstructive sleep apnea
Apnea monitors without an event recorder

J0585

Basic benefit and medical policy

Botox (onabotulinumtoxinA)

Effective July 8, 2020, Botox (onabotulinumtoxinA) is payable for the following updated FDA-approved indications:

Treatment of spasticity in patients ages 2 years and older.

Dosage and administration:

Adult upper limb spasticity: Select dose based on muscles affected, severity of muscle activity, prior response to treatment and adverse event history. Electromyographic guidance recommended
Adult lower limb spasticity: Recommended total dose 300 units to 400 units divided across ankle and toe muscles
Pediatric upper limb spasticity: Recommended total dose 3 units/kg to 6 units/kg (maximum 200 units) divided among affected muscles

Pediatric lower limb spasticity: Recommended total dose of 4 units/kg to 8 units/kg (maximum 300 units) divided among affected muscles

J0587

Basic benefit and medical policy

Myobloc (rimabotulinumtoxinB)

Effective Aug. 20, 2019, Myobloc (rimabotulinumtoxinB) is payable for the following updated FDA-approved indications:

Treatment of chronic sialorrhea in adults

Dosage and administration:

Chronic sialorrhea: Recommended dosage is 1,500 units to 3,500 units; 500 units to 1,500 units per parotid gland and 250 units per submandibular gland; no more frequent than every 12 weeks

J0588

Basic benefit and medical policy

Xeomin (incobotulinumtoxinA)

Effective Aug. 18, 2020, Xeomin (incobotulinumtoxinA) is payable for the following updated FDA-approved indications:

Upper limb spasticity in pediatric patients 2 to 17 years of age, excluding spasticity caused by cerebral palsy

Dosage and administration:

Upper limb spasticity in pediatric patients, excluding spasticity caused by cerebral palsy: the recommended total dose is 8 units/kg (maximum 200 units) per single upper limb or 16 units/kg (maximum 400 units) in both upper limbs, divided among affected muscles

J3490
J3590

Basic benefit and medical policy

Spravato (esketamine)

Effective July 31, 2020, Spravato (esketamine) is covered for the following FDA-approved indications:

Depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior

Limitations of use:

The effectiveness of Spravato in preventing suicide or in reducing suicidal ideation or behavior hasn’t been demonstrated. Use of Spravato doesn’t preclude the need for hospitalization if clinically warranted, even if patients experience improvement after an initial dose of Spravato.

This drug isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Veklury (remdesivir)

Effective Oct. 22, 2020, Veklury (remdesivir) is covered for the following FDA-approved indications:

Veklury is a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor indicated for adults and pediatric patients (ages 12 and older and weighing at least 40 kg) for the treatment of coronavirus disease 2019 requiring hospitalization. Veklury should only be administered in a hospital or in a health care setting capable of providing acute care comparable to inpatient hospital care.

Dosage and administration:

Testing: In all patients, before initiating Veklury and during treatment as clinically appropriate, perform renal and hepatic laboratory testing and assess prothrombin time.
Recommended dosage in adults and pediatric patients ages 12 and older and weighing at least 40 kg: A single loading dose of Veklury 200 mg on Day 1 followed by once-daily maintenance doses of Veklury 100 mg from Day 2 infused over 30 to 120 minutes.
For patients not requiring invasive mechanical ventilation or ECMO, the recommended total treatment duration is five days. If a patient doesn’t demonstrate clinical improvement, treatment may be extended for up to five additional days for a total treatment duration of up to 10 days.
For patients requiring invasive mechanical ventilation or ECMO, the recommended total treatment duration is 10 days.
Administer Veklury via intravenous infusion over 30 to 120 minutes.
Renal impairment: Veklury isn’t recommended in patients with eGFR less than 30 mL/min.
Dose preparation and administration: Refer to the full prescribing information for further details for both formulations.
Storage of prepared dosages: Veklury contains no preservative.

Dosage forms and strengths:

For injection: 100 mg of remdesivir as a lyophilized powder, in a single-dose vial.
Injection: 100 mg/20 mL (5 mg/mL) remdesivir, in a single-dose vial.

This drug isn’t a benefit for URMBT.

J7645

Payment policy

Procedure code J7645

Procedure code J7645 is payable to urgent care providers.

J9023

Basic benefit and medical policy

Bavencio (avelumab)

Effective June 30, 2020, Bavencio (avelumab) is approved for the following updated FDA-approved indication:

Maintenance treatment of patients with locally advanced or metastatic urothelial carcinoma that hasn’t progressed with first-line platinum-containing chemotherapy.

EXPERIMENTAL PROCEDURES

New codes added

0604T, 0605T, 0606T

Experimental

0378T, 0379T

Basic benefit and medical policy

Home monitoring device for age-related macular degeneration

Home monitoring devices using preferential hyperacuity perimetry, or PHP, and telemonitoring of results for age-related macular degeneration are considered experimental. There is insufficient evidence in the peer-reviewed medical literature to demonstrate that these devices improve clinical outcomes over standard monitoring approaches.

New procedure codes have been added to this policy.

The policy effective date is Jan. 1, 2021.

Established

52441, 52442, C9769

Experimental

0619T

Basic benefit and medical policy

Prostatic urethral lift procedure for the treatment of BPH

The safety and efficacy of the prostatic urethral lift procedure for the treatment of benign prostatic hypertrophy, or BPH, have been established.

It’s a useful therapeutic option for men with symptomatic BPH who have failed conventional pharmacologic therapy.

New procedure codes C9769 and 0619T have been added to this policy. The policy effective date is Jan. 1, 2021.

Inclusions:

Candidates for the prostatic urethral lift procedure must meet all the following guidelines:

Age 45 years or older
A documented diagnosis of symptomatic benign prostatic hypertrophy of the lateral lobes of the prostate including, but not limited to, the following symptoms:

Difficulty starting and stopping urination (hesitancy and straining)
Decreased strength of the urine stream (weak flow)
Dribbling after urination
Feeling that the bladder isn’t completely empty
An urge to urinate again soon after urinating (urgency)
Pain during urination (dysuria)
Nocturia – waking up several times during the night with the urge to urinate
Frequent urinary tract infections secondary to urinary obstruction

Documented failure of, inability to tolerate or undesirable side effects of pharmacologic intervention for BPH including, but not limited to:

Alpha blockers, such as Uroxatral, Cardura, Rapaflo, Flomax or Hytrin
5-alpha reductase inhibitors for BPH, such as Avodart or Proscar
Combination drugs using both an alpha blocker and a 5-alpha reductase inhibitor

Exclusions:

Patients not meeting the patient selection criteria above.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.