Billing chart: Blues highlight medical, benefit policy changes

81596

Other code: 91200

Basic benefit and medical policy

Noninvasive techniques for the evaluation and monitoring of patients with chronic liver disease

FibroSURE^® (81596) is payable when used to distinguish hepatic fibrosis from necro-inflammatory activity in patients with hepatitis C, effective Sept. 1, 2020.

The safety and effectiveness of transient elastography, using either M or XL Probe, for the evaluation or monitoring of patients with chronic liver disease have been established. It may be considered a useful diagnostic option when indicated.

The use of other noninvasive imaging, including, but not limited to, magnetic resonance elastography, acoustic radiation force impulse imaging or real-time tissue elastography is considered experimental for the evaluation or monitoring of patients with chronic liver disease. While these services may be safe, their clinical utility in this clinical indication hasn’t been determined.

The use of FibroSURE^® multianalyte assays in chronic liver disease has been established. It may be considered a useful diagnostic option when indicated.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of other multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease. Therefore, these services are considered experimental.

Payment policy

Code *81596 isn’t covered when provided in an office setting or ambulatory surgical center. Modifiers 26 and TC aren’t applicable.

Inclusions:

Noninvasive imaging techniques:

• Transient elastography, using either the M or XL Probe, for the evaluation or monitoring of chronic liver disease

Multianalyte assays:

• FibroSURE when used to distinguish hepatic fibrosis from necro‑inflammatory activity in patients with hepatitis C

Exclusions:

Noninvasive imaging techniques:

• Transient elastography in individuals with ascites
• Magnetic resonance elastography, acoustic radiation force impulse imaging and real-time tissue elastography for the evaluation or monitoring of chronic liver disease

Multianalyte assays:

• Multianalyte assays other than FibroSure
• Multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease not listed above

J0348

Basic benefit and medical policy

Eraxis (anidulafungin)

Effective Sept. 22, 2020, Eraxis (anidulafungin) is an echinocandin antifungal indicated for the treatment of the following infections:

• Candidemia and other forms of candida infections (intra‑abdominal abscess and peritonitis) in adults and pediatric patients (1 month of age and older)
• Esophageal candidiasis in adults

Dosage and administration

Candidemia and other forms of candida infections:

• Adults: 200 mg loading dose on Day 1, followed by 100 mg once daily maintenance dose thereafter for at least 14 days after the last positive culture
• Pediatric patients 1 month of age and older: 3 mg/kg (not to exceed 200 mg) loading dose on Day 1, followed by 1.5 mg/kg (not to exceed 100 mg) once daily maintenance dose thereafter for at least 14 days after the last positive culture

Esophageal candidiasis:

• Adults: 100 mg loading dose on Day 1, followed by 50 mg once daily maintenance dose thereafter for a minimum of 14 days and for at least seven days following resolution of symptoms
• Pediatric patients 1 month of age and older: Not approved

Rate of infusion for adults and pediatric patients

The rate of infusion shouldn’t exceed 1.1 mg/minute (equivalent to 1.4 mL/minute or 84 mL/hour when reconstituted and diluted per instructions).

J3490
J3590

Basic benefit and medical policy

Viltepso (viltolarsen)

Effective Aug. 12, 2020, Viltepso (viltolarsen) is covered for the following FDA-approved indications:

Viltepso (viltolarsen) is an antisense oligonucleotide indicated for the treatment of Duchenne muscular dystrophy, or DMD, in patients who have a confirmed mutation of the DMD gene that is amenable to exon 53 skipping. This indication is approved under accelerated approval based on an increase in dystrophin production in skeletal muscle observed in patients treated with Viltepso. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

Dosage and administration

• Serum cystatin C, urine dipstick and urine protein-to-creatinine ratio should be measured before starting Viltepso.
• Recommended dosage is 80 milligrams per kilogram of body weight once weekly.
• Administer as an intravenous infusion over 60 minutes.
• If the volume of Viltepso required is less than 100 mL, dilution in 0.9% Sodium Chloride Injection, USP, is required.

Dosage forms and strengths

Injection: 250 mg/5 mL (50 mg/mL) in a single-dose vial

This drug isn’t a benefit for URMBT.

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

Keytruda (pembrolizumab) is payable for the
following updated FDA indications:

Microsatellite instability  ̶  high or mismatch repair deficient colorectal cancer, or CRC

• For the first-line treatment of patients with unresectable or metastatic MSI-H or dMMR colorectal cancer.

Tumor mutational burden-high, or TMB-H, cancer

• For the treatment of adult and pediatric patients with unresectable or metastatic tumor mutational burden-high, or TMB-H [≥10 mutations/megabase (mut/Mb)] solid tumors, as determined by an FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options.
• Limitations of use: The safety and effectiveness of Keytruda in pediatric patients with TMB-H central nervous system cancers haven’t been established.

Cutaneous Squamous Cell Carcinoma, or cSCC

• For the treatment of patients with recurrent or metastatic cutaneous squamous cell carcinoma that isn’t curable by surgery or radiation.

Dosing information:

• MSI-H or dMMR CRC: 200 mg every three weeks or 400 mg every six weeks.
• TMB-H cancer: 200 mg every three weeks or 400 mg every six weeks for adults; 2 mg/kg (up to 200 mg) every three weeks for pediatrics
• cSCC: 200 mg every three weeks or 400 mg every six weeks

VanHaren Electric Inc.

VanHaren Electric Inc., group number 71827, will utilize the new Flexlink partner (Blue Water Benefits Administration), effective Jan. 1, 2021. 

Group number: 71827
Alpha prefix: PPO (VKU)
Platform: NASCO Flexlink

Plans offered:
PPO medical/surgical
Prescription drug plan