Billing chart: Blue Cross highlights medical, benefit policy changes

99091, 99453, 99454, 99457, 99458

Basic benefit and medical policy

Remote patient monitoring

The use of remote patient monitoring, or RPM, to collect physiological or psychological data in the medical management of patients is considered established when criteria are met, effective Jan. 1. 2021.

Payment policy:

RPM isn’t payable in an inpatient facility.

RPM (after the first 90 days) is billed with modifier KX (the provider attests that requirements specified in the medical policy have been met).

Note: Denied claims may be resubmitted back to the retroactive effective date.

Benefit policy:

Cost share associated with an office visit applies to procedure codes *99091, *99453 and *99457, based on the group’s benefit plan design.

Inclusionary guidelines:

RPM isn’t intended to be an ongoing modality; it’s intended to be an intervention in response to a complication, decompensation or instability of a medical condition. It may be used during the stabilization period, while a patient returns to the baseline of their condition or establishes a new baseline. Once baseline is achieved, RPM is no longer an integral part of a plan of care.

When Blue Cross Blue Shield of Michigan has an existing medical policy that is specific to the technology or device being considered for RPM, that policy supersedes the information in this policy.

Inclusions:

RPM is approved when both of the following are met:

• A physician or qualified health care practitioner has determined that the patient’s condition:
• Is high-risk for decompensation or complication that may lead to hospitalization or another acute intervention, or
• Requires monitoring for a current or new treatment plan

• There is an order written by a physician or qualified health care practitioner that specifies the medical condition and the length of time for RPM, up to 90 days.

Policy guidelines:

RPM data

• Data may include common physiological parameters, such as heart rate, blood pressure, temperature, respiratory rate, weight, oxygen saturation, peak flow, blood glucose levels and well-being information, etc.

RPM device guidance

• The device used for data collection must be a medical device as defined by the FDA.
• The device is non-invasive and has the potential to be connected to a wireless network through Bluetooth, Wi-Fi or cellular connection.
• The device transmits a patient’s measurements directly to their health care provider or other monitoring entity.
• Some devices may have the potential to apply algorithms to the data, which result in notifications of parameters that are outside the ideal range for that patient.
• The device used must provide secure, HIPAA-compliant transmission of the data.
  Examples: devices may include wearable, hand-held, stationary in-home units and digital interfaces. A device may be a clinical electronic thermometer, electrocardiograph, cardiac monitor, pulse oximeter, non-invasive blood pressure monitor, etc.

Services included in RPM:

• Initial set-up and patient instruction on the monitoring device
• RPM for up to 90 days
• For RPM services beyond 90 days, all the following:
• There is a physician or qualified health care practitioner order for the continuation of RPM.
• The medical record contains documentation that:
• Supports the medical necessity for continued RPM, and
• Reflects that the results of the monitoring are being used in clinical decision-making and intervention, and
• RPM (after the first 90 days) is billed with modifier KX (the provider attests that requirements specified in the medical policy have been met).

Note: Complex patients with chronic conditions who are at high risk for intermittent exacerbations and poor long-term clinical outcomes may benefit from longer-term RPM within the context of a Provider-Delivered Case Management, Health Plan Administered Care Management Program or an approved provider organization or vendor-managed care management program. Participation may be determined on a case-by-case basis, subject to the judgment of the attending physician or qualified health care practitioner and care management program guidelines.

• RPM treatment management services, when in response to physiological parameters that require intervention
• Physician interpretation of the physiological data
• Remote patient monitoring should include daily monitoring or programmed alert transmissions
• Each 30-day billing cycle must include at least 16 days of monitoring
• RPM programs can be offered by health plans, hospital systems, medical specialty groups or clinical practices.
• Reimbursement for remote patient monitoring is driven by current Blue Cross Blue Shield of Michigan payment policy

Exclusions:

• RPM isn’t separately billable if performed during a 90-day global payment period (e.g., following surgery).

The RPM device itself (including any additional apps, software, digital interfaces, etc.) isn’t covered.

J3490

Basic benefit and medical policy

Jemperli (dostarlimab-gxly)

Jemperli (dostarlimab-gxly) is payable for its FDA-approved indications, effective April 22, 2021. Jemperli (dostarlimab-gxly) 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. 

Jemperli (dostarlimab-gxly) is a programmed death receptor-1 (PD-1)-blocking antibody indicated for the treatment of adult patients with mismatch repair deficient, or dMMR, recurrent or advanced endometrial cancer, as determined by an FDA-approved test, that has progressed on or following prior treatment with a platinum-containing regimen.

Dosage and administration:

Dose 1 through 4: 500 mg every three weeks.
Subsequent dosing beginning three weeks after Dose 4 (Dose 5 onwards): 1,000 mg every six weeks
Administer as an intravenous infusion over 30 minutes.

Dosage forms and strengths:

S0317

Basic benefit and medical policy

Pediatric feeding programs

The safety and effectiveness of pediatric feeding programs have been established. The multidisciplinary, integrated programs may be considered a useful therapeutic option when indicated. Criteria have been updated, effective May 1, 2021.

Basic benefit policy group variations

Payment policy:

Outpatient claims must be billed on a professional claim form.

Payable diagnoses: F50.82, F98.21, F98.29, R62.51 and R63.3

Inclusions:

Intensive outpatient day feeding programs may be considered established in children^a when all the following criteria have been met:

• Referral by qualified medical professional experienced in the care of children, after a thorough medical and nutritional evaluation has been completed to identify potentially treatable underlying conditions (endocrine disorders, thyroid disease, etc.)
• A pattern of significant malnutrition or failure-to-thrive exists that is thought to be related to inadequate dietary intake resulting from an abnormal relationship to food (aversion, swallowing dysregulation, etc.)
• Age appropriate growth charts or BMI tables may be used to document growth and weight gain^b.
• A three to four month trial of at least one traditional outpatient approach^c to improve dietary intake and growth has failed.

Intensive inpatient admission for pediatric intensive feeding program services may be considered established when facility-based care is required, and all the following criteria have been met:

• All the above (intensive outpatient day) criteria have been met
• Member is deemed medically unstable as evidence by one or more of the following:
• Bradycardia
• Congestive heart failure
• Dehydration (documented clinically and on labs)
• Electrolyte abnormalities
• Hypotension
• Hypothermia
• Other clinical circumstances where cardiac, pulmonary, hepatic, metabolic or renal status are at risk in the judgment of the attending physician

^aChildren are less than 18 years of age.

^bSpecial growth charts for selected genetic syndromes should be used when indicated (e.g., Down’s syndrome, Turner syndrome, etc.).

^cOutpatient traditional approaches may include but are not limited to parent/caregiver evaluation to determine if parenting dynamics may be impacting ability to eat or gain weight; gastrointestinal evaluation to rule out primary GI diagnosis or intestinal mechanical issues; calorie counts; home-based feeding strategies; behavioral evaluation to ascertain impacts on feeding; physical therapy or occupational evaluation to help assess developmental challenges that may impact feeding.

Exclusions:

• Patients who have mild to moderate feeding difficulties who continue to meet normal growth and developmental milestones
• Services provided by professionals within a pediatric feeding program shouldn’t be duplicated concurrently by providers outside of the feeding program. Such services are duplicative and not a covered benefit
• Maintenance programs

J3490

Basic benefit and medical policy

Abecma (idecabtagene vicleucel)

Effective March 26, 2021, Abecma (idecabtagene vicleucel) is covered for the following FDA-approved indications:

Abecma (idecabtagene vicleucel) is a B-cell maturation antigen, or BCMA, directed genetically modified autologous T-cell immunotherapy indicated for the treatment of adult patients with relapsed or refractory multiple myeloma after four or more prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor and an anti-CD38 monoclonal antibody.

Dosage and administration:
 

• For autologous use only; for intravenous use only.
• Don’t use a leukodepleting filter.
• Administer a lymphodepleting chemotherapy regimen of cyclophosphamide and fludarabine before infusion of Abecma.
• Confirm the patient’s identity before infusion.
• Premedicate with acetaminophen and an H1-antihistamine.
• Avoid prophylactic use of dexamethasone or other systemic corticosteroids.

Dosage forms and strengths:

• Abecma is a cell suspension for intravenous infusion.
• A single dose of Abecma contains a cell suspension of 300 to 460 x 10⁶ CAR-positive T cells in one or more infusion bags. 

Abecma (idecabtagene vicleucel) isn’t a benefit for URMBT.

J3490

Basic benefit and medical policy

Zynrelef (bupivacaine and meloxicam)

Effective May 12, 2021, Zynrelef (bupivacaine and meloxicam) is covered for the following FDA-approved indications:

Zynrelef contains bupivacaine, an amide local anesthetic, and meloxicam, a nonsteroidal anti-inflammatory drug, or NSAID, and is indicated in adults for soft tissue or periarticular instillation to produce postsurgical analgesia for up to 72 hours after bunionectomy, open inguinal herniorrhaphy and total knee arthroplasty.

Limitations of use:
 
Safety and efficacy haven’t been established in highly vascular surgeries, such as intrathoracic, large multilevel spinal, and head and neck procedures.

Dosing information:

• Zynrelef is intended for single-dose administration only.
• The toxic effects of local anesthetics are additive. Avoid additional use of local anesthetics within 96 hours following administration of Zynrelef.
• Zynrelef should only be prepared and administered with the components provided in the Zynrelef kit.
• Zynrelef is applied without a needle into the surgical site following final irrigation and suction and prior to suturing.
• The recommended doses of Zynrelef are as follows: 
• Bunionectomy: Up to 2.3 mL to deliver 60 mg./1.8 mg
• Open inguinal herniorrhaphy: Up to 10.5 mL to deliver 300 mg/9 mg
• Total knee arthroplasty: Up to 14 mL to deliver 400 mg/12 mg

Dosage forms and strengths:

Zynrelef (bupivacaine and meloxicam) extended-release solution is available in four dosage strengths as single-dose glass vials:

• 400 mg bupivacaine and 12 mg meloxicam
• 300 mg bupivacaine and 9 mg meloxicam
• 200 mg bupivacaine and 6 mg meloxicam
• 60 mg bupivacaine and 1.8 mg meloxicam

Zynrelef (bupivacaine and meloxicam) isn’t a benefit for URMBT.

J9153

Basic benefit and medical policy

Vyxeos (daunorubicin and cytarabine)

Effective March 30, 2021, Vyxeos (daunorubicin and cytarabine) is covered for the following FDA-approved indications:

Vyxeos is a liposomal combination of daunorubicin, an anthracycline topoisomerase inhibitor and cytarabine, a nucleoside metabolic inhibitor, that is indicated for the treatment of newly diagnosed therapy-related acute myeloid leukemia, known as t-AML, or AML with myelodysplasia-related changes, known as AML-MRC, in adults and pediatric patients 1 year and older.

Dosage information:

• Induction: Vyxeos (daunorubicin 44 mg/m2 and cytarabine 100 mg/m2) liposome via intravenous infusion over 90 minutes on days 1, 3, and 5 and on days 1 and 3 for subsequent cycles of induction, if needed.
• Consolidation: Vyxeos (daunorubicin 29 mg/m2 and cytarabine 65 mg/m2) liposome via intravenous infusion over 90 minutes on days 1 and 3.