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

NEW PAYABLE PROCEDURES

69705, 69706 Experimental: 0583T

Basic benefit and medical policy

Balloon dilation of the eustachian tube

Effective March 1, 2021, balloon dilation of the eustachian tube for treatment of chronic obstructive eustachian tube dysfunction may be considered established under all the following conditions:

Adults (aged 18 and older) with symptoms of obstructive eustachian tube dysfunction (aural fullness, aural pressure, otalgia or hearing loss) for 12 months or longer in one or both ears that significantly affects quality of life or functional health status.

Aural fullness and pressure present

The patient has undergone a comprehensive diagnostic assessment, including patient-reported questionnaires, history and physical exam, tympanometry if the tympanic membrane is intact, nasal endoscopy and comprehensive audiometry, with the following findings:

Abnormal tympanogram (Type B or C)
Abnormal tympanic membrane (retracted membrane, effusion, perforation or any other abnormality identified on exam)

Failure to respond to appropriate medical management of potential co‑occurring conditions, if any, such as allergic rhinitis, rhinosinusitis and laryngopharyngeal reflux, including four to six weeks of a nasal steroid spray, if indicated.
Other causes of aural fullness, such as temporomandibular joint disorders, extrinsic obstruction of the eustachian tube, superior semicircular canal dehiscence and endolymphatic hydrops have been ruled out.
If the patient had a history of tympanostomy tube placement, symptoms of obstructive eustachian tube dysfunction should have improved while tubes were patent.
The patient doesn’t have patulous eustachian tube dysfunction or another contraindication to the procedure (see policy guidelines).
The patient’s eustachian tube dysfunction has been shown to be reversible (see policy guidelines).
Symptoms are continuous rather than episodic (e.g., symptoms occur only in response to barochallenge, such as pressure changes while flying).
The patient hasn’t had a previous BDET procedure.

Balloon dilation of the eustachian tube is considered experimental if the above criteria aren’t met.

Policy guidelines:

Symptoms of obstructive eustachian tube dysfunction may include aural fullness, aural pressure, otalgia and hearing loss. Nearly all patients will have aural fullness and aural pressure. Many patients will have otalgia, but hearing loss may not be present in all patients (e.g., patients with Type C tympanograms).

Contraindications to balloon dilation of the eustachian tube

The following patients shouldn’t be considered for balloon dilation of the eustachian tube:

Patients with patulous eustachian tube dysfunction

A diagnosis of patulous ETD is suggested by symptoms of autophony of voice, audible respirations, pulsatile tinnitus or aural fullness

Patients with extrinsic reversible or irreversible causes of eustachian tube dysfunction, including but not limited to:

Craniofacial syndromes, including cleft palate spectrum
Neoplasms causing extrinsic obstruction of the eustachian tube
History of radiation therapy to the nasopharynx
Enlarged adenoid pads
Nasopharyngeal mass
Neuromuscular disorders that lead to hypotonia/ineffective eustachian tube dynamic opening
Systemic mucosal or autoimmune inflammatory disease affecting the mucosa of the nasopharynx and eustachian tube (e.g., Samter’s triad, Wegener’s disease, mucosal pemphigus) that is ongoing or active (i.e., not in remission)

Patients with aural fullness but normal exam and tympanogram
Patients with chronic and severe atelectatic ears

Reversibility of eustachian tube dysfunction

Reversibility of eustachian tube dysfunction can be demonstrated by several means, including any of the following:

The patient states that they are able to relieve the pressure by performing a Valsalva maneuver to “pop” their ears.
Performing a Valsalva maneuver produces temporary improvement of the patient’s tympanogram to Type A tympanogram.
Performing a Valsalva maneuver causes the member’s middle ear to aerate, which is indicated by the provider visualizing lateral movement of the tympanic membrane on otoscopy.

Balloon dilation of the eustachian tube used in combination with other procedures

Patients undergoing BDET concurrent with sinus ostial dilation should meet the same diagnostic criteria for BDET as those undergoing BDET alone.
Patients with a middle ear effusion at the time of BDET may benefit from concurrent myringotomy with or without tympanostomy tube placement.

UPDATES TO PAYABLE PROCEDURES

J3490 J3590

Basic benefit and medical policy

Margenza (margetuximab‑cmkb)

Margenza (margetuximab‑cmkb) is payable for its FDA‑approved indications when billed with procedure code J3490 or J3590, effective Dec. 17, 2020. Margenza (margetuximab‑cmkb) 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.

Margenza (margetuximab‑cmkb) is a HER2/neu receptor antagonist indicated, in combination with chemotherapy, for the treatment of adult patients with metastatic HER2‑positive breast cancer who have received two or more prior anti‑HER2 regimens, at least one of which was for metastatic disease.

Dosage and administration:

Administer Margenza (margetuximab‑cmkb) as an intravenous infusion at 15 mg/kg over 120 minutes for the initial dose, then over a minimum of 30 minutes every three weeks for all subsequent doses.

Dosage forms and strengths:

Injection: 250 mg/10 mL (25 mg/mL) in a single‑dose vial

J9299

Basic benefit and medical policy

Opdivo (nivolumab)

Opdivo (nivolumab), procedure code J9299, is payable for its updated FDA‑approved indications.

Indications have been updated to include treatment of adult patients with unresectable malignant pleural mesothelioma, as first‑line treatment in combination with ipilimumab.

POLICY CLARIFICATIONS

J0585

Basic benefit and medical policy

Botox (Onabotulinum‑toxinA)

Effective Feb. 9, 2021, Botox (Onabotulinum‑toxinA) is covered for the following FDA‑approved indications:

Botox is an acetylcholine release inhibitor and a neuromuscular blocking agent indicated for:

Treatment of neurogenic detrusor overactivity, or NDO, in pediatric patients aged 5 years and older who have an inadequate response to or are intolerant of anticholinergic medication.

Dosing information:

Follow indication‑specific dosage and administration recommendations. In a three‑month interval, don’t exceed a total dose of:

Adults: 400 units
Pediatrics: The lesser of 10 units/kg or 340 units

Adult detrusor overactivity associated with a neurologic condition: Recommended total dose 200 units, as 1 mL (~6.7 Units) injections across 30 sites into the detrusor
Pediatric detrusor overactivity associated with a neurologic condition: 0.5 mL injections across 20 sites into the detrusor:

Greater than or equal to 34 kg: Recommended total dose is 200 units
Less than 34 kg: Recommended total dose is 6 units/kg

J3357

Basic benefit and medical policy

Stelara (ustekinumab)

Stelara (ustekinumab) is payable for the following updated FDA indications:

Pediatric patients age 6 and older with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy

Psoriasis pediatric patients (aged 6 to 17) subcutaneous recommended dosage

Weight‑based dosing is recommended at the initial dose, four weeks later, then every 12 weeks thereafter.

Weight range (kilogram)	Dosage regimen
Less than 60 kg	0.75 mg/kg
60 kg to 100 kg	45 mg
Greater than 100 kg	90 mg

J3490 J3590

Basic benefit and medical policy

Amondys 45 (casimersen)

Amondys 45 (casimersen) is considered experimental for all indications. Therefore, the service isn’t payable, effective Feb. 25, 2021.

J3490 J3590 J9999

Basic benefit and medical policy

Breyanzi (lisocabtagene maraleucel)

Effective Feb. 5, 2021, Breyanzi (lisocabtagene maraleucel) is covered for the following FDA‑approved indications:

Breyanzi (lisocabtagene maraleucel) is a CD19‑directed genetically modified autologous T cell immunotherapy indicated for the treatment of adult patients with relapsed or refractory large B‑cell lymphoma after two or more lines of systemic therapy, including diffuse large B‑cell lymphoma, or DLBCL, not otherwise specified (including DLBCL arising from indolent lymphoma), high‑grade B‑cell lymphoma, primary mediastinal large B‑cell lymphoma and follicular lymphoma grade 3B.

Limitation of use:

Breyanzi isn’t indicated for the treatment of patients with primary central nervous system lymphoma.

Dosage and administration:

For autologous use only. For intravenous use only.
A single dose of Breyanzi contains 50 to 110 × 106 CAR‑positive viable T cells (consisting of 1:1 CAR‑positive viable T cells of the CD8 and CD4 components), with each component supplied separately in one to four single‑dose vials.

Dosage forms and strengths:

The dose is 50 to 110 × 106 CAR-positive viable T cells (consisting of CD8 and CD4 components). Administer Breyanzi (lisocabtagene maraleucel) in a certified health care facility.
Each mL contains 1.5 × 106 to 70 × 106 CAR-positive viable T cells.

This drug isn’t a benefit for URMBT.

J3490 J3590

Basic benefit and medical policy

Cosela (trilaciclib dihydrochloride)

Effective Feb. 12, 2021, Cosela (trilaciclib dihydrochloride) is covered for the following FDA‑approved indications:

Indications and usage:

Cosela is a kinase inhibitor used to decrease the incidence of chemotherapy‑induced myelosuppression in adult patients when administered prior to a platinum/etoposide‑containing regimen or topotecan-containing regimen for extensive-stage small cell lung cancer.

Dosage and administration:

Recommended dosage: The recommended dose of Cosela is 240 mg/m2 per dose. Administer as a 30‑minute intravenous infusion completed within four hours prior to the start of chemotherapy on each day chemotherapy is administered.

Dosage forms and strengths:

For injection: 300 mg of trilaciclib as a lyophilized cake in a single‑dose vial

This drug isn’t a benefit for URMBT and MPSERS.

J3490 J3590

Basic benefit and medical policy

Evkeeza (evinacumab‑dgnb)

Effective Feb. 11, 2021, Evkeeza (evinacumab‑dgnb) is covered for the following FDA‑approved indications:

Evkeeza is an ANGPTL3 (angiopoietin-like 3) inhibitor indicated as an adjunct to other low‑density lipoprotein‑cholesterol, or LDL‑C, lowering therapies for the treatment of adult and pediatric patients, age 12 and older, with homozygous familial hypercholesterolemia, or HoFH.

J3490 J3590

Basic benefit and medical policy

Pepaxto (melphalan flufenamide)

Effective Feb. 26, 2021, Pepaxto (melphalan flufenamide) is covered for the following FDA‑approved indications:

Pepaxto is an alkylating drug indicated, in combination with dexamethasone, for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy and whose disease is refractory to at least one proteasome inhibitor, one immunomodulatory agent and one CD38‑directed monoclonal antibody. This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Limitations of use:

Pepaxto isn’t indicated or recommended for use as a conditioning regimen for transplant outside of controlled clinical trials.

Dosage and administration:

The recommended dosage of Pepaxto is 40 mg intravenously over 30 minutes on Day 1 of each 28‑day treatment cycle, in combination with dexamethasone.

Dosage forms and strengths:

For injection: 20 mg melphalan flufenamide as a lyophilized powder in single‑dose vial reconstitution and dilution

Pepaxto isn’t a benefit for MSPERS and URMBT.

GROUP BENEFIT CHANGES

Saginaw Plumbers and Pipe Fitters UA Local 85

Effective July 1, 2021, Saginaw Plumbers and Pipe Fitters UA Local 85, group number 71829, is moving platforms from MOS to Flexlink.

Group number: 71829
Alpha prefix: PPO (SYQ)
Platform: Flexlink

Plans offered:
PPO plans medical/surgical
Prescription drug plan

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.