Billing chart: Blue Cross highlights medical, benefit policy changes

80145, 80230  

Experimental:
80280, 84999**

Basic benefit and medical policy

Measurement of serum and anti-drug antibody levels for selected biologic agents

Measurement of biologic agent drug levels and, if low, anti-drug antibody levels in children with inflammatory bowel disease, or IBD, is established, effective June 1, 2021.

Measurement of antidrug antibodies in other patients being treated with a biologic agent, either alone or as a combination test, which includes the measurement of serum TNF blocking agent levels, is considered experimental. The use of these tests hasn’t been clinically proven to improve patient clinical outcomes or alter patient management.

Payment policy:

Modifiers 26 and TC don’t apply to these codes. Not payable when performed in an office location. Payable for diagnoses related to inflammatory bowel disease only.

Inclusions:

Biologic agent drug levels are established in children (under the age of 21) who are:

• Diagnosed with inflammatory bowel disease and
• Being treated with either Adalimumab or Infliximab
• Being monitored for their response to the agent by biologic agent drug level

If the biologic agent drug level is below the therapeutic range, anti-drug antibody level is established.

Exclusions:

• Individuals age 21 and older
• Any condition other than inflammatory bowel disease

J9299

Basic benefit and medical policy

Opdivo (nivolumab)

Opdivo (nivolumab), procedure code J9299, is covered for the following updated FDA-approved indications:

• Gastric cancer
• Gastroesophageal junction cancer
• Esophageal adenocarcinoma

For patients with advanced or metastatic gastric cancer, gastroesophageal junction cancer and esophageal adenocarcinoma in combination with fluoropyridine and platinum-containing chemotherapy

Esophageal cancer:

• For patients with completely resected esophageal or gastroesophageal junction cancer with residual pathologic disease, who have received neoadjuvant chemoradiotherapy, or CRT

Note: Opdivo is no longer FDA-approved for the treatment of small cell lung cancer, effective Dec. 29, 2020.

81412, 81443, 81479, various**

Basic benefit and medical policy

Carrier screening for genetic diseases

The medical policy statement and inclusionary and exclusionary criteria have been updated, effecttive Nov. 1, 2021

Medical policy statement:

Panethnic expanded carrier testing for autosomal recessive and x-linked genetic disorders has been established. It may be considered a useful diagnostic option when indicated.

The safety and effectiveness of targeted carrier testing for autosomal recessive and x-linked genetic disorders have been established. It may be considered a useful diagnostic option when indicated.

Inclusions:

Panethnic expanded carrier testing for autosomal recessive and x-linked genetic disorders when the female is pregnant or is considering pregnancy.^a

^aIf the initial testing is positive in one partner, then sequential testing in the other partner should be focused on specific gene abnormalities.

Targeted carrier screening for autosomal recessive and x-linked genetic disorders when all the following apply:

• The couple is pregnant or is considering pregnancy.
• The natural history of the disease is well understood and there is a reasonable likelihood that the disease is one with high morbidity in the homozygous or compound heterozygous state.
• Alternative biochemical or other clinical tests to definitively diagnose carrier status aren’t available, or, if available, provide an indeterminate result or are individually less efficacious than genetic testing.
• The genetic test has adequate sensitivity and specificity to guide clinical decision-making and residual risk is understood.
• An association of the marker with the disorder has been established.

Exclusions:

• All targeted and carrier screening panels not meeting the above criteria
• Carrier screen testing of the male partner when the female partner was found not to have risk (i.e., sequential testing)
• Carrier screen testing of the male partner at the same time that the female partner is undergoing carrier screen testing (i.e., simultaneous testing)

90867, 90868, 90869

Basic benefit and medical policy

Transcranial magnetic stimulation as treatment for depression

Transcranial magnetic stimulation of the brain has been established. It may be a useful treatment option in specified situations.

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

Inclusionary and exclusionary guidelines

Inclusions:

Transcranial magnetic stimulation must be administered by an approved U.S. Food & Drug Administration-cleared device for the treatment of major depressive disorder, or MDD, according to specified stimulation parameters, five days a week for six weeks (total of 30 sessions), followed by a three-week taper of three TMS treatments in one week, two TMS treatments the next week and one TMS treatment in the last week.

Must meet all:

1. The member is 18 to 70 years old.
2. A drug screen is obtained if indicated by history, current clinical evaluation or a high degree of clinical suspicion.
3. A confirmed diagnosis of severe major depressive disorder (single or recurrent episode) measured by evidence-based scales such as Beck Depression Inventory (score 30-63), Zung Self-Rating Depression Scale (>70), PHQ-9 (>20), Hamilton Depression Rating Scale (>20) or Montgomery-Asberg Depression Rating Scale (score >34).
4. At least one of the following:

• Current depressive episode treatment:
• Medication treatment resistance, evidenced by:
• Lack of a clinically significant response to 4 trials of psychopharmacologic agents:
• Two single agent trials of antidepressants from at least two different agent classes
• Two augmentation trials with different classes of augmenting agents utilizing either (or both) of the agents used in the single agent trials

Note: Each agent in the treatment trial must have been administered at an adequate course of mono- or poly-drug therapy.
Note: Trial criteria is six weeks of maximal FDA-recommended dosing or maximal tolerated dose of medication with objectively measured evaluation at initiation and during the trial showing no evidence of response (i.e., < 50% reduction of symptoms or scale improvement).

• The patient is unable to tolerate a therapeutic dose of medications. Intolerance is defined as severe somatic or psychological symptoms that can’t be modulated by any means including but not limited to additional medications to ameliorate side effects. Examples of somatic side effects: persistent electrolyte imbalance, pancytopenia, severe weight loss, poorly controlled metabolic syndrome or diabetes. Examples of psychological side effects: suicidal-homicidal thinking/attempts, impulse dyscontrol. Note: A trial of less than one week of a medication is not considered a qualifying trial to establish intolerance.

• The patient has a history of response to rTMS in a previous depressive episode (and it’s been at least three months since the prior episode)
• The patient is a candidate for electroconvulsive therapy; further, electroconvulsive therapy would not be clinically superior to transcranial magnetic stimulation (e.g., in cases with psychosis, acute suicidal risk, catatonia or life-threatening inanition rTMS should not be utilized).

5. The patient failed a trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms (e.g., Becks Depression Inventory, Zung Self-Rating Depression Scale, PHQ-9, Hamilton Depression Rating Scale or MADRS).
6. Conditions that must be met during the entire rTMS treatment:

• A board-certified psychiatrist, trained in this therapy, must deliver the treatment
• An attendant trained in BCLS, the management of complications (such as seizures), and the use of the equipment must be present
• Adequate resuscitation equipment must be available (e.g., suction and oxygen)
• The facility must maintain awareness of response times of emergency services (either fire/ambulance or “code team”), which should be available within five minutes. These relationships are reviewed on at least a one year basis and include mock drills.

Exclusions:

• All other behavioral health, neuropsychiatric or medical conditions (e.g., anxiety disorders, mood disorders, schizophrenia, Alzheimer’s, dysphagia, seizures, obsessive-compulsive disorder**)
  
  **Individual consideration may be extended to patient’s with OCD based on review of applicable medical records.

• Pregnancy
• Maintenance treatment
• Presence of psychosis in the current episode
• Seizure disorder or any history of seizure, except those induced by ECT or isolated febrile seizures in infancy without subsequent treatment or recurrence
• Presence of an implanted magnetic-sensitive medical device located less than or equal to 30 centimeters from the TMS magnetic coil or other implanted metal items, including but not limited to a cochlear implant, implanted cardioverter defibrillator, pacemaker, vagus nerve stimulator, or metal aneurysm clips or coils, staples, or stents
  Note: Dental amalgam fillings aren’t affected by the magnetic field and are acceptable for use with TMS.

• If the patient (or, when indicated, the legal guardian) is unable to understand the risk and benefits of rTMS and provide informed consent
• Presence of a medical or co-morbid psychiatric contraindication to rTMS
• Patient lacks a suitable environmental, or social or professional support system for post-treatment recovery
• There isn’t a reasonable expectation that the patient will be able to adhere to post-procedure recommendations

Note: Caution should be exercised in any situation where the patient’s seizure threshold may be decreased. Examples include:

• Presence in the bloodstream of a variety of agents including, but not limited to, tricyclic antidepressants, clozapine, antivirals, theophylline, amphetamines, PCP, MDMA, alcohol and cocaine as these present a significant risk
• Presence of the following agents including, but not limited to, SSRIs, SNRIs, bupropion, some antipsychotics, chloroquine, some antibiotics and some chemotherapeutic agents as they present a relative risk and should be considered when making risk-benefit assessments
• Withdrawal from alcohol, benzodiazepines, barbiturates and chloral hydrate also present a strong relative hazard

Established:
93895, 93998

Basic benefit and medical policy

U.S. measurement of carotid intima-media as assessment for atherosclerosis

The medical policy statement has been updated, effective Nov. 1, 2021.

Medical policy statement:

Ultrasonographic measurement of carotid artery intima-media thickness to screen, diagnose or manage subclinical atherosclerosis is considered experimental. Although it may be safe, its usefulness hasn’t been definitively proven.

C9399
J3490
J3590

Basic benefit and medical policy

Bridion (sugammadex)

Effective June 25, 2021, Bridion (sugammadex) is covered for the following FDA-approved indications:

Bridion is indicated for the reversal of neuromuscular blockade induced by rocuronium bromide and vecuronium bromide in adults and pediatric patients age 2 and older undergoing surgery.

Dosage information:

• Dosing is based on actual body weight.
• Monitor for twitch responses to determine the timing and dose for Bridion administration.
• Administer as a single bolus injection.

For rocuronium and vecuronium:

• 4 mg/kg is recommended if spontaneous recovery of the twitch response has reached one to two post-tetanic counts, or PTC, and there are no twitch responses to train-of-four, or TOF, stimulation.

• 2 mg/kg is recommended if spontaneous recovery has reached the reappearance of the second twitch in response to TOF stimulation.

For rocuronium only:

• 16 mg/kg is recommended if there is a clinical need to reverse neuromuscular blockade soon (approximately 3 minutes) after administration of a single dose of 1.2 mg/kg of rocuronium. Immediate reversal in pediatric patients hasn’t been studied.

Dosage forms and strengths:

• 200 mg/2 mL (100 mg/mL) in a single-dose vial for bolus injection
• 500 mg/5 mL (100 mg/mL) in a single-dose vial for bolus injection

H0031, H0032, H2014, H2019, S5108,** S5111,** 0362T, 0373T, 0373T, 97151,** 97152, 97153,*** 97154,** 97155,*** 97156,** 97157,** 97158**

**May be delivered via telemedicine

Basic benefit and medical policy

Autism spectrum disorder services

The effectiveness of treatment for autism spectrum disorder has been established. It may be a useful therapeutic option when inclusionary and certificate guidelines are met.

Criteria have been updated, effective Nov. 1, 2021.

Inclusions:

• Full diagnostic criteria for autism spectrum disorder, as published in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, are met.
• The maladaptive behavior must affect the child’s personal safety or the safety of others within the child’s environment, or must significantly interfere with the child’s ability to function.
• Services in Michigan must be provided or supervised by one of the following:
• A clinician who is a licensed behavior analyst
• A psychiatrist who has the appropriate training
• A licensed psychologist who has the appropriate education, training and experience
• A person who holds a license, certificate or registration that authorizes them to perform services included in applied behavior analysis
• Services outside of Michigan must be provided by a clinician who meets their state requirements to provide ABA therapy.
• There is a treatment plan that:
• Is child centered
• Defines target behaviors
• Records objective measures of baseline levels and progress
• Identifies and documents specific interventions and techniques
• Documents transitional and discharge plans

Exclusions:

• People who don’t meet the diagnostic criteria based on the most recent criteria by the American Psychiatric Association (i.e., most current version of the Diagnostic and Statistical Manual)
• In Michigan, therapy delivered or supervised by clinicians who are not licensed behavior analysts or those who don’t meet state requirements to provide ABA therapy
• Outside of Michigan, therapy delivered or supervised by clinicians who don’t meet their state requirements to provide ABA therapy
• Therapy for people older than age 18

Autism services allowed via telemedicine synchronous care:

• Specific autism services allowed via telemedicine synchronous care are noted in the CPT section.
• Adaptive behavior treatment that is part of a treatment plan (code *97153) is allowed if the child meets appropriateness criteria.
• At a minimum, the child should exhibit basic skills of joint attention, basic discrimination, basic echoic and basic motor imitation. The child should be able to follow common one-step instructions, participate in sessions with limited caregiver assistance and sit independently at a computer or tablet for 8 to 10 minutes. Safety concerns and challenging behaviors must be minimal.

(For the complete guidelines, refer to the Blue Cross’ Provider Alert “Additional autism interventions now payable via telemedicine on an ongoing basis and restrictions are removed from protocol modification (*97155).” To find the alert, go to bcbsm.com and click on Learn more after What you need to know about the coronavirus, COVID-19. Then click on the Health Care Providers tab. The guidelines are under the Read our Provider Alerts for recent updates section.)

• Autism services provided via telemedicine may not be effective for all children. When services are provided via telemedicine and the child doesn’t show progress, it’s expected that the treatment plan would be modified to face-to-face interactions.

Autism services delivered via telemedicine are synchronous care only; asynchronous care isn’t appropriate for autism services.

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

Effective June 28, 2021, Keytruda (pembrolizumab) is covered for the following updated FDA-approved indications:

Keytruda (pembrolizumab) is a programmed death receptor-1 (PD-1)-blocking antibody indicated for:

Cutaneous squamous cell carcinoma, or cSCC,
for the treatment of patients with recurrent or metastatic cSCC or locally advanced cSCC that isn’t curable by surgery or radiation.

Dosage and administration:

• cSCC: 200 mg every three weeks or 400 mg every six weeks