Billing chart: Blue Cross highlights medical, benefit policy changes

86341,** 86337

Basic benefit and medical policy

Islet cell autoantibody testing

Islet cell autoantibody testing is considered established when used for medical management of a patient with diabetes when criteria is met, effective March 1, 2021.

Islet cell autoantibody testing for any other indication, such as predicting the onset of diabetes, is considered experimental as the clinical utility hasn’t been established.

Payment policy:

Modifiers 26 and TC don’t apply to these procedures.

Inclusions:

Islet cell autoantibody testing is considered established when it is used to distinguish Type 1 diabetes from Type 2 diabetes in a patient whose clinical history is ambiguous and there is suspicion of one of the following:

• Latent autoimmune diabetes in adults, known as LADA
• Idiopathic (atypical, ketosis-prone) diabetes

Exclusions:

Islet cell autoantibody testing for any indication other than above (such as predicting the onset of diabetes) is considered experimental as the clinical utility hasn’t been established.

19318

Basic benefit and medical policy

Breast reduction for breast-related symptoms

The medical policy statement has been updated, effective Sept. 1, 2021, for breast reduction for breast-related symptoms.

The safety and effectiveness of breast reduction have been established. It may be considered a useful therapeutic option (and not considered cosmetic) when one of the following is met:

• Patient selection guidelines in this policy are met
• Performed in conjunction with medically necessary breast reconstruction for the purposes of attaining breast symmetry**
• Performed for gender affirming surgery in biological female-to-male transitions**

Refer to the medical policy “Reconstructive Breast Surgery-Management of Implants” or “Transgender Services” for guidelines.

Inclusions:

Note: Patients under the age of 18 years can’t give legal consent for surgery. The parent or legal guardian must support and authorize a reduction mammaplasty (breast reduction).

Emancipated minors may be extended individual consideration.

Must meet A or must meet both B and C

1. Must meet both 1 and 2:
1. Patient’s breasts are fully grown (i.e., breast size stable for approximately one year)
2. Removal of more than 500 grams of tissue from each breast

Must meet both B and C:

2. One of the following – 1, 2 or 3 – must be met:
1. Pain (must meet both a and b)
1. Documented pain in the neck and/or shoulders or postural backache which must be of long-standing duration
2. Failure of conservative therapy (e.g., an appropriate support bra, exercises, heat/cold treatments, non-steroidal anti-inflammatory agents or muscle relaxants)
2. Shoulder grooving
3. Recurrent intertrigo between the breasts and the chest wall

3. Both of the following criteria must be met:
1. Patient’s breasts are fully grown (i.e., breast size stable for approximately one year)
2. The amount of tissue to be removed from each breast must be greater than or equal to the 22nd percentile on the Schnur Scale.**

**If one breast meets the tissue amount based on the Schnur Scale, (even if the other breast doesn’t) this criterion is met.

If one breast meets the Schnur scale criteria and all other criteria for breast reduction are met, breast tissue may be removed from the other breast in order to achieve symmetry.

The Schnur Sliding Scale (see below) is used by physicians to evaluate individuals being considered for breast reduction surgery.

Body surface area, along with average weight of breast tissue removed, is incorporated into the chart. If the individual's body surface area and weight of breast tissue removed fall below the 22nd percentile, then the surgery is not medically necessary. If the individual's body surface area and weight of breast tissue removed is above the 22nd percentile, then the surgery is considered medically necessary if other applicable criteria are met.

Calculation of body surface area:
 
Body surface area = the square root of height (cm) times weight (kg) divided by 3,600.

To convert pounds to kilograms, multiply pounds by 0.45.
To convert inches to meters, multiply inches by .0254.        
To calculate body surface area, go to www-users.
med.cornell.edu/~spon/picu/calc/bsacalc.htm.***

Exclusions:

Breast reduction isn’t covered for either of the following indications because it’s considered cosmetic in nature and not medically necessary:

• Surgery is being performed to treat psychological symptomatology or psychosocial complaints, in the absence of significant physical, objective signs.
• Surgery is being performed for the sole purpose of improving appearance.

***Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Established – autologous transplant:
38206, 38207, 38210, 38211, 38212, 38213, 38214, 38215, 38232, 38241, S2150

Not established – allogeneic, per medical policy:
38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38230, 38240, 38242, 38243, 81267, 81268, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813, 86816, 86817, 86821, S2140, S2142, S2150

Basic benefit and medical policy

BMT- HCT for central nervous system embryonal tumors and ependymoma

The medical policy statement, and inclusionary and exclusionary criteria have been updated for BMT- HCT for central nervous system, or CNS, embryonal tumors and ependymoma, effective Sept. 1, 2021.

Medical policy statement:

Embryonal tumors of the CNS
The safety and effectiveness of specified autologous hematopoietic cell transplants for embryonal tumors of the central nervous system have been established. It may be considered a useful therapeutic tool when indicated for patients who meet established patient selection guidelines.

Ependymoma
Autologous, tandem autologous and allogeneic hematopoietic cell transplants are experimental for the treatment of ependymoma. They haven’t been scientifically demonstrated to improve patient clinical outcomes better than conventional treatment.

Triple tandem transplant
The effectiveness and clinical utility of an autologous triple tandem stem cell transplant have been established. It’s a useful therapeutic option for patients with pediatric CNS tumors who meet specific selection criteria.

Inclusions and exclusions:

Embryonal tumors and choroid plexus tumors of the CNS

Inclusions:

• Autologous hematopoietic cell transplantation for previously untreated embryonal tumors of the CNS that show partial or complete response to induction chemotherapy or stable disease after induction therapy
• Autologous hematopoietic cell transplantation for the treatment of recurrent embryonal tumors of the CNS
• Triple tandem autologous hematopoietic cell transplant for the treatment of embryonal or choroid plexus tumors when both of the following are met:
• Procedure may lead to reduced toxicities or less risk to future neurocognition
• Other established treatments, such as single autologous transplant, have been deemed too risky

Exclusions:

• Allogeneic hematopoietic cell transplantation for the treatment of embryonal or choroid plexus tumors of the CNS

Ependymoma

Inclusions:
N/A

Exclusions:

• Autologous, tandem autologous and tandem allogeneic hematopoietic cell transplants are experimental for the treatment of ependymoma.

Established:
81210, 81235, 81275, 81276, 81404, 81405, 81406, 81445, 81455, 81479

Not covered:
0179U, 0239U, 0242U

Basic benefit and medical policy

Circulating tumor DNA for management of non-small-cell-lung-cancer

The medical policy statement for circulating tumor DNA for management of non-small-cell-lung-cancer has been updated, effective Sept. 1, 2021.

Medical policy statement

The effectiveness and clinical utility of circulating tumor DNA of individual genes and listed multiple gene panels when more than five genes are tested for the management of non-small-cell lung cancer (liquid biopsy) have been established. It may be considered a useful therapeutic option when indicated.

Inclusions:

Analyzing cell-free/circulating tumor DNA (ctDNA) alterations in the ALK, EGFR, BRAF V600E, KRAS, ROS1, NTRK, MET exon14 skipping and RET gene when all the following apply:

• Advanced stage III or IV non-small-cell lung cancer
• Clinical circumstances reflect one of the following:
• Patient is medically unfit for invasive tissue sampling
• Following pathologic confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis 
• Follow-up tissue-based analysis is planned for all patients in which an oncogenic driver isn’t identified
• Used to detect ctDNA for targeted therapy benefit or to identify patients who will not benefit from further molecular testing

Exclusions:

• Use of circulating tumor DNA (ctDNA) for any indications not mentioned above

81595        

Experimental/not covered:
0055U, 0118U, 83006, 81479,** 84999**

Basic benefit and medical policy

Post-transplant kidney and heart, and heart failure lab testing

The safety and effectiveness of peripheral blood gene expression profiling (AlloMap™) for the detection of heart transplant rejection have been established. It may be considered a useful therapeutic option when specified criteria have been met.

The measurement of volatile organic compounds (e.g., breath test/Heartsbreath™) for the evaluation of heart transplant rejection is considered experimental. The effectiveness and clinical utility of this test hasn’t been clearly established.

The use of Presage ST2^® Assay in patients diagnosed with chronic heart failure (1) to evaluate the prognosis, (2) to guide management (e.g., pharmacologic, device-based, exercise), or (3) in the post cardiac transplantation period, including, but not limited to, predicting prognosis and predicting acute cellular rejection is considered experimental.

The use of peripheral blood measurement of donor-derived cell-free DNA (e.g., AlloSure™, myTAIHEART^®, Prospera^®, Viracor TRAC^®) in the management of patients after transplantation (renal or cardiac) to predict (1) prognosis, (2) acute cellular rejection or (3) graft dysfunction, is considered experimental. The effectiveness and clinical utility of this test have not been clearly established.

Exclusionary criteria have been updated, effective Sept. 1. 2021.

Inclusions:

Peripheral blood gene expression profiling (AlloMap) may be appropriate as a screening technique for heart transplant rejection in recipients who meet all the following:

• At least 15 years old
• 6 months post-heart transplant and

Recipient must have stable heart allograft function demonstrated by all the following:

• Left ventricular ejection fraction ≥ 45% which has been confirmed by echocardiogram
• No evidence of CHF
• No evidence of severe cardiac allograft vasculopathy and

Recipient must have a low probability of moderate or severe acute cellular rejection as demonstrated by all the following:

• Clinical assessment (e.g., International Society for Heart and Lung Transplantation rejection status Grade of 0R or 1R)
• No history or evidence of antibody mediated rejection

Exclusions:

• Gene expression profiling (e.g., AlloMap) for any indication not listed above
• Measurement of volatile organic compounds (e.g., breath test/Heartsbreath™)
• Presage ST2 Assay in patients diagnosed with chronic heart failure
• Peripheral blood measurement of donor-derived cell-free DNA (e.g. AlloSure, myTAIHEART, Prospera, Viracor TRAC^®) to detect acute renal or cardiac transplant rejection, renal or cardiac transplant graft dysfunction

96900, 96910, 96912, 96913, 96999, E0691, E0692, E0693, E0694

Basic benefit and medical policy

Light and laser therapy for vitiligo and atopic dermatitis

The medical policy statement and the inclusionary and exclusionary criteria have been updated for light and laser therapy for vitiligo and atopic dermatitis, effective Sept. 1, 2021.

Medical policy statement:

Psoralen plus ultraviolet A, known as PUVA, narrowband ultraviolet B, known as NB-UVB, and targeted phototherapy with excimer laser, with or without the use of oral or topical medications for the treatment of vitiligo are considered established treatments. They may be useful therapeutic options when indicated.

Phototherapy and photochemotherapy (i.e., ultraviolet A, known as UVA, UVB and PUVA) are considered established treatments with severe cases of atopic dermatitis, contact dermatitis and other eczema when criteria are met.

Home ultraviolet B light therapy is considered established for any one of the following diagnoses:

• Atopic dermatitis, when topical treatment alone has failed
• Pityriasis lichenoides
• Pruritus of hepatic disease
• Pruritus of renal failure
• Psoriasis, when topical treatment alone has failed
• Cutaneous T-cell lymphoma including mycosis fungoides and Sézary syndrome

Inclusions:

PUVA, NB-UVB and targeted phototherapy with excimer laser, with or without the use of oral or topical medications for the treatment of vitiligo, are considered established treatments for the following:

• Vitiligo that isn’t responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations).
• NB-UVB and excimer laser phototherapy in individuals ≥ 3 years of age.
• Topical PUVA can be performed in children ≥ 2 years of age when up to 20% of their body surface area is affected.
• Systemic PUVA or oral PUVA is restricted to children > 12 years who have widespread vitiligo ( ≥ 20% body surface area).
• Treatment of vitiligo is restricted to the face, neck, trunk and extremities.

Phototherapy and photochemotherapy (i.e., UVA, UVB and PUVA) are considered established treatments with severe cases of atopic dermatitis, contact dermatitis and other eczema when criteria are met:

• PUVA and NB-UVB for severe atopic dermatitis, contact dermatitis or eczema not responding to first-line therapy

Home ultraviolet light booth UVB phototherapy is considered established when conditions A and B are met:

1. The treatment is for one of the following conditions:
1. Atopic dermatitis when topical treatment alone has failed
2. Pityriasis lichenoides
3. Pruritus of hepatic disease
4. Pruritus of renal failure
5. Psoriasis, when topical treatment alone has failed
6. Cutaneous T-cell lymphoma including mycosis fungoides and Sézary syndrome

2. The treatment meets all the following criteria:
1. Treatment is conducted under a physician’s supervision with regularly scheduled exams
2. Treatment is expected to be long term (three months or longer)
3. The individual meets any of the following:
1. The individual is unable to attend office-based therapy due to a serious medical or physical condition (for example, confined to the home, leaving home requires special services or involves unreasonable risk).
2. Office based therapy has failed to control the disease and it’s likely that home-based therapy will be successful.
3. The individual suffers from severe psoriasis with a history of frequent flares that require immediate treatment to control the disease.

Exclusions:

• Systemic PUVA or oral PUVA is contraindicated in children < 12 years of age.
• Treatment of vitiligo of the acral areas (fingers, palms, soles of feet).
• Laser treatment for atopic dermatitis, contact dermatitis or other eczema.
• An in-home UVB light therapy device for all other conditions not mentioned above including, but not limited to, vitiligo, and when the criteria above are not met.
• UVA home therapy devices are not appropriate for home therapy. UVA therapy requires the use of photosensitizers, that should only be used under controlled conditions and under the supervision of a physician.

J2796

Basic benefit and medical policy

Nplate (romiplostim)

Effective Jan. 28, 2021, Nplate (romiplostim) is covered for the following updated FDA-approved indications:

• Nplate is indicated to increase survival in adults and in pediatric patients, including term neonates, acutely exposed to myelosuppressive doses of radiation (hematopoietic syndrome of acute radiation syndrome, or HSARS).

Dosing information:

• Patients with immune thrombocytopenia, or ITP
• Recommended initial dose: 1 mcg/kg once weekly as a subcutaneous injection. Adjust dose based on platelet response.

• Patients acutely exposed to myelosuppressive doses of radiation
• Recommended dose: 10 mcg/kg administered once as a subcutaneous injection. Administer the dose as soon as possible after suspected or confirmed exposure to myelosuppressive doses of radiation.

Dosage forms and strengths: 

For injection: 125 mcg, 250 mcg or 500 mcg of deliverable Nplate as a sterile, lyophilized, solid white powder in single-dose vials.

J9999

Basic benefit and medical policy

Rybrevant (amivantamab-vmjw)

Rybrevant (amivantamab-vmjw) is a bispecific EGF receptor-directed and MET receptor directed antibody indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer, or NSCLC, with epidermal growth factor receptor exon 20 insertion mutations, as detected by an FDA-approved test, whose disease has progressed on or after platinum-based chemotherapy.

Dosage and administration:

• The recommended dosage of Rybrevant is based onbaseline body weight and administered as anintravenous infusion after dilution.
• Administer premedications as recommended.
• Administer via a peripheral line on Week 1 and Week 2.
• Administer Rybrevant weekly for four weeks, with theinitial dose as a split infusion in Week 1 on Day 1 andDay 2, then administer every two weeks thereafter.
• Administer diluted Rybrevant intravenously accordingto the infusion rates in table below.

Dosage forms and strengths:

Injection: 350 mg/7 mL (50 mg/mL) solution in a single-dose vial

Basic benefit and medical policy

Private-duty nursing

Private-duty nursing may be considered established when specified criteria are met (refer to inclusionary and exclusionary guidelines).

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

Basic benefit policy group variations:

Refer to member benefits

Payment policy:

Private duty nursing is a pay-subscriber service

Inclusions:

• The member must have a need for skilled nursing care as identified in InterQual Skilled Nursing Criteria. The BCBSM Modifications of Skilled Nursing found on web-DENIS apply to private duty nursing. The services are for the skilled needs of the member and not the family or caregiver or solely for respite purposes. Custodial care doesn’t qualify for private duty nursing. The services are to be provided in the member’s home. Under unusual and special circumstances, private-duty nursing may be performed in a hospital.
• The member must have a medically complex and or medically fragile condition that requires continuous assessments, observation and monitoring for 24 hours a day. Skilled nursing services need not be provided for 24 hours to meet this criterion. The need for such services is required to meet this criterion. The patient must be medically stable such that private-duty nursing services can be provided safely. The member’s need for skilled nursing exceeds that found in the Home Health Care benefit.
• At least eight hours of private duty-nursing per day are required to meet the needs of the patient. During transition from inpatient to home care up to16 hours per day of private-duty nursing may be required.
• At least two trained caregivers (family, friend, etc.) must be trained and competent to give care when the nurse isn’t in attendance.
• The family or caregivers must provide at least eight hours of skilled care per day.
• The private duty nursing services must be ordered by a physician (M.D. or D.O.) who is involved in the ongoing care of the patient.

Specific clinical criteria (all must be met):

• Continuous assessment, observation and monitoring of a complex and fragile clinical condition. Hourly documentation of the clinical information and services performed is required.
• Training and teaching activities by the skilled nurse to teach the patient, family or caregivers how to manage the treatment regimen is required and considered a skilled nursing service. Training is no longer appropriate if, after a reasonable period of time, the member, family or caregiver won’t or isn’t able to be trained.
• Criteria and documentation requirements for specific conditions, if present, in addition to the medically complex and or fragile condition of the patient:
• Tracheostomy tube suctioning is necessary for secretion control and required at least twice per eight-hour shift. (Tracheostomy tube changing is skilled; tracheostomy hygiene care isn’t.)
• Ventilator management recording initial settings of mode of ventilation, tidal volume, respiratory rate and wave form modifications, if any, PEEP, and FIO2 at the beginning of the shift. Oxygen saturation must be measured continuously for ventilator patients and any changes from baseline recorded thereafter. Hourly observations of the patient’s clinical condition related to the ventilator management must be documented along with any changes in oxygen saturation.
• Management of tube drainage, complex wounds, cavities and irrigations require documentation of services on the record when they occur.
• Complex medication administration (excluding PO medications that would ordinarily be taken by self-administration) of drugs with potential for serious side effects or drug interactions require documentation and appropriate monitoring. This includes intravenous administration of drugs or nutrition.
• Tube feedings that require frequent changes in formulation or administration rate or have conditions that increase the aspiration risk requires documentation.