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April 2022

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:

  • Log in to web-DENIS.
  • 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

0003U, 0007U, 0016U, 0017U, 0022U, 0023U, 0026U, 0027U, 0034U, 0039U, 0040U, 0041U, 0042U, 0043U, 0044U, 0046U, 0047U, 0049U, 0064U, 0065U, 0068U, 0077U, 0093U, 0107U, 0111U, 0155U, 0177U, 0202U, 0223U, 0224U, 0226U, 0240U, 0241U

Experimental

0001U, 0002U, 0005U, 0008U, 0009U- 0014U, 0019U, 0021U, 0024U, 0025U, 0029U- 0033U, 0035U- 0038U, 0045U, 0048U, 0050U- 0056U, 0058U- 0063U, 0066U, 0067U, 0069U, 0070U- 0080U, 0082U, 0083U, 0084U, 0086U, 0087U- 0092U, 0094U-0097U, 0101U, 0102U, 0103U, 0105U, 0106U, 0108U, 0109U, 0110U, 0112U-0123U, 0129U-0138U, 0140U-0154U, 0156U-0167U, 0169U-0176U, 0178U-0201U, 0203U-0207U, 0209U-0222U, 0225U, 0227U-0239U, 0242U-0284U

Basic benefit and medical policy

Proprietary laboratory analyses codes

Proprietary laboratory analyses, or PLA, codes
are considered experimental until the laboratory test the code represents is formally documented as established.

Established CPT codes may be used to represent and reimburse testing for incremental codes or multi-target codes.

This policy is effective March 1, 2022.

27899,** 29999,** L8699,** 0707T

**Used to report a not otherwise classified service

Basic benefit and medical policy

Subchondroplasty

The Subchondroplasty®, or SCP®, procedure is considered experimental.

Evidence-based conclusions regarding safety, efficacy and the effect on net health outcomes has yet to be determined.

K1015

Basic benefit and medical policy

Orthotic devices

The safety and effectiveness of orthotics that are used to protect, restore, or improve all or part of an impaired body function, (e.g, braces, collars or supports) have been established.

An adjustable corrective foam foot brace with a rigid heel cup may be used on pediatric patients, effective Nov. 1, 2021. It’s used for the treatment of metatarsus adductus.

Payment policy:

Authorization requirements may apply. Claims processing may be handled by Northwood. Check member benefits for coverage details.

A maximum of two per lifetime applies (one right, one left).

Inclusions:

Guidelines are generally based on Medicare Part B and Blue Cross Blue Shield of Michigan and Blue Care Network certificate language. Specific certificate language may vary.

The orthotic device must:

  • Be prescribed by a qualified health care provider
  • Meet the Medicare/CMS definition of an orthotic (essentially, that it is a rigid or semi-rigid appliance, often referred to as a brace, used for the purpose of supporting or correcting a weak or deformed body part)

Orthotic devices may include, but are not limited to:

  • Splints for spine, neck and shoulders
  • Ankle-foot orthoses, or AFO, and knee-ankle-foot orthoses, or KAFO, for extremities
  • Shoes designed for attachment to medically appropriate leg braces**
  • Substitution of a somewhat different device required by change in medical condition, fit or function
  • Cervical spine orthosis
  • Cervical-thoracic-lumbar-sacral orthosis
  • Thoracic-lumbar-sacral orthosis, or TLSO
  • Lumbar orthosis
  • Lumbar-sacral orthosis, or LSO
  • Sacroiliac orthosis

While traveling: Orthotic devices are covered when the individual is traveling or staying at another location for a specified time period. Check individual contract/certificate language and any specific medical policy related to the item. Repair, replacement or adjustment is also covered as defined by the contract/certificate language and the applicable medical policy.

Exclusions:

Excluded orthotic devices and related services include, but are not limited to:

  • Arch supports or supportive devices for the feet
  • Dental appliances and bite splints
  • Investigational, experimental or research devices or appliances
  • Items excluded in individual certificates or riders
  • Orthopedic or corrective shoes (except when either one or both are an integral part of a leg brace)**
  • Orthotic devices used for participating in strenuous physical activity beyond normal activities of daily living
  • Repair and replacement made necessary because of loss or damage caused by misuse or mistreatment
  • Any item that is primarily made of elastic material, including, but not limited to:
    • Thoracic rib belt
    • Knee or kneecap orthosis, elastic, with or without stays or condylar pads, prefabricated
    • Ankle orthosis, elastic, prefabricated
    • Shoulder orthosis, elastic, prefabricated
    • Elbow orthosis, elastic, with or without stays, prefabricated
    • Wrist, hand or finger orthosis, elastic, prefabricated

**BCN only. For Blue Cross members, see BCBSM policy Orthopedic Footwear.

Specific riders may apply and override exclusions.
UPDATES TO PAYABLE PROCEDURES

0161

Basic benefit and medical policy

New revenue code

The National Uniform Billing Committee new revenue code 0161 will be accepted effective July 1, 2022.

Occurrence code 82

Basic benefit and medical policy

New occurrence code

The National Uniform Billing Committee approved new occurrence code 82, will be accepted effective July 1, 2022.
POLICY CLARIFICATIONS

1111F

Basic benefit and medical policy

Procedure code 1111F

Procedure code 1111F is changing from payable to non-payable non-payable for Blue Cross Blue Shield of Michigan commercial claims. This change is effective July 1, 2022.

Medicare Plus Blue℠ and BCN Advantage℠ will continue to separately reimburse for 1111F.

20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21073, 21085, 21116, 21240, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 70328, 70330, 70332, 70336, 70350, 70355, 70486, 70487, 70488, 97010, 97024

21089, 21299, E1399, J7321, J7323- J7326

Basic benefit and medical policy

Temporomandibular joint disorders

Certain tests, non-surgical and surgical procedures are considered safe and effective for the diagnosis and treatment of temporomandibular joint, or TMJ, disorders. They may be considered useful therapeutic options when indicated. This policy is effective Jan. 1, 2022.    

Basic benefit policy group variations:

Procedures described in this policy don’t change member benefits for TMJ disorder. Refer to current certificate of coverage.

Inclusions:

The following diagnostic procedures when used to diagnose temporomandibular joint dysfunction:

  • Diagnostic X-ray, tomograms and arthrograms
  • Medical grade CT scan or MRI (generally CT scans and MRIs are reserved for presurgical evaluations)
  • Cephalograms (X-rays of jaws and skull)
  • Pantograms (panoramic X-rays of maxilla and mandible)

The following non-surgical treatments for the treatment of TMJ dysfunction:

  • Intraoral removable prosthetic devices/appliances (encompassing fabrication, insertion, adjustment) of any and all devices/appliances constructed (excludes dental devices – see below)
  • Pharmacologic treatment (such as anti-inflammatory, muscle relaxing and analgesic medications)
  • Trigger-point therapy with anesthetic or corticosteroid for the treatment of myofascial pain syndrome are limited to no more than four injections in a 12-month period when all the following are met:
    • There is a regional pain complaint in the expected distribution of referral pain from a trigger point.
    • There is spot tenderness in a palpable taut band in a muscle.
    • There is restricted range of motion.
    • Conservative therapy (e.g., physical therapy, active exercises, ultrasound, heating or cooling, massage, activity modification or pharmacotherapy) doesn’t result in adequate symptom relief within two to three weeks, or isn’t feasible.
    • Trigger-point injections are provided as a component of a comprehensive therapy program

The following surgical procedures for the treatment of TMJ dysfunction:

  • Arthrocentesis, with or without ultrasound guidance
  • Manipulation for reduction or dislocation of the TMJ
  • Arthroscopic surgery in patients who objectively demonstrate (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease and who have failed conservative treatment
  • Open surgical procedures (when TMJ dysfunction results from congenital anomalies, trauma or disease in patients who have failed conservative treatment) including, but not limited to, arthroplasties, condylectomies, condylotomies, meniscus or disc plication and disc removal

Note: Dental restorations for reconstruction of tooth form and function that are a result of TMJ dysfunction or bruxism are considered a dental service and aren’t a covered medical-surgical benefit unless otherwise specified in the individual medical certificate.

Exclusions:

The following diagnostic procedures when used to diagnose bruxism** or TMJ dysfunction:

  • Electromyography, or EMG, including surface EMG
  • Kinesiography
  • Thermography
  • Neuromuscular junction testing
  • Somatosensory testing
  • Transcranial or lateral skull X-rays
  • Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJ dysfunction)
  • Muscle testing
  • Standard dental radiographic procedures
  • Range of motion measurements
  • Computerized mandibular scan (this measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJ dysfunction)
  • Ultrasound/sonogram (ultrasonic Doppler auscultation)
  • Arthroscopy of the TMJ for purely diagnostic purposes
  • Joint vibration analysis
  • Cone beam computed tomography**
  • Trigger point therapy for all other indications or any medications not listed above
  • Image guidance of trigger point injections

The following non-surgical procedures for the treatment of TMJ dysfunction:

  • Electrogalvanic stimulation
  • Iontophoresis
  • Biofeedback
  • Ultrasound
  • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function
  • Orthodontic services/treatment (e.g., dental appliance that is intended to treat malocclusion by tooth and support structure movement)
  • Dental restorations/prosthesis/treatment/appliances**
  • TENS, or transcutaneous electrical nerve stimulation
  • PENS, or percutaneous electrical nerve stimulation
  • Acupuncture
  • Platelet concentrates

**Intra-oral reversible orthotic device (also known as occlusal orthotic, occlusal guard or bite splint), including fabrication, insertion and adjustment of all devices fabricated, cone beam tomography and bruxism treatment are certificate exclusions in most cases. Refer to current certificate of coverage.

32701, 77300, 77520, 77522, 77523, 77525

Basic benefit and medical policy

Charged-particle (proton or helium ion) radiotherapy

Charged-particle irradiation with proton or helium ion beams may be considered established for specific patient populations. It’s a useful therapeutic option when indicated. Inclusionary criteria have been updated, effective March 1, 2022.

If safe and effective, charged-particle irradiation with proton or helium ion beams may be open for individual consideration in the treatment of cancer based on the analysis of dosimetric data including comparative models if necessary.

Other applications of charged-particle irradiation with proton beams are considered experimental.

Note: There is insufficient evidence to show that PBRT provides an incremental benefit in the treatment of localized prostate cancer when compared to lower cost alternative procedures.

Payment policy:

Use of proton beam therapy, or PBT, may require prior authorization to verify that Blue Cross Blue Shield of Michigan and Blue Care Network criteria are met and, where appropriate, to explore the appropriateness of using alternative therapeutic modalities, such as IMRT 3-dimensional conformal radiation therapy.

Inclusions:

Charged-particle irradiation with proton or helium ion beams is established for the following indications:

  • In the treatment of intracranial arteriovenous malformation not amenable to surgical excision or other conventional forms of treatment or adjacent to critical structures, such as the optic nerve, brain stem or spinal cord
  • Primary or metastatic central nervous system malignancies, such as gliomas, when adjacent to critical structures such as the optic nerve, brain stem or spinal cord and when other standard radiation techniques such as IMRT or standard stereotactic modalities would not reduce the risk of radiation damage to the critical structure
  • Post-operative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II), chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma), cervical spine or sacral/lower spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
  • Tumor that involves the base of skull and proton therapy is needed to spare the orbit, optic nerve, optic chiasm or brainstem (sinonasal cancer)
  • To treat melanoma of the uveal tract (including the iris, choroid or ciliary body) with no evidence of metastasis or extrascleral extension.
  • In the treatment of all pediatric tumor types (through 21 years of age).
  • Repeat irradiation of previously treated fields where the dose tolerance of surrounding normal structures would be exceeded with 3-D conformal radiation or IMRT
  • Hepatocellular carcinoma and intrahepatic cholangiocarcinoma to treat unresectable, non-metastatic hepatocellular cancer or intrahepatic cholangiocarcinoma with curative intent

Exclusions:

  • All other applications of charged-particle irradiation including, but not limited to, clinically localized prostate cancer, non-small-cell lung cancer at any stage or for recurrence, breast cancer and pancreatic cancer are experimental
  • Proton beam therapy for the treatment of macular degeneration or choroidal neovascularization and hemangiomas

33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369

Experimental:
33999**

**Unlisted procedure

Transcatheter aortic valve implantation

Transcatheter aortic valve replacement performed with an FDA-approved transcatheter heart valve system, when performed with an approach consistent with the device’s FDA-approved labeling, may be indicated for patients with aortic stenosis.

Inclusionary and exclusionary criteria have been updated, effective March 1, 2022.

Inclusions:

Transcatheter aortic valve replacement with a device approved by the FDA and performed via an approach consistent with the device’s FDA-approved labeling is established for patients with aortic stenosis when all the following conditions are present:

  • Severe aortic stenosis with a calcified aortic annulus or failure (stenosed, insufficient, or combined) of a surgical bioprosthetic aortic valve
  • New York Heart Association heart failure class II, III or IV symptoms
  • Left ventricular ejection fraction greater than 20% and one of the following:
    • Patient isn’t an operable candidate for open surgery, as judged by at least two cardiovascular specialists including a cardiac surgeon.
    • Patient is an operable candidate but is at high risk** for open surgery.
    • Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien XT transcatheter heart valve; see below).
    • Patient is at low surgical risk** for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien 3, Sapien 3 Ultra, CoreValve Evolut R or CoreValve Evolut PRO).

Edwards SAPIEN XT transcatheter heart valve:

  • Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
    • An aortic valve area of ≤ 1.0 cm2 or aortic valve area index ≤ 0.6 cm2/m2
    • A mean aortic valve gradient ≥ 40 mmHg
    • A peak aortic-jet velocity ≥ 4.0 m/sec
    • Native anatomy appropriate for the 23-, 26-, or 29-mm valve system (between 18 and 28 mm)
  • New York Heart Association heart failure Class II, III or IV symptoms
  • Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon, or is at high or greater risk** for open surgical therapy.
  • Patient is at intermediate surgical risk** for open aortic valve replacement.

Edwards SAPIEN and Edwards SAPIEN 3 Ultra

Patient with severe aortic valve stenosis who is at low risk** for death or major complications associated with open-heart surgery

Medtronic CoreValve™ (Evolut) system

  • Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
    • An aortic valve area of ≤ 1.0 cm2 OR aortic valve area index ≤ 0.6 cm2/m2
    • A mean aortic valve gradient ≥ 40 mmHg
    • A peak aortic-jet velocity ≥ 4.0 m/sec
    • Native aortic annulus diameters between 23 and 31 mm
  • New York Heart Association heart failure Class II, III or IV symptoms
  • Patient with severe aortic valve stenosis who is at low risk or higher** for death or major complications associated with open-heart surgery

Portico™ Transcatheter Aortic Valve Implantation System

  • Aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis who are judged by a heart team, including a cardiac surgeon, to be at high** or greater risk for open surgical therapy (e.g., predicted risk of surgical mortality ≥ 8% at 30 days, based on the Society of Thoracic Surgeons risk score and other clinical comorbidities unmeasured by the STS risk calculator).

Exclusions:

Transcatheter aortic valve replacement is considered experimental for all other indications including, but not limited to:

  • The individual is appropriate candidate for the standard, open surgical approach but has refused
  • Hypersensitivity or contraindication to an anticoagulation/antiplatelet regimen
  • Presence of active bacterial endocarditis or other active infections
  • Presence of unicuspid or bicuspid aortic valve
  • Non-FDA-approved systems or approaches including:
    • JenaValve systems
    • Transcaval approach

54500, 54800, 55300, 58100, 58340, 58345, 58350, 58555, 58558, 58559, 58561, 58660, 58661, 58662, 58740, 58900, 74740, 74742, 80414, 80415, 81224, 82670, 82681, 83001, 83002, 83498, 83727, 84144, 84146, 84402, 84403, 84410, 88230, 88261, 88262, 89300, 89310, 89320, 89321, 89325, 89329, 89330, 89331, G0027, J0725

Basic benefit and medical policy

Infertility diagnosis

The safety and effectiveness of diagnostic testing for the evaluation of infertility have been established. These services may be considered useful in the diagnosis of a medical condition that may affect fertility. Procedure codes *88230, *88261 and *88262 were added to the policy as tests that may utilized to determine male factor infertility, effective March 1, 2022.

76999,** 0398T, C9734

Experimental:
0071T, 0072T

**Unlisted procedure code

Basic benefit and medical policy

MRgFUS

The safety and effectiveness of magnetic resonance-guided high-intensity ultrasound ablation have been established. It may be a considered a useful therapeutic option in specified situations.

Inclusionary criteria have been updated, effective March 1, 2022.

Inclusions:

Magnetic resonance-guided high-intensity ultrasound ablation may be considered established for the following indications:

  • Pain palliation in adults with bone metastases who fail or aren’t candidates for radiotherapy
  • Treatment of medication-refractory essential tremors (e.g., a failure, intolerance or contraindication to at least two trials of medication therapy)

Magnetic resonance-guided high-intensity ultrasound ablation is considered experimental in all other situations including, but not limited to:

  • Treatment of uterine fibroids
  • Treatment of other tumors (e.g., brain cancer, breast cancer, desmoid)
  • Treatment of tremor-dominant Parkinson disease

78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, G0235, A9593, A9594, A9595  

Not covered:
G0219, G0252

Basic benefit and medical policy

PET for oncologic conditions

The safety and effectiveness of PET scanning for selected oncologic applications have been established. It’s a useful diagnostic option for patients meeting patient selection criteria. Inclusionary criteria regarding prostate cancer have been updated, effective March 1, 2022.

Payment policy:

Prior authorization may be required. Please check member benefits.

Inclusions:

All inclusionary and exclusionary statements apply to both positron emission tomography, or PET, scans and PET/computed tomography, or CT, scans, i.e., PET scans with or without PET/CT fusion.

A PET or PET/CT may be appropriate for a patient with known diagnosis of a malignancy to determine the optimal anatomic site for a biopsy or other invasive diagnostic procedure if standard imaging is equivocal. It also may replace conventional imaging when conventional imaging would be inadequate for accurate staging, and when clinical management will depend upon the stage of disease. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for staging, not diagnosis. If the results of the PET scan won’t influence treatment decisions, these situations would be considered not medically necessary.

PET scans may be considered appropriate for the following oncologic conditions:

Anal cancer

  • Inclusions:
    • For the diagnosis, staging, restaging and monitoring of anal cancer
  • Exclusions:
    • Conditions not listed above

Bladder cancer

  • Inclusions:
    • For the staging or restaging of muscle invasive bladder cancer
  • Exclusions:
    • Conditions not listed above

Bone cancer

  • Inclusions:
    • For the staging of Ewing sarcoma and osteosarcoma
  • Exclusions:
    • For the staging of chondrosarcoma

Brain cancer

  • Inclusions:
    • For diagnosis and staging, where lesions metastatic from the brain are identified but no primary is found
    • For restaging, to distinguish recurrent tumor from radiation necrosis
  • Exclusions:
    • Conditions not listed above

Breast cancer

  • Inclusions:
    • Staging and restaging of breast cancer
    • Detecting locoregional or distant recurrence or metastasis (except axillary lymph nodes) when suspicion of disease is high and other imaging is inconclusive
    • Staging axillary lymph nodes
  • Exclusions:
    • For the differential diagnosis in patients with suspicious breast lesions or an indeterminate/low suspicion finding on mammography
    • For predicting pathologic response to neoadjuvant therapy for locally advanced disease.

Cancer of unknown primary

  • Inclusions:
    • Patients with an unknown primary who meet all the following criteria:
    • In patients with a single site of disease outside the cervical lymph nodes
    • Patient is considering local or regional treatment for a single site of metastatic disease
    • Patient has received a negative workup for an occult primary tumor
    • The PET scan will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or regional treatment
  • Exclusions:
    • For patients with an unknown primary including, but not limited to, the following:
    • As part of the initial workup of an unknown primary
    • As part of the workup of patients with multiple sites of disease

Cervical cancer

  • Inclusions:
    • For the initial staging of patients with locally advanced cervical cancer
    • For the evaluation of known or suspected recurrence
  • Exclusions:
    • For the initial diagnosis of cervical cancer in all other situations

Colorectal cancer

  • Inclusions:
    • Staging and restaging (initial and subsequent treatment strategy) to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer
    • To evaluate a rising and persistently elevated carcinoembryonic antigen, or CEA, level when standard imaging, including CT scan, is negative
  • Exclusions:
    • When used as a technique to assess the presence of scarring versus local bowel recurrence in patients with previously resected colorectal cancer
    • When used as a technique contributing to radiotherapy treatment planning

Endometrial cancer

  • Inclusions (must include both):
    • Detection of lymph node metastases
    • Assessment of endometrial cancer recurrence
  • Exclusions:
    • Conditions not listed above

Esophageal cancer

  • Inclusions:
    • Staging and restaging of esophageal cancer 
    • Determining response to preoperative induction therapy
  • Exclusions:
    • Detection of primary esophageal cancer

Gastric (stomach) cancer

  • Inclusions:
    • Diagnosis, staging and restaging of gastric carcinoma if other imaging is inconclusive
    • Determining response to preoperative induction therapy
  • Exclusions:
    • Conditions not listed above

Head and neck cancer

  • Inclusions:
    • For the evaluation of the head and neck in the diagnosis of suspected head and neck cancer
    • For the initial staging of the disease
    • For restaging of residual or recurrent disease during follow up after treatment for their head and neck cancer
  • Exclusions:
    • Conditions not listed above

Hepatobiliary cancer

  • Inclusions:
    • When standard imaging studies are equivocal or nondiagnostic regarding extent of disease
    • When standard imaging prior to planned curative surgery has been performed and has not demonstrated metastatic disease
  • Exclusions:
    • Conditions not listed above

Lung cancer

  • Inclusions:
    • Patients with a solitary pulmonary nodule as a single-scan technique (not dual-time) to distinguish between benign and malignant disease when prior CT scan and chest X-ray findings are inconclusive or discordant
    • To determine resectability for patients with a presumed solitary metastatic lesion from lung cancer
    • As a staging or restaging technique in those with known non-small-cell lung cancer
    • PET scanning may be considered established in staging of small-cell lung cancer if limited stage is suspected based on standard imaging
  • Exclusions:
    • PET scanning in staging of small-cell lung cancer if extensive stage is established and in all other aspects of managing small-cell lung cancer
    • Conditions not listed above

Lymphoma, including Hodgkin’s disease

  • Inclusions:
    • PET scanning as a technique for staging lymphoma either during initial staging or for restaging at follow-up
  • Exclusions:
    • Conditions not listed above

Melanoma

  • Inclusions:
    • Assessing extranodal spread of malignant melanoma at initial staging or at restaging during follow-up treatment for advanced disease.
  • Exclusions:
    • In managing stage 0, I or II melanoma
    • When used as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy

Multiple myeloma

  • Inclusions:
    • For the initial and subsequent treatment strategy of multiple myeloma
  • Exclusions
    • N/A

Merkel cell carcinoma

  • Inclusions:
    • As clinically indicated

Neuroendocrine tumors

  • Inclusions:
    • For the diagnosis, staging, restaging and monitoring of neuroendocrine tumors
  • Exclusions:
    • Conditions not listed above

Ovarian cancer

  • Inclusions:
    • Initial staging of ovarian cancer
    • For the evaluation of patients with signs or symptoms of suspected ovarian cancer recurrence (restaging) when standard imaging, including CT scan, is inconclusive.
  • Exclusions:
    • For the initial evaluation (not staging) of known or suspected ovarian cancer in all other situations

Pancreatic cancer

  • Inclusions:
    • For the initial diagnosis and staging of pancreatic cancer when other imaging and biopsy are inconclusive
  • Exclusions:
    • Evaluating other aspects of pancreatic cancer

Penile cancer

  • Inclusions:
    • Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis.
  • Exclusions:
    • All other indications

Pleural, thymus, heart and mediastinum cancer

  • Inclusions:
    • For situations in which surgical resection is being considered and metastatic disease hasn’t been detected by CT or MRI
    • For restaging after induction chemotherapy if the patient is a surgical candidate
  • Exclusions:
    • All other indications

Prostate cancer

  • Inclusions:
    • PET scanning with 11C-choline for evaluating response to primary treatment in prostate cancer
    • PET scanning with Gallium Ga-68 prostate-specific membrane antigen (PSMA)-11 and Piflufolastat fluorine-18 for the following indications: 
    • As an alternative to standard imaging of bone and soft tissue for initial staging, for the detection of biochemically (elevated PSA) recurrent disease
    • As workup for progression with bone scan plus CT or MRI for the evaluation of bone, pelvis and abdomen
  • Exclusions:
    • PET scanning for all other indications

Renal cell carcinoma

  • Inclusions:
    • For initial treatment strategy, subsequent treatment strategy and surveillance of biopsy proven kidney cancer
  • Exclusions:
    • N/A

Soft tissue sarcoma

  • Inclusions:
    • For initial staging prior to resection of an apparently solitary metastasis
    • When the grade of an unresectable tumor remains in doubt after biopsy
    • Differentiation of suspected tumor from radiation or surgical fibrosis
    • Determination of response to therapy, gastrointestinal stromal tumor, or GIST, for initial staging and re-staging when there is documented recurrence
  • Exclusions:
    • When used in evaluation of soft tissue sarcoma, including, but not limited to the following applications:
      • Distinguishing between low grade and high- grade soft tissue sarcoma
      • Detecting locoregional recurrence
      • Detecting distant metastasis

Testicular cancer

  • Inclusions:
    • PET scanning in the evaluation of residual mass following chemotherapy of stage IIB and III seminomas
  • Exclusions:
    • All other indications

Thyroid cancer

  • Inclusions:
    • For the initial treatment strategy of thyroid cancer types known not to concentrate radioactive iodine, or RAI
    • For subsequent treatment strategy for differentiated thyroid cancer of follicular cell origin which is known to concentrate radioactive iodine, or RAI, in all the following situations:
      • When done following prior treatment with thyroidectomy and radioiodine ablation
      • With a current serum thyroglobulin > 10 ng/ml (except in the setting of documented anti-thyroglobulin antibodies)
      • With a negative whole-body RAI scan in the past
  • Exclusions:
    • For the evaluation of known or suspected differentiated or poorly differentiated thyroid cancer in all other situations

Vaginal/vulvar cancers

  • Inclusions:
    • Radiation planning
    • Standard imaging studies are equivocal or nondiagnostic for recurrent or progressive disease
    • Restaging of local recurrence when pelvic exenteration surgery is planned
  • Exclusions:
    • All other indications

Cancer surveillance

  • Inclusions:
    • N/A
  • Exclusions:
    • When used as a surveillance tool for patients with cancer or with a history of cancer. A scan is considered surveillance if performed more than six months after completion of cancer therapy (12 months for lymphoma) in patients without objective signs or symptoms suggestive of cancer recurrence.

81161-81479, 88271, 88272, 88273, 88274, 88275, 88291, 89290, 89291

Experimental:
0254U

Basic benefit and medical policy

Genetic testing: Preimplantation

Preimplantation genetic diagnosis may be considered established as an adjunct to in-vitro fertilization in individuals or couples who have the IVF benefit and who meet specific criteria (see inclusions).

Preimplantation genetic screening as an adjunct to IVF is considered experimental.

Inclusionary criteria have been updated, effective March 1, 2022.

Inclusions:

  1. For preimplantation genetic diagnosis in an embryo identified as at elevated risk of a significant genetic disorder, the individual or couple must have the benefit for in-vitro fertilization and meet criteria to access the benefit (i.e., have a diagnosis of infertility) and meet one of the following criteria:
    1. Both partners are known carriers of a single gene autosomal recessive disorder.
    2. One partner is a known carrier of a single gene autosomal recessive disorder and the partners have an offspring who has been diagnosed with that recessive disorder.
    3. One partner is a known carrier of a single gene autosomal dominant disorder.
    4. One partner is a known carrier of a single X-linked disorder.
  2. For preimplantation genetic diagnosis in an embryo identified as at elevated risk for a structural chromosomal abnormality, the individual or couple must have the benefit for in-vitro fertilization and meet criteria to access the benefit (e.g., have a diagnosis of infertility) and one partner with balanced or unbalanced chromosomal translocation.
  3. Individual consideration may be given to the individual or couple who have the in-vitro fertilization benefit and meets at least one criterion under 1. or 2. (above) but doesn’t have a diagnosis of infertility.

Exclusions:

All other situations than those specified above

Preimplantation genetic screening, or PGS, as an adjunct to IVF considered experimental

81235, 81275, 81404, 81405, 81445, 81479, 81406

Basic benefit and medical policy

Non-small-cell lung cancer

Molecular analysis for targeted therapy or immunotherapy for NSCLC has gene criteria updates, effective March 1, 2022.

EGFR testing

  • The safety and effectiveness of analysis of somatic variants in exons 18 (such as G719X), 19 (such as L858R, T790M), 20 (such as S678I) or 21 (such as L861Q) within the EGFR gene have been established to predict treatment response to an EGFR tyrosine kinase inhibitor, or TKI, therapy (e.g., erlotinib [Tarceva®], gefitinib [Iressa®], or afatinib [Gilotrif®]), or osimertinib (Tagrisso) in patients with advanced lung adenocarcinoma, large cell carcinoma, advanced squamous cell NSCLC and NSCLC, not otherwise specified
  • The analysis for other EGFR mutations within exons 22-24 or other applications related to NSCLC is considered experimental. The peer-reviewed medical literature hasn’t yet demonstrated the clinical utility of this testing for this indication.

ALK testing

  • The safety and effectiveness of analysis of somatic rearrangement mutations of the ALK gene in tissue have been established. It’s an effective diagnostic option for predicting treatment response to crizotinib (Xalkori®), ceritinib (Zykadia™, alectinib [Alecensa] or brigatinib [Alunbrig]) in patients with advanced lung adenocarcinoma and large cell carcinoma or for patients in whom an adenocarcinoma component can’t be excluded.
  • Analysis of somatic rearrangement mutations of the ALK gene is considered experimental in all other situations.

BRAF V600E testing

  • Analysis of the BRAF V600E variant is established to predict treatment response to BRAF or MEK inhibitor therapy (e.g., dabrafenib [Tafinlar] and trametinib [Mekinist®]) in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component cannot be excluded.

ROS1 testing

  • Analysis of somatic rearrangement variants of the ROS1 gene is established to predict treatment response to ALK inhibitor therapy (crizotinib [Xalkori]) in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component can’t be excluded.

KRAS testing

  • Analysis of somatic mutations of the KRAS gene is established as a technique to predict treatment nonresponse to anti-EGFR therapy with tyrosine kinase inhibitors and for the use of the anti-EGFR monoclonal antibody cetuximab in NSCLC. The peer-reviewed medical literature has demonstrated the clinical utility of this testing for this indication.
  • Analysis of somatic variants of the KRAS gene in tissue may be considered established to predict treatment response to sotorasib (Lumakras) in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component can’t be excluded.

HER2 testing

  • Analysis of genetic alterations in the HER2 gene for targeted therapy in patients with NSCLC is considered established to identify rare oncogenic driver variants for which effective therapy may be available.

NTRK gene fusion testing

  • Analysis of gene fusions is established to predict treatment response to larotrectinib in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component can’t be excluded.

RET rearrangement testing

  • Analysis of genetic alteration in the RET gene may be considered established to predict treatment response to pralsetinib or selpercatinib in patients with metastatic NSCLC.

MET exon 14 skipping alteration

  • Analysis of genetic alteration that leads to MET exon 14 skipping may be considered established to predict treatment response to capmatinib in patients with metastatic NSCLC.
  • Analysis of genetic alterations of the MET gene is considered experimental in all other situations.

PD-L1 testing

  • PD-L1 testing may be considered established to predict treatment response to atezolizumab or to the combination of nivolumab plus ipilimumab in patients with metastatic NSCLC.

Tumor mutational burden testing

May be established for the treatment of adult and pediatric patients with unresectable or metastatic tumor mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors, as determined by an FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options (for example, Keytruda)

81420, 81507, 81599,** 81479***

Experimental:
81422, 0060U, 0168U

**If the codes above don’t apply and the test involves multianalyte assays and an algorithmic analysis

***If the codes above don’t apply and the test does not involve an algorithmic analysis

Basic benefit and medical policy

Noninvasive prenatal screening for fetal aneuploidies

The safety and effectiveness of noninvasive prenatal screening for fetal aneuploidies using cell-free fetal DNA have been established. It may be considered a useful diagnostic option when indicated.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of noninvasive prenatal screening for microdeletions using cell-free fetal DNA. Therefore, this service is considered experimental.

Inclusionary and exclusionary criteria have been updated, effective March 1, 2022.

Inclusions:

  • Nucleic acid sequencing-based testing of maternal plasma to screen for trisomy 21 in women with singleton and twin pregnancies (Karyotyping would be necessary to exclude the possibility of a false positive nucleic acid sequencing-based test.)
  • Concurrent nucleic acid sequencing-based testing of maternal plasma for trisomy 13 and/or 18 in women who are eligible for and are undergoing nucleic acid sequencing-based testing of maternal plasma for trisomy 21 
  • Nucleic acid sequencing-based testing of maternal plasma for fetal sex or fetal sex chromosome aneuploidy only when certain fetal abnormalities are noted on ultrasound such as cases of ambiguous genitalia or cystic hygroma when the determination of fetal sex is necessary to help guide medical management

Exclusions:

  • Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 in women with multiple gestation pregnancies
  • Nucleic acid sequencing-based testing of maternal plasma for trisomy 13 or 18, other than in the situations specified above
  • Nucleic acid sequencing-based testing of maternal plasma for fetal sex determination or fetal sex chromosome aneuploidies other than the situation specified above
  • Nucleic acid sequencing-based testing of maternal plasma for microdeletions
  • Nucleic acid sequencing-based testing of maternal plasma for twin zygosity
  • Vanadis® NIPT of maternal plasma to screen for trisomy 21, 18 and 13

For other aneuploidies or genetic disorders not specified above

97039,** 97139,** 97799**

**Unlisted procedure code

Basic benefit and medical policy

Vibracussor (percussion therapy)

Vibracussor (percussion therapy) has been added as an experimental service, effective March 1, 2022.

J3490
J3590

Basic benefit and medical policy

Besremi (ropeginterferon alfa-2b-njft)

Effective Nov. 12, 2021, Besremi (ropeginterferon alfa-2b-njft) is covered for the following FDA-approved indications:

Besremi (ropeginterferon alfa-2b-njft) is an interferon alfa-2b, indicated for the treatment of adults with polycythemia vera.

Dosage and administration:

  • Recommended starting dose: 100 mcg by subcutaneous injection every two weeks (50 mcg if receiving hydroxyurea).
  • Increase the dose by 50 mcg every two weeks (up to a maximum of 500 mcg) until hematological parameters are stabilized.
  • Interrupt or discontinue dosing if certain adverse reactions occur.

Dosage forms and strengths:

Injection: 500 mcg/mL solution in a single-dose prefilled syringe

Besremi (ropeginterferon alfa-2b-njft) isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Korsuva (difelikefalin)

Effective Aug. 23, 2021, Korsuva (difelikefalin) is covered for the following FDA-approved indications:

  • Korsuva is a kappa opioid receptor agonist indicated for the treatment of moderate-to-severe pruritus associated with chronic kidney disease (CKD-aP) in adults undergoing hemodialysis, or HD.

Dosage and administration:

Recommended dosage is 0.5 mcg/kg.

  • Administer by intravenous bolus injection into the venous line of the dialysis circuit at the end of each HD treatment.
  • Don’t mix or dilute Korsuva prior to administration.
  • Administer within 60 minutes of syringe preparation.

Dosage forms and strengths:

Injection: 65 mcg /1.3 mL (50 mcg/mL) of difelikefalin

This drug isn’t a benefit for URMBT.

J7525

Basic benefit and medical policy

Prograf (tacrolimus)

Effective Aug. 1, 2021, Prograf (tacrolimus) is covered for the following updated FDA-approved indications:

  • Prograf is a calcineurin-inhibitor immunosuppressant indicated for the prophylaxis of organ rejection in adult and pediatric patients receiving allogeneic liver, kidney, heart or lung transplants, in combination with other immunosuppressants.

Dosing information:

Adult lung transplant with azathioprine or MMF

Initial oral dosage (formulation): 0.075 mg/kg/day capsules, divided in two doses, every 12 hours

Whole blood trough concentration range: Months 1-3: 10-15 ng/mL; months 4-12: 8-12 ng/mL

Pediatric lung transplant

Initial oral dosage (formulation): 0.3 mg/kg/day2, capsules or oral suspension, divided in two doses, every 12 hours

Whole blood trough concentration range: Weeks 1-2: 10-20 ng/mL; Week 2 to Month 12: 10- 15 ng/mL

Dosage forms and strengths: 

  • Capsules: 0.5 mg, 1 mg and 5 mg
  • Injection: 5 mg/ml
  • For oral suspension: 0.2 mg, 1 mg unit-dose packets containing granules

J9177

Basic benefit and medical policy

Padcev (enfortumab vedotin-ejfv)

Padcev (enfortumab vedotin-ejfv) is payable for the
following updated FDA-approved indications:

Padcev is a Nectin-4-directed antibody and microtubule inhibitor conjugate indicated for the treatment of adult patients with locally advanced or metastatic urothelial cancer who:

  • Are ineligible for cisplatin-containing chemotherapy and have previously received one or more prior lines of therapy

Dosage information:

  • For intravenous infusion only. Don’t administer Padcev as an intravenous push or bolus. Don’t mix with or administer as an infusion with other medicinal products.
  • The recommended dose of Padcev is 1.25 mg/kg (up to a maximum dose of 125 mg) given as an intravenous infusion over 30 minutes on days 1, 8 and 15 of a 28-day cycle until disease progression or unacceptable toxicity.
  • Avoid use in patients with moderate or severe hepatic impairment.
EXPERIMENTAL PROCEDURES

53451, 53452, 53453, 53454

Basic benefit and medical policy

ProACT™ adjustable continence therapy device

The ProACT adjustable continence therapy device is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment, effective March 1, 2022.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2021 American Medical Association. All rights reserved.
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