Billing chart: Blue Cross highlights medical, benefit policy changes

90677

Basic benefit and medical policy

Pneumococcal conjugate 20-valent vaccine

The pneumococcal conjugate 20-valent vaccine (Prevnar 20™) is established. It’s been approved by the U.S. FDA.     

The FDA approved this vaccine (also known as Prevnar 20) on June 8, 2021, for adults 18 years of age and older.

The CPT code for this vaccine is effective July 1, 2021.

On Jan. 28, 2022, Morbidity and Mortality Weekly Report published “Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2022”:

“Adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not previously received pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive 1 dose of PCV20.

“Adults aged ≥65 years who have not previously received pneumococcal conjugate vaccine whose previous vaccination history is unknown should receive 1 dose of PCV20.”

20983, 32994, 50250, 50542, 50593

Experimental
19105, 32999,** 48999,** 0581T

Basic benefit and medical policy

Cryosurgical ablation of tumors

The safety and effectiveness of cryosurgical ablation to treat localized renal cell carcinoma have been established. It may be considered a useful therapeutic option when indicated.

The safety and effectiveness of cryosurgical ablation to treat lung cancer have been established. It may be considered a useful therapeutic option when indicated.

The safety and effectiveness of cryosurgical ablation to palliate pain in patients with osteolytic bone metastases have been established. It may be considered a useful therapeutic option when indicated.

The safety and effectiveness of cryosurgical ablation to treat osteoid osteoma have been established. It may be considered a useful therapeutic option when indicated.

Cryosurgical ablation as a treatment of benign or malignant tumors of the breast or pancreas is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

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

Inclusions:

Renal cell carcinoma with no evidence of metastasis and when either of the following criteria is met:

• The tumor is no more than 4 cm in its greatest dimension, preservation of kidney function is necessary (i.e., the patient has one kidney or renal insufficiency defined by a glomerular filtration rate, or GFR, of less than 60 mL/min per m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function.
• The tumor is no more than 4 cm in its greatest dimension and the patient isn’t considered a surgical candidate.

Cryosurgical ablation to treat lung cancer when either of the following criteria is met:

• The patient has early-stage non-small cell lung cancer and is a poor surgical candidate.
• The patient requires palliation for a central airway obstructing lesion.

Cryosurgical ablation to palliate pain in patients with osteolytic bone metastases when all the following criteria are met:

1. Patient is 18 years or older.
2. One or two painful bone metastasis lesions, 1-11 cm in size.
3. Patient has failed or is a poor candidate for standard treatments such as radiation or opioids
4. Patient has pain score ≥ 4 on scale 0-10.
5. Life expectancy is more than 2 months.
6. The lesion is > 1 cm away from the spinal cord, brain, other critical nerve structure, large abdominal vessel such as the aorta or inferior vena cava, bowel or bladder.
7. The coagulation profile is normal (platelets > 50,000 and INR < 1.5).
8. The site of the lesion isn’t at imminent risk of fracture.
9. Patient must not have a primary musculoskeletal malignancy, lymphoma or leukemia.

Cryosurgical ablation to treat osteoid osteoma when any of the following criteria are met:

1. Those who have failed medical therapy.
2. Those being considered for surgical resection.
3. Those who have failed previous surgical therapy and have recurrent symptoms or pain.

Exclusions:

Other indications not noted in the policy inclusions

59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409

Basic benefit and medical policy

Fetal (prenatal) surgery

Prenatal (fetal) surgery is established for specific congenital abnormalities or conditions. The safety and effectiveness of these surgeries have been proven.

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

Inclusions:

The following prenatal surgical interventions are considered established when there are no maternal contraindications to the surgery and criteria for the surgery are met:

Fetal urinary tract obstruction

Vesicoamniotic shunting is considered established when all the following are present:

• Megacystis due to urinary tract obstruction
• Progressive oligohydramnios
• Adequate renal function
• No other lethal abnormalities or chromosomal defects

Congenital pulmonary airway malformation

Placement of a thoraco-amniotic shunt or in utero resection of malformed pulmonary tissue is considered established when all the following are present:

• Congenital pulmonary airway malformation, or CPAM, is identified.
• The malformations are progressing in size.
• CPAM volume ratio (CVR) >1.6.
• Gestational age of one of the following:
• 32 weeks or less for shunting
• Less than 27 weeks for in utero resection with plan for continuing pregnancy
• Greater than 32 weeks for EXIT procedure

Sacrococcygeal teratoma

In utero resection of sacrococcygeal teratoma is considered established when all the following are present:

• Cardiomegaly with compromised cardiac output,
• Gestational age of one of the following:
• 28 weeks or less for resection
• 32 weeks or less for radiofrequency ablation

Myelomeningocele

Repair of myelomeningocele is considered established when all the following are present:

• Myelomeningocele is identified, with an upper boundary located between T1 and S1 with evidence of hindbrain herniation
• Gestational age of 26 weeks or less
• No other clinically significant fetal abnormalities

Congenital diaphragmatic hernia

Tracheal occlusion in the treatment of congenital diaphragmatic hernia is considered established when all the following are present:

• Gestational age is less than 30 weeks
• Evidence of liver herniation
• Lung-to-head ratio, or LHR, observed-to-expected for gestational age is ≤ 15%

Prenatal surgery should only be performed by facilities with the expertise, multidisciplinary teams, services and facilities to provide the intensive care required for these patients.

Exclusions:

• Prenatal (fetal) surgery that doesn’t meet criteria listed above.
• All other applications of prenatal (fetal) surgery including, but not limited to, treatment of congenital heart defects.

Note: Twin-to-twin transfusion syndrome, or TTTS, is addressed in medical policy, “In Utero Laser Therapy for the Treatment of Twin-to-Twin Transfusion Syndrome (TTTS).”

64999**

Basic benefit and medical policy

Peripheral subcutaneous field stimulation and nerve stimulation

The peripheral subcutaneous field stimulation and nerve stimulation medical policy statement has been updated, effective May 1, 2022.

Medical policy statement:

Peripheral nerve stimulation, or PNS, therapy and peripheral subcutaneous field stimulation, or PSFS, are experimental. They haven’t been scientifically demonstrated to improve patient clinical outcomes.

Inclusions and exclusions:

Not applicable

92227, 92228, 92229,** 92250

Basic benefit and medical policy

Retinal care for diabetic retinopathy

The safety and effectiveness of retinal telescreening with digital imaging and manual grading of images as a diagnostic screening technique and for the monitoring and management of diabetic retinopathy have been established.

The clinical utility of FDA-approved digital retinal imaging with image interpretation by artificial intelligence software (e.g., IDX-DR, EyeArt) to screen for diabetic retinopathy has been established.

Retinal telescreening is considered experimental for all other indications.

C9254, J3490, J3590

Basic benefit and medical policy

Vimpat (lacosamide)

Effective Oct. 14, 2021, Vimpat (lacosamide) is payable for the following updated FDA-approved indication:

• Adjunctive therapy in the treatment of primary generalized tonic-clonic seizures in patients 1 month of age and older.

Dosing information:

Pediatric patients 1 month of age to less than 17 years: The recommended dosage is based on body weight and is administered orally twice daily.

J0248

Basic benefit and medical policy

Veklury (remdesivir)

Veklury (remdesivir) is payable for the following updated indications, effective Jan. 19, 2022.

Veklury is a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor indicated for the treatment of COVID-19 in adults and pediatric patients (12 years and older and weighing at least 40 kg) with positive results of direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral testing, who are one of the following:

• Hospitalized
• Not hospitalized and have mild-to-moderate COVID-19 and are at high risk for progression to severe COVID-19, including hospitalization or death

J3490

Basic benefit and medical policy

Cortrophin (corticotropin)

Effective Nov. 1, 2021, Cortrophin (corticotropin) is covered for the following FDA-approved indications:

Purified Cortrophin Gel is a porcine-derived purified corticotropin (ACTH) in a sterile solution of gelatin. It’s made up of a complex mixture of ACTH, ACTH-related peptides and other porcine pituitary derived peptides.

Purified Cortrophin Gel is indicated in the following disorders:

• Rheumatic disorders: As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in:
• Psoriatic arthritis
• Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy)
• Ankylosing spondylitis
• Acute gouty arthritis

• Collagen diseases: During an exacerbation or as maintenance therapy in selected cases of:
• Systemic lupus erythematosus
• Systemic dermatomyositis(polymyositis)

• Dermatologic diseases:
• Severe erythema multiforme (Stevens Johnson syndrome)
• Severe psoriasis
• Allergic states:
• Atopic dermatitis
• Serum sickness

• Ophthalmic diseases: Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as:
• Allergic conjunctivitis
• Keratitis
• Iritis and iridocyclitis
• Diffuse posterior uveitis and choroiditis
• Optic neuritis
• Chorioretinitis
• Anterior segment inflammation
• Respiratory diseases:
• Symptomatic sarcoidosis

• Edematous states: To induce a diuresis or a remission of proteinuria in the nephrotic syndrome without uremia of the idiopathic type or that is due to lupus erythematosus.

• Nervous system: Acute exacerbations of multiple sclerosis

Dosage and administration:

• Standard tests for verification of adrenal responsiveness to corticotropin may utilize as much as 80 units as a single injection or one or more injections of a lesser dosage. Verification tests should be performed prior to treatment with corticotropins. The test should utilize the routes of administration proposed for treatment. Following verification dosage should be individualized according to the disease under treatment and the general medical condition of each patient. Frequency and dose of the drug should be determined by considering severity of the disease, plasma and urine corticosteroid levels and the initial response of the patient. Only gradual change in dosage schedules should be attempted after full drug effects have become apparent.
• In the treatment of acute exacerbations of multiple sclerosis, daily intramuscular doses of 80-120 units for two to three weeks.
• The chronic administration of more than 40 units daily may be associated with uncontrollable adverse effects.
• When reduction in dosage is indicated, this should be accomplished gradually by either reducing the amount of each injection or administering injections at longer intervals, or by a combination of both of the above. During reduction of dosage, careful consideration should be given to the disease being treated, the general medical condition of the patient and the duration over which corticotropin was administered.
• This product may be administered subcutaneously or intramuscularly.
• Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

Dosage forms and strengths:

• Purified Cortrophin Gel is supplied sterile in 5 mL multiple-dose vials containing 80 USP units/mL.

Cortrophin (corticotropin) isn’t a benefit for URMBT.

Various

Basic benefit and medical policy

Cosmetic surgery

Reconstructive surgery is an established service when it involves the restoration of a patient to a normal functional status, or when it’s done to repair a defect arising from congenital defects, developmental abnormalities, trauma, infection, involutional defects, tumors or disease. It may be a therapeutic option when indicated.

Cosmetic surgery is performed solely to preserve or enhance appearance or self-esteem. It’s considered not medically necessary.

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

Abdominoplasty/panniculectomy:

• Reconstructive if patient meets policy guidelines. See joint policy “Abdominoplasty.”

Blepharoplasty of lower lids:

• Cosmetic

Blepharoplasty of upper lids:

• Cosmetic when done to improve appearance only.
• Reconstructive if criteria are met. Refer to policy “Blepharoplasty and Repair of Brow Ptosis.”

Breast:

• Cosmetic if done solely to improve appearance
• Reconstructive if done following prophylactic mastectomy in high-risk patients. May also be considered reconstructive following medically necessary mastectomy. This would include reconstruction of the nipple and areolar complex. Reconstruction/revision of the contralateral breast may be necessary to provide symmetry between the breasts.
  

  Note: See medical policy titled “Reconstructive Breast Surgery/Management of Breast Implants” for tattooing the breast/nipple in conjunction with breast reconstruction.

Breast reduction:

• Cosmetic if done to improve appearance in the absence of functional deficits
• Reconstructive if policy guidelines are met. See joint policy titled “Reduction Mammoplasty for Breast-Related Symptoms.”

Chemical peels:

• Cosmetic when done for aging skin (for example, skin damage due to overexposure to sun, etc.), wrinkles, acne scarring or when using chemical peel and hydrating agents that don’t require physician supervision for application
• Reconstructive when guidelines are met:
• Chemical peels performed no more than three to four times in a 12-month period are appropriate as follows:
• Dermal (medium and deep) chemical peels, up to four times per in a 12-month period, used to treat patients with numerous (>10) actinic keratoses or other premalignant skin lesions
• Epidermal (superficial) peels, up to six times in a 12-month period, used to treat active acne in patients who have failed other therapy

Note: Requests for chemical peels should be carefully evaluated to determine if the request is primarily cosmetic in nature. Refer to the joint policy titled “Chemical Peels.”

Cheek (malar) or chin (genioplasty) implants:

• Cosmetic

Correction of telangiectasias or spider veins:

• Cosmetic

Cryotherapy for skin conditions:

• Cosmetic when used to treat acne scarring or other dermatologic conditions in which the primary purpose is to change or improve appearance when there is no specific functional deficit or imminent health risk. Cryotherapy isn’t recommended for the treatment of active acne vulgaris.
• Reconstructive when used to treat actinic keratosis or other pre-cancerous skin lesions

Dermabrasion/microdermabrasion:

• Cosmetic when used for treatment of wrinkling, hyperpigmentation, or acne scarring. Dermabrasion and microdermabrasion aren’t recommended for the treatment of active acne vulgaris.
• Reconstructive when used to treat actinic keratosis or other pre-cancerous skin lesions

Dermal fillers:

• Cosmetic-only used to improve appearance.

Diastasis recti repair absent a true midline hernia:

• Cosmetic

Electrolysis:

• Cosmetic
• Reconstructive if patient meets policy guidelines. Refer to the Transgender Services policy for criteria.

Excision of excessive skin of the thigh, leg, hip, buttock, arm, forearm, hand, submental fat pad or other areas:

• Cosmetic if the primary purpose is to change or improve appearance when there is no specific functional deficit (e.g., interference with ADLs) or imminent health risk (e.g., infection) that can be removed or improved by the procedure
• Reconstructive if done to correct a functional problem including, but not limited to, severe rashes or intertrigo, skin ulceration or pain, etc. that hasn’t responded to conventional medical therapy (e.g., topical antifungals, topical or systemic corticosteroids, or local or systemic antibiotics)

Excision of glabellar frown lines:

• Cosmetic

Fat grafts:

• Cosmetic

Hairplasty for any form of alopecia:

• Cosmetic. Coverage may be available only for the treatment of the underlying condition only.

Insertion or injection of prosthetic material to replace absent adipose tissue:

• Reconstructive only when used to repair a significant deformity from accidental injury, surgery or trauma

Laser resurfacing of the skin:

• Cosmetic when done to treat wrinkling or aging skin, acne scars, telangiectasias or other skin conditions in which the primary purpose is to change or improve appearance when there is no specific functional deficit or imminent health risk. Laser resurfacing isn’t recommended for the treatment of active acne vulgaris.
• Reconstructive when done to treat patients with numerous (>10) actinic keratoses or other premalignant or nonmalignant skin lesions when treatment of the individual lesions would be impractical

Laser resurfacing of burn scars (ablative/non-ablative fractional and micro-fractional CO2 laser resurfacing):

• Reconstructive when used to help correct the abnormal texture and pliability of burn scars

Laser treatment of port wine stains:

• Reconstructive if done due to functional impairment related to the port wine stain (e.g., bleeding).

Liposuction/suction-assisted lipectomy

• Cosmetic if it’s the sole procedure done
• It’s commonly performed on the abdomen (tummy), buttocks (behind), hips, thighs and knees, chin, upper arms, back and calves.
• Long-term effectiveness of treatment of lower extremity lymphedema has not been established.
• Reconstructive if done in conjunction with covered reconstruction surgery. For example, if a covered breast reduction is done by conventional means, there may be a need for minor liposuction to smooth the edges of the incisions.

Otoplasty:

• Cosmetic when done to treat psychological symptomatology or psychosocial complaints related to one’s appearance
• Reconstructive in following circumstances: when done to correct absent or deformed ears due to congenital deformity/absence, trauma or accidental injury.

Pectus excavatum – minimally invasive repair (e.g., Nuss procedure):

• Cosmetic: Criteria below aren’t met
• Reconstructive: Two or more of the following are met:
• Medical history reveals the patient is symptomatic. Symptoms include shortness of breath with exercise, lack of endurance and chest pain.
• Physical exam reveals moderate^a to severe^a pectus excavatum deformity that may be symmetric or asymmetric.
• CT or MRI of the chest indicates severe^a pectus deformity defined by a Haller index greater than 3.2 or correction index greater than 10%, cardiac or pulmonary compression or displacement.
• Pulmonary function studies demonstrate a restrictive or obstructive pattern.
• Cardiology evaluation reveals cardiac compression or displacement, rhythm disturbance, and/or mitral valve prolapse.
• Psycho-social maladjustment.^b

^aHaller index score – Normal is 2 or less. Mild deformity is between 2 and 3.2. Moderate deformity is between 3.2 and 3.5. Severe deformity is greater than 3.5.

^bTwo additional bullets must be applied with this criteria for surgery to be covered.

Poly-L-lactic acid injection (e.g., Sculptra^®):

• Cosmetic for all indications, including HIV lipoatrophy

Reduction of labia majora and minora, or labiaplasty:

• Cosmetic. In situations where there is discomfort from the condition, these symptoms can be managed with personal hygiene and avoidance of form-fitting clothes.

Rhinoplasty:

• Cosmetic if done to improve appearance only.
• Reconstructive if done for repair of nasal deformity due to trauma, accidental injury or chronic condition affecting the nasal structures (e.g., Wegener’s granulomatosis).

Salabrasion (a technique in which salt or a salt solution is used to abrade the skin, e.g., to remove the pigment from a tattoo or permanent makeup):

• Cosmetic

Scar revision:

• Cosmetic if scars are asymptomatic
• Reconstructive for the revision of symptomatic scars

Tattoo removal:

• Cosmetic if done for the removal of decorative tattoos
• Reconstructive if done for the removal of hyperpigmentation resulting from trauma, surgery or other procedures

Testicular prostheses:

• Reconstructive for replacement of congenitally absent testes, or testes lost due to disease, injury or surgery.

Vaginal rejuventation/vulvovaginal atrophy:

• Cosmetic
• Includes use of energy-based devices (e.g., laser, radiofrequency thermal treatment)

Varicose veins:

• Cosmetic
• Reconstructive if patients met policy guidelines. Refer to Echoscleortherapy for the Treatment of Varicose Veins and/or Endovenous Ablation for the Treatment of Varicose Veins (e.g., ClariVein^®, VenaSeal™, Closure System)

Voice-lifting procedures (e.g., Restylane injections):

• Cosmetic. Implants or injections of fat or collagen are used to bring vocal cords closer together or to plump cords in an attempt to restore elasticity of vocal cords and reinstate a youthful quality to the patient’s voice.

81327, 81479,** 0163U **Used to report not otherwise classified service

Basic benefit and medical policy

Serologic genetic and molecular screening for colorectal cancer

The effectiveness and clinical utility of serologic genetic (i.e., SEPT9 methylated DNA testing [ColoVantage^®, Epi proColon^®]) or molecular screening for colorectal cancers (i.e., gene expression profiling [ColonSentry^®, BeScreened™-CRC, FirstSight™]) haven’t been demonstrated. There is insufficient scientific evidence of the analytical and clinical validity, as well as clinical utility of these tests on patient management and outcomes. They are therefore considered experimental, effective May 1, 2022.