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September 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 |
0483T, 0484T
Additional covered codes:
33418, 33419, 0345T
Experimental codes:
0543T, 0544T |
Basic benefit and medical policy
Transcatheter mitral valve procedures
The safety and effectiveness of transcatheter mitral valve repair (e.g., MitraClip®) have been established and may be considered a useful option when performed via the devices when FDA-approved labeling and specified criteria are met.
The safety and effectiveness of transcatheter mitral valve implantation (replacement) (e.g., Edwards Sapien 3 Transcatheter Heart Valve®, Sapien 3 Ultra Transcatheter Heart Valve®) have been established and may be considered a useful option when performed via the devices when FDA-approved labeling and specified criteria are met. Coverage is effective May 1, 2022.
The safety and efficacy of transcatheter implantable mitral valve annulus reshaping devices for the treatment of mitral valve regurgitation are under clinical trial evaluation. Therefore, this service is considered experimental.
Payment policy:
Payable in inpatient, outpatient and ambulatory surgery center locations
Inclusions:
Mitraclip® is indicated when all the following criteria are met:
- Significant symptomatic mitral regurgitation (MR ≥ 3+) due to one of the following:
- Primary abnormality of the mitral apparatus (degenerative MR)
- Heart failure and secondary mitral regurgitation despite the use of maximally tolerated guideline-directed medical therapy
- Patients who have been determined to be at prohibitive risk for open mitral valve surgery by a heart team, which includes a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease
- Existing comorbidities wouldn’t preclude the expected benefit from reduction of the mitral regurgitation
Percutaneous transcatheter mitral valve-in-valve implantation (replacement) using an FDA-approved device (e.g., Edwards Sapien 3 Transcatheter Heart Valve System, Sapien 3 Ultra Transcatheter Heart Valve System) when all the following are met:
- Symptomatic heart disease due to failure (stenosed, insufficient, or combined) of a surgical bioprosthetic mitral valve or a prosthetic ring from a prior repair
- Determination by a heart team, including a cardiac surgeon, that the individual is at high or greater risk for open surgical therapy (i.e., predicted risk of surgical mortality greater than or equal to 8% at 30 days, based on the Society of Thoracic Surgeons risk score and other clinical co-morbidities)
Exclusions:
- Transcatheter mitral valve repair or transcatheter mitral valve-in-valve implantation (replacement) procedures when one of the following apply:
- Patients who can’t tolerate procedural anticoagulation or post procedural antiplatelet regimen
- Active endocarditis of the mitral valve
- Rheumatic mitral valve disease
- Evidence of intracardiac, inferior vena cava, or IVC, or femoral venous thrombus
- The individual is an appropriate candidate for the standard, open surgical approach but has refused
- Transcatheter mitral valve annulus reshaping devices
- Non-FDA approved systems or approaches including Permavalve™ system
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S8042 |
Basic benefit and medical policy
Low-field magnetic resonance imaging
Low-field magnetic resonance imaging is considered established in specific clinical situations, effective Jan. 1, 2022.
Payment policy:
Subject to the PPO Radiology Management Program specialty privileging where applicable. Not payable in an ambulatory surgical facility.
Inclusions:
Low-field magnetic resonance imaging may be considered established when both of the following criteria are met:
- The patient meets criteria for a magnetic resonance imaging test.
- The health care provider determines low-field MRI is clinically appropriate.
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| POLICY CLARIFICATIONS |
1111F |
Basic benefit and medical policy
1111F is non-payable
Procedure code 1111F is changing from payable to non-payable. This change is effective July 1, 2022. |
37242 |
Basic benefit and medical policy
Prostatic arterial embolization
Prostatic arterial embolization for benign prostatic hyperplasia is experimental. There is insufficient scientific evidence in the current medical literature regarding the safety and efficacy of this technology or that it improves health outcomes. The policy is effective May 1, 2022.
Payment policy:
Diagnoses N40.0, N40.1, N40.2 and N40.3 aren’t covered. |
80503
80504
80505
80506 |
Basic benefit and medical policy
Codes added to Physician Office Laboratory List
The procedure codes listed were added to the Physician Office Laboratory List. They can be performed in a physician’s office. |
B4185 |
Basic benefit and medical policy
SMOFlipid (lipid injectable emulsion)
Effective March 22, 2022, SMOFlipid (lipid injectable emulsion) is covered for the following updated FDA-approved indications:
SMOFlipid is indicated in adult and pediatric patients, including term and preterm neonates, as a source of calories and essential fatty acids for parenteral nutrition when oral or enteral nutrition isn’t possible, insufficient or contraindicated.
Dosing information:
The recommended daily dosage in pediatric patients is:
Pediatric age group: Birth to 2 years (including preterm and term neonates)
Initial dose: 0.5 to 1 g/kg/day. Increase the dose by 0.5 to 1 g/kg/day
Maximum dose: 3 g/kg/day
Duration of infusion: 20 to 24 hours for preterm and term neonates. 12 to 24 hours for patients 1 month to 2 years
Pediatric age group: 2 to <12 years of age
Initial dose: 1 to 2 g/kg/day. Increase the dose by 0.5 to 1 g/kg/day
Maximum dose: 3 g/kg/day
Duration of infusion: 12 to 24 hours
Pediatric age group: 12 to 17 years of age
Initial dose: 1 to 2 g/kg/day
Maximum dose: 2.5 g/kg/day
Duration of infusion: 12 to 24 hours |
J0129 |
Basic benefit and medical policy
Orencia (abatacept)
Effective Dec. 15, 2021, Orencia (abatacept) is payable for the following updated FDA-approved indications:
The prophylaxis of acute graft versus host disease, known as aGVHD, in combination with a calcineurin inhibitor and methotrexate, in adults and pediatric patients ages 2 and older undergoing hematopoietic stem cell transplantation, or HSCT, from a matched or one allele-mismatched unrelated donor
Dosing information:
Intravenous use for prophylaxis of aGVHD:
- For patients 6 years and older, administer at a 10 mg/kg dose (maximum dose 1,000 mg) as a 60-minute infusion on the day before transplantation, followed by a dose on Day 5, 14 and 28 after transplant.
For patients 2 to less than 6 years old, administer a 15 mg/kg dose as a 60-minute infusion on the day before transplantation, followed by a 12 mg/kg dose as a 60-minute infusion on Day 5, 14 and 28 after transplant. |
J0695
|
Basic benefit and medical policy
Zerbaxa (ceftolozane and tazobactam)
Zerbaxa (ceftolozane and tazobactam) is payable for the following updated indications, effective April 21, 2022:
- Complicated intra-abdominal infections, or cIAI, used in combination with metronidazole, in adult and pediatric patients (birth to less than 18 years old).
- Complicated urinary tract infections, or cUTI, including pyelonephritis, in adult and pediatric patients (birth to less than 18 years old).
Recommended dosage of Zerbaxa by infection in pediatric patients (birth to less than 18 years of age) with estimated glomerular filtration rate, or eGFR,+ greater than 50 mL/min/1.73 m2.
Infection: Complicated intra-abdominal infections
Dose: 30 mg/kg maximum dose of 1.5g**
Duration of treatment: 5 to 14 days
Infection: Complicated urinary tract infections, including pyelonephritis
Dose: 30 mg/kg up to a maximum dose of 1.5 g**
Duration of treatment: 7 to 14 days
+Estimated GFR using an age-appropriate equation for use in the pediatric population
**Pediatric patients weighing greater than 50 kg should not exceed a maximum dose of 1.5g.
Note: For the treatment of cIAI, Zerbaxa should be used in conjunction with metronidazole. |
J2182 |
Basic benefit and medical policy
Nucala (mepolizumab)
Effective July 29, 2021, Nucala (mepolizumab) is payable for the following updated FDA-approved indications:
Add-on maintenance treatment of adult patients ages 18 and older with chronic rhinosinusitis with nasal polyps, or CRSwNP
Dosing information:
CRSwNP: 100 mg administered subcutaneously once every four weeks |
J9246 |
Basic benefit and medical policy
Evomela (melphalan)
Effective Aug. 9, 2021, Evomela (melphalan) is no longer payable for the following usage:
Evomela is no longer indicated for the palliative treatment of patients with multiple myeloma for whom oral therapy is not appropriate based on FDA guidelines. |
J9318 |
Basic benefit and medical policy
Romidepsin
Romidepsin is no longer FDA approved for the following indication:
Treatment of peripheral T-cell lymphoma, or PTCL, in adult patients who have received at least one prior therapy |
Q2041 |
Basic benefit and medical policy
Yescarta (axicabtagene ciloleucel)
Effective April 5, 2022, Yescarta (axicabtagene ciloleucel) is payable for the following updated FDA-approved indications:
Yescarta is a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of adult patients with large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy. |
Q5107 |
Basic benefit and medical policy
Mvasi (bevacizumab-awwb)
Effective Nov. 15, 2021, Mvasi (bevacizumab-awwb) is covered for the following updated FDA-approved indications:
- Epithelial ovarian, fallopian tube or primary peritoneal cancer:
- In combination with carboplatin and paclitaxel, followed by Mvasi as a single agent, for stage III or IV disease following initial surgical resection
- In combination with paclitaxel, pegylated liposomal doxorubicin or topotecan for platinum-resistant recurrent disease who received no more than two prior chemotherapy regimens
- In combination with carboplatin and paclitaxel or carboplatin and gemcitabine, followed by Mvasi as a single agent, for platinum-sensitive recurrent disease
Dosing information:
Stage III or IV epithelial ovarian, fallopian tube or primary peritoneal cancer following initial surgical resection:
- 15 mg/kg every three weeks with carboplatin and paclitaxel for up to six cycles, followed by 15 mg/kg every three weeks as a single agent, for a total of up to 22 cycles
Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer:
- 10 mg/kg every two weeks with paclitaxel, pegylated liposomal doxorubicin or topotecan given every week
- 15 mg/kg every three weeks with topotecan given every three weeks
Platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer:
- 15 mg/kg every three weeks with carboplatin and paclitaxel for six to eight cycles, followed by 15 mg/kg every three weeks as a single agent
- 15 mg/kg every three weeks with carboplatin and gemcitabine for six to 10 cycles, followed by 15 mg/kg every three weeks as a single agent
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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. |
