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

90619

MenQuadfi (meningococcal vaccine)

CPT code *90619 has been changed from experimental to payable, effective Nov. 1, 2020.

MenQuadfi (meningococcal vaccine) is payable for the FDA‑approved indications when billed with CPT code *90619.

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 adult patients with unresectable malignant pleural mesothelioma, as first‑line treatment in combination with nivolumab.

Q5101

Basic benefit and medical policy

Zarxio (filgrastim‑sndz)

Zarxio (filgrastim‑sndz), procedure code Q5101, is payable for the FDA‑approved indication to reduce the incidence and duration of sequelae of severe neutropenia (e.g.‚ fever‚ infections‚ oropharyngeal ulcers) in symptomatic patients with congenital neutropenia‚ cyclic neutropenia or idiopathic neutropenia.

POLICY CLARIFICATIONS

11950, 11951, 11952, 11954, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17380, 21120, 21121, 21122, 21123, 21125, 21127, 30400, 30410, 30420, 30430, 30435, 30450

Basic benefit and medical policy

Transgender services

A clarification regarding facial feminization / masculinization was added to the exclusions of the transgender services policy, effective May 1, 2021.

Basic benefit policy group variations:

For University of Michigan Gender‑Affirming Services (facial feminization, hair removal or chondrolaryngoplasty), reference the Medical Policy Partner document.

Exclusions:

Facial feminization surgery and facial masculinization surgery are considered cosmetic and not medically necessary. Some procedures are listed below but the list isn’t all-inclusive.

Procedures that are primarily cosmetic and not medically necessary, including but not limited to:

Abdominoplasty
Blepharoplasty
Breast enhancements
Brow lift
Calf implants
Cheek/malar implants
Chin/nose implants
Chondrolaryngoplasty (Adam’s apple reduction)
Collagen injections
Drugs for hair loss or growth
Forehead lift
Hair removal
Hair transplantation
Lip reduction
Liposuction
Mastopexy
Neck tightening
Pectoral implants
Removal of redundant skin
Rhinoplasty

20979, E0760

Basic benefit and medical policy

Bone growth stimulation for fracture healing

The safety and effectiveness of low‑intensity ultrasound treatment for the treatment of specified fractures have been established. It’s useful therapeutic option for patients at high risk for delayed fracture healing or nonunion.

Inclusionary criteria have been updated, effective May 1, 2021.

Inclusions:

Low‑intensity ultrasound treatment may be considered established when used as an adjunct to conventional management (e.g., closed reduction and cast immobilization) for the treatment of fresh, closed fractures in skeletally mature individuals. A fracture is most commonly defined as “fresh” for 7 days after the fracture occurs. Candidates for ultrasound treatment are those at high risk for delayed fracture healing or nonunion. These risk factors may include either locations of fractures or patient comorbidities and include the following.

Patient comorbidities:

Diabetes
Steroid therapy
Osteoporosis
Autoimmune disease
Chemotherapy
History of alcoholism
History of smoking

Fracture locations:

Jones fracture (fracture in the meta‑diaphyseal junction of the fifth metatarsal of the foot)
Fracture of navicular bone in the wrist (also called the scaphoid)
Closed fractures of the distal radius (Colles fracture)
Closed or grade I open, tibial diaphyseal fractures
Fracture of metatarsal
Fractures associated with extensive soft tissue or vascular damage

Low‑intensity ultrasound treatment may be considered established when used as a treatment of delayed union of bones, excluding the skull and vertebra. Delayed union is defined as a decelerating healing process as determined by serial X‑rays, together with a lack of clinical and radiologic evidence of union, bony continuity, or bone reaction at the fracture site for no less than three months from the index injury or the most recent intervention.
Low‑intensity ultrasound treatment may be considered established for nonunions of the appendicular skeleton (non‑skull or vertebrae) if there has been no X‑ray evidence of progression of healing for three or more months despite appropriate fracture care, and all the following criteria are met:

Bone is noninfected
Bone is stable on both ends by means of cast or fixation
The two portions of the involved bone are separated by less than 1cm
Nonunion isn’t related to or secondary to malignancy

Exclusions:

Other applications of low‑intensity ultrasound treatment are experimental, including but not limited to, treatment of:

Congenital pseudarthroses
Open fractures
Fresh surgically treated closed fractures in patients who aren’t at high risk for delayed fracture healing or nonunion stress fractures
Stress fractures
Arthrodesis
Failed arthrodesis

21120, 21121, 21122, 21123, 21141, 21196, 21198, 21199, 21685, 42140, 42145, 64568, 0466T, 0467T, 0468T

Experimental/not covered: 41512, 41530, 42299,** S2080

**Used to report a not otherwise classified procedure

Basic benefit and medical policy

Surgical treatments for OSA

Certain surgical procedures have been established as safe and effective for the treatment of clinically significant obstructive sleep apnea, or OSA, when conservative therapies or CPAP have failed. The procedure selected should be based on the patient’s anatomy and the OSA etiology.

Hypoglossal nerve stimulation, using an FDA‑approved device, is considered established when criteria are met.

Hypoglossal nerve stimulation for those not meeting the inclusion criteria is considered experimental.

Implantable hypoglossal nerve stimulators that aren’t FDA‑approved are considered experimental.

Inclusionary criteria have been updated, effective May 1, 2021.

Inclusions:

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty) for the treatment of clinically significant** OSA syndrome in adult patients who haven’t responded to or don’t tolerate continuous positive airway pressure or failed an adequate trial of an oral appliance
Hyoid suspension, surgical modification of the tongue or maxillofacial surgery, including mandibular‑maxillary advancement, or MMA, in adult patients with clinically significant** OSA and objective documentation of hypopharyngeal obstruction who haven’t responded to or don’t tolerate CPAP or failed an adequate trial of an oral appliance
Adenotonsillectomy in pediatric patients with OSA, hypertrophic tonsils and one of the following:

AHI or RDI of at least five per hour
AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems or hyperactivity

**Clinically significant OSA is defined as patients who have one of the following:

AHI or RDI of 15 or more events per hour
AHI or RDI of at least five events per hour with one or more signs or symptoms associated with OSA (e.g., excessive daytime sleepiness, hypertension, cardiovascular heart disease, or stroke)

Hypoglossal nerve stimulation (must meet all the following):

Member is 22 years of age or older
AHI is ≥15 events per hour
Total number of central and mixed apneas are less than 25% of the total AHI
Member has a minimum of 30 days of CPAP documentation monitoring one of the following that:

Demonstrates CPAP failure (AHI ≥15 despite usage of four or more hours per night, five nights per week)
Demonstrates CPAP intolerance (usage is less than four hours per night, five nights per week)

Non‑concentric retropalatal obstruction on drug‑induced sleep endoscopy
Body mass index is less than 32 kg/m2; AND
The sleep study used for the AHI is performed within 24 months of the first consultation for the hypoglossal nerve stimulator

Adolescent or young‑adult member (must meet all the following):

Between the ages of 18 and 21
Moderate to severe OSA (15 ≤ AHI ≤ 65)
Non‑concentric retropalatal obstruction on drug‑induced sleep endoscopy
A contraindication to, or not effectively treated by, adenotonsillectomy
Has been confirmed to fail, or can’t tolerate, PAP therapy despite attempts to improve compliance**
Has followed standard of care in considering all other alternative/adjunct therapies

** PAP failure is defined as an inability to eliminate OSA (AHI of greater than 15 despite PAP usage), and PAP intolerance is defined as one of the following:

Inability to use PAP (greater than five nights per week of usage; usage defined as greater than four hours of use per night)
Unwillingness to use PAP (for example, a patient returns the PAP system after attempting to use it)

Adolescent or young‑adult member with Down syndrome (must meet all the following):

Member is 10 to 21 years of age
Member had a prior adenotonsillectomy:

AHI is greater than 10 and less than 50
Total number of central and mixed apneas are less than 25% of the total AHI following adenotonsillectomy

Member has one of the following:

A tracheostomy
Ineffective treatment with CPAP due to noncompliance, discomfort, undesirable side effects, persistent symptoms despite compliant use or refusal to use the device

BMI at the 95th percentile or lower for age
Non‑concentric retropalatal obstruction on drug‑induced sleep endoscopy

Exclusions:

Laser‑assisted palatoplasty, or LAUP
Midline glossectomy, or MLG
Palatal stiffening procedures (e.g., cautery‑assisted and injection snoreplasty)
Palatal implants
Radiofrequency volumetric tissue reduction, or RVTR, of the tongue
Radiofrequency reduction of the palatal tissues (i.e., Somnoplasty)
Tongue base suspension (e.g., Repose system)
All other minimally invasive surgical procedures not described above
All interventions for the treatment of snoring in the absence of documented OSA; snoring alone isn’t considered a medical condition

Exclusions for hypoglossal nerve stimulation:

Any anatomical finding that would compromise the performance of the device
Any condition or procedure that has compromised neurological control of the upper airway
Members who are unable or don’t have the necessary assistance to operate the sleep remote
Members who are pregnant or plan to become pregnant
Members who are known to require magnetic resonance imaging (doesn’t apply to a model that is MR compatible)
Members with an implantable device that may be susceptible to unintended interaction with the device
Hypoglossal nerve stimulation for those not meeting the inclusion criteria is considered experimental

31295, 31296, 31297, 31298

Basic benefit and medical policy

Balloon ostial dilation for treatment of chronic and recurrent rhinosinusitis

The safety and effectiveness of the use of a catheter‑based inflatable device (balloon ostial dilation) for the treatment of chronic and recurrent acute rhinosinusitis have been established. It may be considered a useful therapeutic option when indicated.

Inclusionary criteria have been updated, effective May 1, 2021.

Inclusions:

Chronic rhinosinusitis (all the following)

Documentation of chronic rhinosinusitis greater than three months
Documented failure of medical therapy greater than three months demonstrated by persistent upper respiratory symptoms despite treatment consisting of all the following:

Minimum of two different antibiotics
Trial of steroid nasal spray
Trial of antihistamine nasal spray and/or decongestant

Radiological evidence, in the sinus to be dilated, of at least one of the following:

Air fluid levels
Mucosal thickening
Opacification
Nasal polyposis

Recurrent acute rhinosinusitis (all the following):

Documentation of four or more episodes of acute rhinosinusitis in one year
Documented medical therapy for each episode consisting of all the following:

Antibiotic therapy, if suspected bacterial infection
Saline nasal irrigation
Trial of steroid nasal spray

Radiological evidence, in the sinus to be dilated, of at least one of the following:

Air fluid levels
Mucosal thickening
Opacification
Nasal polyposis

Exclusions:

Ciliary dysfunction
Cystic fibrosis
Sinonasal tumors or obstructive lesions
Severe/gross polypoid disease
Adolescent or child with incomplete bony development

Balloon sinus ostial dilation, used in the same sinus cavity, during endoscopic sinus surgery, or FESS, is considered integral to the primary FESS procedure and not separately reimbursable.

81220, 81221, 81222, 81223, 81224, 88299

Basic benefit and medical policy

Genetic testing for cystic fibrosis

The safety and effectiveness of genetic testing for cystic fibrosis have been established. Genetic testing may be considered a useful diagnostic tool when indicated and should be performed in conjunction with appropriate pre‑ and post‑test genetic counseling.

Inclusionary criteria have been updated, effective May 1, 2021.

Inclusions:

Individuals planning pregnancy who have a family history of CF and the reproductive partners of those with CF.
The prenatal population and those in the early stages of pregnancy when the test results will be used to make informed decisions regarding childbearing or a need for fetal diagnosis.
Individuals who have not undergone newborn screening, have an inconclusive sweat chloride test and there remains a suspicion of CF, when the results of the testing shall result in a definitive plan of patient management.
Diagnostic testing in male infertility due to congenital bilateral absence of the vas deferens and carrier testing of their partners.
Prenatal ultrasound findings that indicate an increased risk for CF (e.g., echogenic bowel or dilated loops of bowel)
Gene mutation testing in patients with cystic fibrosis when used to guide medication regimens per FDA‑approved indications

Genetic testing should be performed in conjunction with appropriate pre‑ and post‑test genetic counseling.

Exclusions:

Complete analysis of the CFTR gene by DNA sequencing isn’t appropriate for routine carrier screening.

81406

Basic benefit and medical policy

Genetic testing of CADASIL syndrome

The medical policy statement and inclusionary and exclusionary criteria have been updated, effecttive May 1, 2021, for genetic testing of CADASIL syndrome.

Medical policy statement:

Genetic testing of CADASIL syndrome is considered established in select patient populations who meet clinical criteria. This testing may be a useful diagnostic option when indicated.

Inclusions:

Genetic testing of NOTCH3 to confirm a diagnosis of CADASIL syndrome is considered established when clinical signs, symptoms, and imaging results, such as MRI, are suggestive of CADASIL syndrome.
Genetic testing of NOTCH3 of an asymptomatic individual who has a first‑ or second‑degree relative with CADASIL syndrome is established:

When there is a family member (first‑ or second‑degree) with a known variant, targeted genetic testing of the known NOTCH3 familial variant is considered established.
When the family member’s genetic status is unknown, genetic testing of NOTCH3 is considered established.

Note: First-degree relative: parent, full sibling, child
Second‑degree relative: grandparent, grandchild, aunt, uncle, nephew, niece, half‑sibling

Exclusions:

All other situations not addressed in the inclusions above are excluded.

Established
81406, 81307, 81308

Not covered
81408, 81479

Basic benefit and medical policy

Breast cancer gene variants

The medical policy statement for breast cancer gene variants has been updated, effective May 1, 2021.

Medical policy statement

The safety and effectiveness of testing for PALB2 variants for breast cancer risk assessment in adults have been established. It may be considered a useful diagnostic option when indicated.

Inclusions:

Testing for PALB2 variants for breast cancer risk assessment in adults who meet the criteria for genetic risk evaluation (BRCA testing).

Exclusions:

Testing for PALB2 sequence variants in individuals who don’t meet the criteria outlined above is considered experimental.
Testing for CHEK2 and ATM variants in the assessment of breast cancer risk is considered experimental.

81479,** 81525, 81599,** 84999,** 88299,** 0229U

**Codes that may be used to report unclassified service

Basic benefit and medical policy

Testing for prognosis of colon cancer

Gene expression assays for determining the prognosis of stage 2 or stage 3 colon cancer following surgery are considered experimental. The peer reviewed medical literature hasn’t yet shown that these tests have been scientifically demonstrated to improve patient clinical outcomes.

Circulating tumor DNA assays for determining the prognosis of stage 2 or 3 colon cancer following surgery are considered experimental, effective May 1, 2021.

90625

Basic benefit and medical policy

Vaxchora (cholera vaccine, live)

Effective Jan. 4, 2021, Vaxchora (cholera vaccine, live) is covered for the following FDA‑approved indications.

Vaxchora is a vaccine indicated for active immunization against disease caused by Vibrio cholerae serogroup O1. Vaxchora is approved for use in people ages 2 through 64 traveling to cholera‑affected areas.

Limitations of use:

The effectiveness of Vaxchora hasn’t been established in people living in cholera‑affected areas.

The effectiveness of Vaxchora hasn’t been established in people who have pre‑existing immunity due to previous exposure to V. cholerae or receipt of a cholera vaccine.

Vaxchora hasn’t been shown to protect against disease caused by V. cholerae serogroup O139 or other non‑O1 serogroups.

Dosage information:

For oral administration only.

Prepare and administer Vaxchora in a health care setting equipped to dispose of medical waste.

Prepare Vaxchora by reconstituting the buffer component in 100 milliliters of purified bottled or spring bottled water; for children younger than 6 years of age, discard half the reconstituted buffer solution, then add the active component (lyophilized V. cholerae CVD 103‑HgR). After preparation, a single dose of Vaxchora is 100 mL for people ages 6 through 64 or 50 mL for children younger than 6 years.

Instruct recipients to avoid eating or drinking for 60 minutes before and after oral ingestion of Vaxchora.
Administer Vaxchora a minimum of 10 days before potential exposure to cholera.

92273, 92274

Experimental: 0509T

Basic benefit and medical policy

Electroretinography procedures

The safety and effectiveness of full-field electroretinography, or ffERG, and multifocal electroretinography, or mfERG, have been established. They may be considered a useful diagnostic option for selected indications.

Pattern electroretinography, or pERG, is considered experimental for all indications. There is insufficient scientific evidence in the current medical literature to indicate that this technology is as beneficial as the established alternatives.

This policy is effective May 1, 2021.

Inclusions:

Full‑field electroretinography may be considered medically necessary when used to:

Detect loss of retina function.
Distinguish between retinal and optic nerve lesions.

Multifocal electroretinography may be considered medically necessary when used to detect chloroquine (Aralen^®) or hydroxychloroquine (Plaquenil^®) toxicity.

Note: See policy guidelines for more information regarding diagnosis of loss of retinal function or distinguishing between retinal lesions and optic nerve lesions.

Exclusions:

Any indications not listed above
Full‑field electroretinography, or ERG, multifocal ERG and pattern ERG used to evaluate, monitor or screen suspected or confirmed glaucoma
Pattern electroretinography for any indication

Policy guidelines:

Full‑field electroretinography, or ffERG

To diagnose loss of retinal function or distinguish between retinal lesions and optic nerve lesions:

Toxic retinopathies, including those caused by intraocular metallic foreign bodies and Vigabatrin

Achromatopsia
Assessment of retinal function after trauma, especially in vitreous hemorrhage, dense cataracts, and other conditions where the fundus can’t be visualized photoreceptors; absent b-wave indicates abnormality in the bipolar cell region
Autoimmune retinopathies such as cancer associated retinopathy, melanoma associated retinopathy and acute zonal occult outer retinopathy
Choroideremia
Cone dystrophy
Congenital stationary night blindness
Diabetic retinopathy
Disorders mimicking retinitis pigmentosa
Goldmann‑Favre syndrome
Gyrate atrophy of the retina and choroid
Ischemic retinopathies including central retinal vein occlusion, branch vein occlusion and sickle cell retinopathy
Leber's congenital amaurosis
Retinal detachment
Retinitis pigmentosa and related hereditary degenerations
Retinitis punctata albescens
Usher Syndrome
X‑linked juvenile retinoschisis

Multifocal electroretinography, or mfERG

To detect chloroquine (Aralen^®) and hydroxychloroquine (Plaquenil^®) toxicity per the American Academy of Ophthalmology guidelines

93292, 93745, E0617, K0606, K0607, K0608, K0609

Basic benefit and medical policy

Wearable cardioverter defibrillators

The wearable cardioverter defibrillator is considered a temporary therapy for patients with a high risk for sudden cardiac death. A wearable cardioverter defibrillator is considered established when medical criteria is met, effective May 1, 2021.

Inclusions:

The wearable cardioverter defibrillator for the prevention of sudden cardiac death is considered established when a patient meets one of the following conditions:

Patients who meet qualifications for implantation of an Implantable Cardioverter Defibrillator, or ICD, but because of the presence of a medical condition (e.g., localized skin/soft tissue infection at or near site of ICD implant, systemic infection), the implantation must be temporarily postponed

Patients who have an ICD that must be removed because of medical complication (e.g., infected ICD pocket, systemic infection), and must undergo a waiting period until the ICD can be replaced

Patients with familial or inherited conditions with a high risk of life‑threatening ventricular tachycardia such as Long QT syndrome or hypertrophic cardiomyopathy

Patients with a recent myocardial infarction or coronary revascularization with severely reduced left ventricular ejection fraction (LVEF <35%)

Patients with newly diagnosed nonischemic cardiomyopathy with LVEF<35%

Patients who meet FDA criteria for this device

Exclusions:

Wearable cardioverter defibrillators for all other indications

J0586

Basic benefit and medical policy

Dysport (abobotulinumtoxinA)

Dysport (abobotulinumtoxinA) is payable for the
following updated FDA‑approved indications:

The treatment of spasticity in patients age 2 and older

Spasticity in pediatric patients

Select dose based on the affected muscle, severity of spasticity, and treatment and adverse reaction history with all botulinum toxins.
Recommended dosing for upper limb spasticity: 8 units/kg to 16 units/kg per limb. The maximum recommended total dose administered per treatment session must not exceed 16 units/kg or 640 units, whichever is lower.
Recommended dosing for lower limb spasticity: 10 units/kg to 15 units/kg per limb. Total dose per treatment session must not exceed 15 units/kg for unilateral lower limb injections, 30 units/kg for bilateral injections, or 1,000 units, whichever is lower.
The maximum recommended total dose per treatment session is 30 units/kg or 1,000 units, whichever is lower. Re‑treatment, based on return of clinical symptoms, shouldn’t occur in intervals of less than three months.

J2357

Basic benefit and medical policy

Xolair (omalizumab)

Xolair (omalizumab) is payable for the following updated FDA‑approved indications:

Nasal polyps in adult patients ages 18 and older with inadequate response to nasal corticosteroids, as add‑on maintenance treatment

Dosing information:

Nasal polyps: Xolair 75 to 600 mg SC every two or four weeks. Determine dose (mg) and dosing frequency by serum total IgE level (IU/mL), measured before the start of treatment and body weight (kg).

J3262

Basic benefit and medical policy

Actemra (tocilizumab)

Effective Jan. 21, 2021, Actemra (tocilizumab) is covered for the following updated indications:

Adult‑onset Still’s disease

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

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

Classical Hodgkin lymphoma, or cHL

For the treatment of adult patients with relapsed or refractory cHL
For the treatment of pediatric patients with refractory cHL, or cHL that has relapsed after two or more lines of therapy
Triple‑negative breast cancer, or TNBC
In combination with chemotherapy, for the treatment of patients with locally recurrent unresectable or metastatic TNBC whose tumors express PD‑L1 [Combined Positive Score (CPS) ≥10] as determined by an FDA-approved test.

Dosing information:

cHL: 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
TNBC: 200 mg every three weeks or 400 mg every six weeks

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.