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

Billing chart: Blue Cross highlights 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

POLICY CLARIFICATIONS

J0878

Basic benefit and medical policy

Daptomycin

Effective May 5, 2021, Daptomycin is covered for the following FDA-approved indications:

Daptomycin for injection is a lipopeptide antibacterial indicated for the treatment of:

Complicated skin and skin structure infections, or cSSSI, in adult and pediatric patients (ages 1 to 17)
Staphylococcus aureus bloodstream infections (bacteremia) in pediatric patients (ages 1 to 17).

Limitation of use:

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Daptomycin for injection and other antibacterial drugs, Daptomycin for injection should be used to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

J9317

Basic benefit and medical policy

Trodelvy (sacituzumab govitecan-hziy)

Effective April 7, 2021, Trodelvy (sacituzumab govitecan-hziy) is covered for the following updated FDA-approved indications:

Trodelvy is a Trop-2-directed antibody and topoisomerase inhibitor conjugate indicated for the treatment of adult patients with unresectable locally advanced or metastatic triple-negative breast cancer, known as mTNBC, who have received two or more prior systemic therapies, at least one of them for metastatic disease.

Patients with locally advanced or metastatic urothelial cancer, or mUC, who have previously received a platinum-containing chemotherapy and either programmed death receptor-1 (PD-1) or programmed death-ligand 1 (PDL1) inhibitor

This indication is approved under accelerated approval, based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

Dosage and administration:

The recommended dose for Trodelvy is 10 mg/kg once weekly on days 1 and 8 of continuous 21-day treatment cycles until disease progression or unacceptable toxicity.

Dosage forms and strengths:

For injection: 180 mg lyophilized powder in single-dose vials for reconstitution.

This change isn’t a benefit for URMBT.

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 copyright 2020 American Medical Association. All rights reserved. CPT^® is a registered trademark of the American Medical Association.