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

0356T

Other covered procedures:

67027, 67028, J1096, J7311, J7312, J7313, J7314

Basic benefit and medical policy

Intravitreal and punctum corticosteroid implants

The safety and effectiveness of punctum dexamethasone inserts and dexamethasone intravitreal and fluocinolone acetonide intravitreal implants have been established. They may be considered a useful therapeutic option when indicated.

All other uses of intravitreal implants are considered experimental.

Some inclusions and exclusions have been added to the policy, effective Jan. 1, 2021. Procedure code 0356T will be payable for insertion of Dextenza^®, an FDA‑approved medication for members meeting selection criteria.

Payment policy:

Modifiers 26 and TC don’t apply to this procedure.

Inclusions:

Fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) for the treatment of:

Chronic non‑infectious intermediate, posterior uveitis or panuveitisa.

Fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq) for the treatment of:

Chronic non‑infectious uveitis affecting the posterior segment of the eye^a.

Fluocinolone acetonide intravitreal implant 0.19 mg (IIuvien™) for the treatment of:

Diabetic macular edema in patients who have been previously treated with a course of corticosteroids and didn’t have a clinically significant rise in intraocular pressure

Dexamethasone intravitreal implant 0.7 mg (Ozurdex^®) for the treatment of any of the following:

Non‑infectious ocular inflammation, or uveitis, affecting the intermediate or posterior segment of the eyea
Macular edema following branch or central retinal vein occlusion
Diabetic macular edema

Dexamethasone punctum insert (Dextenza^® 0.4 mg) for the treatment of inflammation and pain following ophthalmic surgery.

^a Refer to Exclusions for use as prophylactic when undergoing cataract surgery.

Exclusions:

A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) or 0.19 mg (Iluvien^®) or dexamethasone intravitreal implant 0.7 mg (Ozurdex™) is considered investigational for the treatment of:

Birdshot retinochoroidopathy
Cystoid macular edema related to retinitis pigmentosa
Idiopathic macular telangiectasia type 1
Postoperative macular edema
Circumscribed choroidal hemangiomas
Proliferative vitreoretinopathy
Radiation retinopathy
Prophylaxis of cystoid macular edema in patients who meet both of the following:

Non‑infectious intermediate uveitis or posterior uveitis
Cataract undergoing cataract surgery^b

All other uses of a corticosteroid intravitreal implant or punctum insert.

^b Refer to Inclusions for use in the absence of cataract surgery.

Established
43647,43648, 43881, 43882, 64590
64595, 95980, 95981, 95982

Experimental

43659, 43999

Basic benefit and medical policy

Gastric electrical stimulation

The listed established procedures were made payable for the Gastric Electrical Stimulation policy. The policy effective date is Nov.1, 2020.

Medical policy statement:

Gastric electrical stimulation for the treatment of gastroparesis is established for individuals who meet specified criteria.

Gastric pacing for the treatment of obesity is experimental. The safety and effectiveness of this procedure hasn’t been established.

Inclusions:

Gastric electrical stimulation for the treatment of gastroparesis may be considered medically necessary with the use of an FDA‑approved device (e.g., Enterra™) when all the following criteria have been met:

Gastroparesis of diabetic or idiopathic etiology
Refractory to medical management or medical management is contraindicated

Includes dietary modification or both antiemetics (anti‑nausea/vomiting) and prokinetics (anti‑reflux)

Exclusions:

When above criteria aren’t met
As an initial treatment for gastroparesis
For the treatment of obesity

Payable diagnoses are E10.43, E11.43 and K31.84.

UPDATES TO PAYABLE PROCEDURES

J3490

J3590

Basic benefit and medical policy

Danyelza (naxitamab‑gqgk)

Effective Nov. 25, 2020, Danyelza (naxitamab‑gqgk) is payable for its FDA‑approved indications when billed with procedure code J3490 or J3590. Danyelza (naxitamab‑gqgk) 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.

Danyelza (naxitamab‑gqgk) is a GD2‑binding monoclonal antibody indicated, in combination with granulocyte‑macrophage colony‑stimulating factor, or GMCSF, for the treatment of pediatric patients 1 year of age and older, and adult patients with relapsed or refractory high‑risk neuroblastoma in the bone or bone marrow who have demonstrated a partial response, minor response or stable disease to prior therapy.

Dosage and administration:

The recommended dosage of Danyelza is 3 mg/kg per day (up to 150 mg per day), administered as an intravenous infusion after dilution on days 1, 3 and 5 of each treatment cycle. Treatment cycles are repeated every four weeks until complete response or partial response, followed by five additional cycles every four weeks. Subsequent cycles may be repeated every eight weeks.

Dosage forms and strengths:

Injection: 40 mg/10 mL (4 mg/mL) in a single‑dose vial.

J3490

J3590

Basic benefit and medical policy

Sesquient (fosphenytoin)

Sesquient (fosphenytoin) is payable for the FDA‑approved indications when billed with procedure code J3490 or J3590, effective Nov. 5, 2020. Sesquient (fosphenytoin) 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.

Sesquient (fosphenytoin) is indicated for the following:

For the treatment of generalized tonic‑clonic status epilepticus in adult patients
Prevention and treatment of seizures occurring during neurosurgery in adult patients
For short-term substitution for oral phenytoin in age patients 2 and older. Sesquient should be used only when oral phenytoin administration isn’t possible.

Dosage and administration:

The dose, concentration and infusion rate of Sesquient should always be expressed as phenytoin sodium equivalents, or PE

For status epilepticus in adults:

Loading dose is 15 mg PE/kg to 20 mg PE/kg at a rate of 100 mg PE/min to 150 mg PE/min

For non-emergent loading and maintenance dosing:

Adult loading dose is 10 mg PE/kg to 20 mg PE/kg given intravenously; initial maintenance dose is 4 mg PE/kg to 6 mg PE/kg/day in divided doses
Pediatric loading dose is 10 mg PE/kg to 15 mg PE/kg given intravenously; initial maintenance dose is 2 mg PE/kg to 4 mg PE/kg every 12 hours. Because of the betadex sulfobutyl ether sodium ingredient in Sesquient, administration rate in pediatric patients shouldn’t exceed 0.4 mg PE/kg/min. The rate of administration of intravenous Sesquient in pediatric patients differs from that of other intravenous fosphenytoin products.

Dosage forms and strengths:

50 mg phenytoin sodium equivalents (PE)/mL available as:

500 mg PE per 10 mL (50 mg PE/mL) in single‑dose vials
100 mg PE per 2 mL (50 mg PE/mL) in single‑dose vials

POLICY CLARIFICATIONS

J1190

Basic benefit and medical policy

Totect (dexrazoxane)

Effective Nov. 2, 2020, Totect (dexrazoxane) is covered for the following FDA‑approved indications:

Totect is a cytoprotective agent indicated for:

Reducing the incidence and severity of cardiomyopathy associated with doxorubicin administration in women with metastatic breast cancer who have received a cumulative doxorubicin dose of 300 mg/m² and who will continue to receive doxorubicin therapy to maintain tumor control.

Dosage information:

Reconstitute and further dilute Totect before use.
Extravasation: Administer Totect by intravenous infusion over one to two hours once daily for three consecutive days.
Initiate the first infusion as soon as possible and within the first six hours after extravasation.

Recommended dose — Day 1: 1,000 mg/m²
Maximum daily dose — 2,000 mg

Recommended dose — Day 2: 1,000 mg/m²
Maximum daily dose — 2,000 mg

Recommended dose — Day 3: 500 mg/m²
Maximum daily dose — 1,000 mg

Cardiomyopathy: Administer Totect by intravenous infusion over 15 minutes until discontinuation of doxorubicin.
Don’t administer via intravenous push.
The recommended dosage ratio of Totect to doxorubicin is 10:1, (e.g., 500 mg/m² Totect to 50 mg/m² doxorubicin).
Don’t administer doxorubicin before Totect.
Administer doxorubicin within 30 minutes after the completion of Totect infusion.
Dose modifications: Reduce dose by 50% for patients with creatinine clearance < 40 mL/min.

J3490

J3590

Basic benefit and medical policy

Ebanga (ansuvimab‑zykl)

Effective Dec. 21, 2020, Ebanga (ansuvimab‑zykl) is covered for the following FDA‑approved indications:

Ebanga (ansuvimab‑zykl) is a Zaire ebolavirus glycoprotein, or EBOVGP‑directed human monoclonal antibody indicated for the treatment of infection caused by Zaire ebolavirus in adult and pediatric patients, including neonates born to a mother who is RT‑PCR positive for Zaire ebolavirus infection.

Limitation of use:

The efficacy of Ebanga hasn’t been established for other species of the Ebolavirus and Marburgvirus genera.
Zaire ebolavirus can change over time, and factors such as emergence of resistance or changes in viral virulence could diminish the clinical benefit of antiviral drugs. Consider available information on drug susceptibility patterns for circulating Zaire ebolavirus strains when deciding whether to use Ebanga.

Dosage and administration:

The recommended dose of Ebanga for adult and pediatric patients is 50 mg/kg reconstituted, further diluted and administered as a single intravenous infusion over 60 minutes.

Dosage forms and strengths:

For injection: 400 mg lyophilized powder in a single-dose vial for reconstitution and further dilution

This drug isn’t a benefit for URMBT.

J3490

J3590

Basic benefit and medical policy

Oxlumo (lumasiran)

Effective Nov. 23, 2020, Oxlumo (lumasiran) is covered for the following FDA‑approved indications:

Oxlumo is a HAO1‑directed small interfering ribonucleic acid, or siRNA, indicated for the treatment of primary hyperoxaluria type 1, or PH1, to lower urinary oxalate levels in pediatric and adult patients.

Dosage information:

Body weight less than 10 kg

Loading dose ‑ 6 mg/kg once monthly for three doses
Maintenance dose (begin one month after the last loading dose) ‑ 3 mg/kg once monthly

Body weight 10 kg to less than 20 kg

Loading dose ‑ 6 mg/kg once monthly for three doses
Maintenance dose (begin one month after the last loading dose) ‑ 6 mg/kg once every three months (quarterly)

Body weight 20 kg and above

Loading dose ‑ 3 mg/kg once monthly for three doses
Maintenance dose (begin one month after the last loading dose) ‑ 3 mg/kg once every three months (quarterly)

Dosage forms and strengths:

Injection: 94.5 mg/0.5 mL in a single‑dose vial.

This drug isn’t a benefit for URMBT.

J9022

Basic benefit and medical policy

Tecentriq (atezolizumab)

Tecentriq (atezolizumab) is indicated for the following updated FDA‑approved indications:

Melanoma

In combination with cobimetinib and vemurafenib for the treatment of patients with BRAF V600 mutation‑positive unresectable or metastatic melanoma

Dosing Information:

Injection: 840 mg/14 mL (60 mg/mL) and 1,200 mg/20 mL (60 mg/mL) solution in a single‑dose vial

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, or UC, that hasn’t progressed with first‑line platinum‑containing chemotherapy.

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