|
November 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
|
| UPDATES TO PAYABLE PROCEDURES |
J9299 |
Basic benefit and medical policy
Opdivo (nivolumab)
Effective March 4, 2022, Opdivo (nivolumab), procedure code J9299, is covered for the following updated FDA-approved indication:
Adult patients with resectable (tumors ≥4 cm or node positive) non-small cell lung cancer in the neoadjuvant setting, in combination with platinum-double chemotherapy.
Dosage and administration:
360 mg with platinum-doublet chemotherapy on the same day every three weeks for three cycles |
| POLICY CLARIFICATIONS |
29914, 29915, 29916, 27299**
**Unlisted procedure may also represent experimental/non-covered service per policy criteria |
Basic benefit and medical policy
Surgical treatment of FAI
Open or arthroscopic treatment of femoroacetabular impingement has been established in specified situations.
Inclusionary and exclusionary criteria have been updated, effective Sept. 1, 2022.
Inclusions:
Open or arthroscopic treatment of femoroacetabular impingement may be appropriate when all of the following conditions have been met:
Age
- 15 years of age and older
Surgical candidates should be skeletally mature with documented closure of growth plates and not candidates for hip replacement.
Symptoms (all the following)
- Significant hip pain worsened by flexion activities (e.g., squatting or prolonged sitting) that limits daily activities for at least six months
- Unresponsive to conservative (non-operative) treatment for at least three months (including activity modifications, restriction of athletic pursuits, avoidance of symptomatic motion, etc.)
- Positive impingement sign on clinical examination (pain elicited with 90 degrees of flexion, adduction and internal rotation of the femur – FADIR test; or with 90 degrees of flexion, abduction and external rotation – FABER test).
Imaging evidence
- Impingement, as follows:
- Cam impingement confirmed by:
- Alpha angle of > 50 degrees, or
- Pincer impingement confirmed by:
- Center edge angle > 39 degrees
- Positive cross-over sign
- Acetabular retroversion or over-coverage
- Coxa profunda
- Minimal degeneration of the hip (Tonnis grade 1 or less), absence of joint space narrowing on weight-bearing X-rays and minimal cartilage injury (Outerbridge grade II or less)
Exclusions:
- Evidence of advanced osteoarthritis (i.e., Tonnis grade 2 or 3, or joint space of less than 2 mm)
- Evidence of advanced chondral damage (Outerbridge grade III or IV)
Treatment of femoroacetabular impingement is considered experimental in all other situations.
The use of capsular plication for the treatment of femoroacetabular impingement is considered experimental. |
61736, 61737 |
Basic benefit and medical policy
Laser interstitial therapy for neurological conditions
Laser interstitial thermal therapy is considered established for the treatment of epilepsy in patients who meet the selection criteria.
Laser interstitial thermal therapy is considered experimental for all other neurological conditions including, but not limited to, brain tumors and radiation necrosis of the brain, due to insufficient evidence of its effectiveness in the medical literature.
Procedure codes *61736 and *61737 added as payable for all groups, effective May 1, 2022.
Inclusions:
Laser interstitial thermal therapy, or LITT, is considered established in the treatment of refractory epilepsy when all the following criteria are met:
- There is documentation of disabling seizures** despite use of two or more antiepileptic drug regimens*** (i.e., medication-refractory epilepsy).
- There are well-defined epileptogenic foci accessible by LITT.
- A multidisciplinary team of physicians that includes at least two specialties (e.g., neurology, neurosurgery), after considering all possible treatments, agrees that LITT is the best treatment option for the patient.
**Disabling seizures can be defined as seizures that result in impairment or a loss of functional status.
***Antiepileptic drug regimens are defined as two tolerated and appropriately chosen and used antiepileptic drug schedules (as monotherapies or in combination) to achieve sustained seizure freedom.
Exclusions:
Laser interstitial thermal therapy for epilepsy that doesn’t meet the above criteria.
Laser interstitial thermal therapy is considered experimental for all other neurological conditions, including, but not limited to, brain tumors and radiation necrosis of the brain. |
C9399
J3490
J3590 |
Basic benefit and medical policy
Lanreotide SC (lanreotide)
Effective Dec. 17, 2021, Lanreotide SC (lanreotide) is covered for the following FDA-approved indications:
Lanreotide injection is a somatostatin analog indicated for:
- The long-term treatment of acromegalic patients who have had an inadequate response to or can’t be treated with surgery or radiotherapy
- The treatment of adult patients with unresectable, well- or moderately differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors, or GEP-NETs, to improve progression-free survival
Dosage and administration:
Administration:
- For deep subcutaneous injection only
- Intended for administration by a health care provider
- Administer in the superior external quadrant of the buttock
- Alternate injection sites
Recommended dosage:
- Acromegaly: 90 mg every four weeks for three months. Adjust thereafter based on GH and/or IGF-1 levels. See full prescribing information for titration regimen.
- GEP-NETs: 120 mg every four weeks
Dosage forms and strengths:
Injection: 60 mg/0.2 mL, 90 mg/0.3 mL and 120 mg/0.5 mL of Lanreotide in single-dose prefilled syringes |
J2506 |
Basic benefit and medical policy
Neulasta (pegfilgrastim)
Neulasta (pegfilgrastim) is payable for the following FDA-approved indications:
- Agranulocytosis secondary to cancer chemotherapy
- Encounter for antineoplastic chemotherapy
- Malignant neoplasm of the bilateral ovaries
|
J3490
J3590 |
Basic benefit and medical policy
Amvuttra (vutrisiran)
Effective June 13, 2022, Amvuttra (vutrisiran) is covered for the following FDA-approved indications:
Amvuttra (vutrisiran) is a transthyretin-directed small interfering RNA indicated for the treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults.
Dosage and administration:
- The recommended dosage of Amvuttra (vutrisiran) is 25 mg administered by subcutaneous injection once every three months.
- Amvuttra (vutrisiran) is for subcutaneous use only and should be administered by a health care professional.
Dosage forms and strengths
Injection: 25 mg/0.5 mL in a single-dose prefilled syringe
Amvuttra (vutrisiran) isn’t a benefit for URMBT. |
J3490
J3590 |
Basic benefit and medical policy
Skyrizi (risankizumab-rzaa)
Effective June 16, 2022, Skyrizi (risankizumab-rzaa) is payable for the following new indication:
Skyrizi (risankizumab-rzaa) is an interleukin-23 antagonist indicated for the treatment of moderately to severely active Crohn's disease in adults.
Dosage and administration:
Crohn’s disease:
- Obtain liver enzymes and bilirubin levels prior to initiating treatment with Skyrizi.
The recommended induction dosage is 600 mg administered by intravenous infusion over at least one hour at Week 0, Week 4 and Week 8. The recommended maintenance dosage is 360 mg administered by subcutaneous injection at Week 12 and every eight weeks thereafter. |
J7599 |
Basic benefit and medical policy
Cellcept (mycophenolate mofetil)
Cellcept (mycophenolate mofetil) is payable for the following updated indications, effective June 6, 2022.
- Cellcept is an antimetabolite immunosuppressant indicated for the prophylaxis of organ rejection in adult and pediatric recipients 3 months of age and older of allogeneic kidney, heart or liver transplants, in combination with other immunosuppressants.
Dosage and administration:
Pediatrics
Kidney transplant: 600 mg/m2 orally twice daily, up to maximum of 2 g daily
Heart transplant: 600 mg/m2 orally twice daily (starting dose) up to a maximum of 900 mg/m2 twice daily (3 g or 15 mL of oral suspension)
Liver transplant: 600 mg/m2 orally twice daily (starting dose) up to a maximum of 900 mg/m2 twice daily (3 g or 15 mL of oral suspension) |
J9025 |
Basic benefit and medical policy
Vidaza (azacitidine)
Vidaza (azacitidine) is payable for the following updated indications, effective May 20, 2022:
Pediatric patients age 1 month and older with newly diagnosed juvenile myelomonocytic leukemia. |
J9228 |
Basic benefit and medical policy
Yervoy (ipilimumab)
Yervoy (ipilimumab) is covered for the following updated FDA-approved indications:
Renal cell carcinoma
Treatment of patients with intermediate or poor risk, previously untreated advanced renal cell carcinoma, in combination with nivolumab
Dosing information:
Advanced renal cell carcinoma: Yervoy 1 mg/kg immediately following nivolumab 3 mg/kg on the same day, every three weeks for four doses. After completing four doses of the combination, administer nivolumab as a single agent. |
J9299 |
Basic benefit and medical policy
Opdivo (nivolumab)
Opdivo (nivolumab) has been approved for the following updated indications, effective May 27, 2022.
Patients with unresectable advanced or metastatic esophageal squamous cell carcinoma as first-line treatment in combination with fluoropyrimidine- and platinum-containing chemotherapy
Patients with unresectable advanced or metastatic esophageal squamous cell carcinoma as first-line treatment in combination with ipilimumab |
Q5123 |
Basic benefit and medical policy
Riabni (rituximab-arrx)
Effective June 3, 2022, Riabni (rituximab-arrx) is payable for the following updated FDA-approved indications:
Riabni is a CD20-directed cytolytic antibody indicated for the treatment of:
- Rheumatoid arthritis in combination with methotrexate in adult patients with moderately to severely active RA who have inadequate response to one or more TNF antagonist therapies
Dosing information:
The dose for RA in combination with methotrexate is two 1,000 mg intravenous infusions separated by two weeks (one course) every 24 weeks or based on clinical evaluation, but not sooner than every 16 weeks. Methylprednisolone 100 mg intravenous or equivalent glucocorticoid is recommended 30 minutes prior to each infusion. |
| EXPERIMENTAL PROCEDURES |
97039,** 97139,** 97799**)
**Not otherwise classified procedures used to report service |
Basic benefit and medical policy
Alternative physical therapy modalities
IntraDiscNutrosis® was added as an experimental, non-covered service, effective Sept. 1, 2022. |
None of the information included in this billing chart is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations. |
