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February 2023

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

0245U

Basic benefit and medical policy

Molecular markers in fine needle aspirates of the thyroid

Procedure code *0245U is payable when criteria are met, effective June 1, 2022.

Inclusions:

The use of any of the following types of molecular marker testing or gene variant analysis in fine needle aspirates of thyroid nodules with indeterminate findings (Bethesda diagnostic category III [atypia/follicular lesion of undetermined significance] or Bethesda diagnostic category IV [follicular neoplasm/suspicion for a follicular neoplasm]) or suspicious findings (Bethesda diagnostic category V [suspicious for malignancy]) to rule in malignancy to guide surgical planning for initial resection rather than a two-stage surgical biopsy followed by definitive surgery may be considered established:

  • ThyroSeq®
  • ThyraMIR microRNA®/ThyGeNEXT®
  • Afirma BRAF® after Afirma Genomic Sequencing Classifier
  • Afirma MTC® after Afirma Genomic Sequencing Classifier

75571, S8092

Basic benefit and medical policy

CT to detect coronary artery calcification

Computed tomography for the detection of coronary artery calcification is considered established when criteria are met.

Payment policy:
 
May be subject to pre-authorization through the PPO Radiology Management Program. Check member benefits.

Payable effective Sept. 1, 2022.

Inclusions:

Coronary artery calcium, or CAC, testing is considered established to assist with decisions regarding management of hypercholesterolemia when all the following apply:

  • No known atheromatous vascular disease
  • Not diabetic
  • Age ≥ 40 years and ≤ 75 years
  • Low-density lipoprotein cholesterol ≥ 70 mg/dL and ≤ 190 mg/dL
  • 10-year risk (using atherosclerotic cardiovascular disease Pooled Cohort Equations) ≥ 5% and ≤ 20%

Exclusions:

Any of the following:

  • Family history of premature atherosclerotic cardiovascular disease
  • Persistently elevated low-density lipoprotein (≥ 160 mg/dL)
  • Persistently elevated triglyceride (> 175mg/dL)
  • Metabolic syndrome
  • Chronic kidney disease (eGFR 15-59 mL/min/1.73 m2)
  • Chronic inflammatory condition
  • History of menopause before age 40 years
  • History of preeclampsia
  • High risk race/ethnicity (for example, South Asian ancestry)
  • Markers associated with increased risk of atherosclerotic cardiovascular disease (if measured):
    • Elevated high-sensitivity C-reactive protein (≥ 2.0 mg/L)
    • Elevated lipoprotein(a) (> 50mg/dL)
    • Apolipoprotein B > 130mg/dL
    • Ankle-brachial index less than 0.9

81513, 81514      

Basic benefit and medical policy

Procedure codes *81513 and *81514

Procedure codes *81513 and *81514 are payable effective June 1, 2022.

Payment policy:

Not payable in an office location

Modifiers 26 and TC don’t apply to this procedure.

89337, 89346, 89356      

Other covered procedures:
58679,** 58825, 58970, 58974, 76948, 89250, 89254, 89258, 89259, 89268, 89337, 89342, 89343, 89346, 89352, 89353, 89356

**Unlisted procedure used to report transposition of ovary

Basic benefit and medical policy

Infertility related to cancer treatment

Preservation of fertility (including procurement of oocytes and spermatozoa; cryopreservation, storage and thawing of embryos, oocytes and spermatozoa) may be considered established for individuals diagnosed with cancer and facing treatment-related infertility, when criteria are met. This policy is effective July 1, 2022.

Note: This policy doesn’t cover further assisted reproductive techniques, or ART, procedures. Infertility treatment and ART benefits would have to be included in the member’s contract.

Basic benefit policy group variations:

  • The member must have coverage on the date that services are performed.
  • Benefit documents may exclude cryopreservation, storage or thawing of embryos, oocytes or spermatozoa.
  • Benefit documents may allow fertility preservation for indications other than cancer treatment; indications other than cancer treatment are not discussed in this policy.
  • For medications that may be used during the fertility preservation process, the individual’s prescription drug benefit should be referenced.

Payment policy:

All codes must be billed with a malignant diagnosis if criteria below are met.

Modifiers 26 and TC don’t apply to *89337, *89346 and *89356.     

Inclusions:

Preservation of fertility may be considered established when both criteria are met:

  • A post-pubertal biological female, through 39 years of age; or a post-pubertal biological female, 40 years of age through 43 years of age, with no diminished ovarian reserve; or a post-pubertal biological male
  • The individual is diagnosed with cancer, and the cancer treatment will result in irreversible infertility, such as with:
    • Gonadotoxic chemotherapy
    • Radiation therapy of the pelvis, lower abdomen or total body
    • Surgical removal of ovaries or testicles (testes)

Procedures that may be considered established in fertility preservation:

  • Procurement of mature oocytes and spermatozoa
  • Cryopreservation of embryos, mature oocytes and spermatozoa
  • Storage of embryos, mature oocytes and spermatozoa for up to one year
  • Thawing of embryos, mature oocytes and spermatozoa within one year of the procurement
  • Culture of oocytes
  • Ovarian transposition (in anticipation of pelvic or lower abdominal radiation)
  • Embryo transfer, back to the member, within one year from cryopreservation

Exclusions:

  • Storage of sperm, oocytes or embryos for longer than one year
  • Co-culture of embryo or embryos
  • Post-menopausal females
  • Individuals who have undergone elective sterilization (vasectomy, tubal sterilization), with or without reversal
  • Request for fertility preservation that doesn’t meet inclusion criteria
  • Other assisted reproductive techniques, unless the member has additional benefit coverage for these services

95836   

Additional covered procedures:
61850, 61860, 61863, 61864, 61880,
61885, 61888, 95970, 95971, L8680

L8686, L8688

Basic benefit and medical policy

Responsive neurostimulation for refractive epilepsy

Responsive neurostimulation is considered established for patients with focal epilepsy. It’s considered established when medical criteria are met. 

Procedure code *95836 was added as a covered procedure, effective Sept. 1, 2022.

Payment policy:

This procedure isn’t payable to a facility.

Inclusions:

  • Responsive neurostimulation may be considered established for patients with focal epilepsy who meet all the following criteria:
    • Are 18 years or older
    • Have a diagnosis of focal seizures with 1 or 2 well-localized seizure foci identified
    • Have an average of three or more disabling seizures (for example, motor focal seizures, complex focal seizures or secondary generalized seizures) per month over the prior three months
    • Are refractory to medical therapy (have failed ≥2 appropriate antiepileptic medications at therapeutic doses)
    • Aren’t candidates for focal resective epilepsy surgery (for example, have an epileptic focus near the eloquent cerebral cortex; have bilateral temporal epilepsy)
    • Don’t have contraindications for responsive neurostimulation device placement** 
  • The replacement or revision of the neurostimulator, battery, leads and monitor is considered established for an individual who meets all the above criteria, and the existing neurostimulator/lead/monitor is no longer under warranty and cannot be repaired.

Exclusions:

  • Responsive neurostimulation is considered experimental for all other indications.

**Contraindications for responsive neurostimulation device placement include three or more specific seizure foci, presence of primary generalized epilepsy, or presence of a rapidly progressive neurologic disorder.

POLICY CLARIFICATIONS

0440T, 0441T, 0442T, 64624, 64640

Basic benefit and medical policy

Cryoablation of peripheral nerves

Cryoablation for the treatment of peripheral neuropathy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Cryoneurolysis of peripheral nerves to treat pain associated with knee osteoarthritis or total knee arthroplasty is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Cryoneurolysis of peripheral nerves to treat pain associated with cervicogenic headache is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Cryoablation/cryoneurolysis of peripheral nerves to treat pain is experimental in all other conditions with the exception of facet joint pain. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

The medical policy statement has been updated, effective Jan. 1, 2023.

Inclusionary and exclusionary criteria:

Not applicable

11976, 11981, 11982, 11983, 55250,
57170, 58300, 58301, 58600, 58605,  
58611, 58615, 58661, 58670, 58671,

58700

    

Basic benefit and medical policy

Contraception and voluntary sterilization

Various contraceptive and sterilization methods are established for the prevention of unintended pregnancy. They may be a useful option when covered by the member’s certificate.

Inclusionary language has been modified, effective Jan. 1, 2023.

Note: Contraceptive or sterilization coverage is based on the member’s certificate benefits. These services may not be covered on all certificates.

Inclusions:

  • FDA-approved contraceptive drugs or devices, prescribed by a qualified health care provider
  • Vasectomy performed in the office setting
  • Sterilization procedures in individuals with a uterus

Exclusions:

  • Contraceptive drugs or devices that aren’t FDA approved
  • Vasectomy in an outpatient facility

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

Experimental
21089,** 21299,** E1399,** J7321, J7323, J7324, J7325, J7326

**Unlisted procedure code

Basic benefit and medical policy

Temporomandibular joint disorder

Certain tests, non-surgical and surgical procedures are considered safe and effective for the diagnosis and therapeutic treatment of temporomandibular joint disorders. They may be considered useful therapeutic options when indicated.

Inclusionary and exclusionary criteria have been updated, effective Jan. 1, 2023.

Inclusions:

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

  • Diagnostic X-ray, tomograms and arthrograms
  • Medical grade computed tomography scan or magnetic resonance imaging (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 (in other words, anti-inflammatory, muscle relaxing and analgesic medications)
  • Trigger point therapy with anesthetic and/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 (for example, 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 that objectively demonstrate (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease 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 and/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** and/or TMJ dysfunction:

  • Electromyography, 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 any indication not listed above
  • Use of any medication not listed above (for example, botulinum toxin, methylprednisolone)
  • 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 (for example, dental appliance that is intended to treat malocclusion by tooth and support structure movement)
  • Dental restorations, prosthesis, treatment and appliances**
  • Transcutaneous electrical nerve stimulation, or TENS
  • Percutaneous electrical nerve stimulation, PENS
  • Acupuncture
  • Platelet concentrates
  • Dextrose prolotherapy

**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.

38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, S2140, S2142, S2150

Experimental

0337U

    

Basic benefit and medical policy

BMT: Hematopoietic cell transplantation for plasma cell dyscrasias

The safety and efficacy of specified bone marrow/hematopoietic cell transplants for plasma cell dyscrasias, including multiple myeloma and POEMS syndrome, have been established. They may be considered useful therapeutic options for patients meeting patient selection criteria.

Inclusionary criteria have been updated effective Jan. 1, 2023.

Inclusions:

The following hematopoietic cell transplantations for multiple myeloma are considered established:

  • Single or second (salvage – refers to treatments used after a condition hasn’t responded to standard therapy) autologous hematopoietic cell transplantation
  • Tandem transplant with or without maintenance therapy can be considered for any of the following:
    • All patients who are candidates for hematopoietic cell transplantation
    • Patients who don’t achieve at least a very good partial response, or VGPR, after the first autologous hematopoietic cell transplantation. A very good partial response, as defined by the International Myeloma Working Group is a serum and urine M-protein detectable by immunofixation but not on electrophoresis or ≥90% reduction in serum M-protein plus urine M-protein level < 100 mg per 24 hr.  (Revised based on the new criteria by IMWG).
    • Patients with high-risk features
  • Tandem transplantation with an initial round of autologous hematopoietic cell transplantation followed by a non-marrow-ablative conditioning regimen and allogeneic hematopoietic cell transplantation for the treatment of newly diagnosed multiple myeloma patients
  • Myeloablative or nonmyeloablative allogeneic hematopoietic cell transplant is an acceptable option in patients with responsive or primary progressive disease as salvage therapy when these patients have undergone a prior autologous hematopoietic cell transplant

Exclusions:

  • Allogeneic hematopoietic cell transplantation, myeloablative or nonmyeloablative, as initial therapy of newly diagnosed multiple myeloma is considered experimental.
  • More than two tandem transplants, two single transplants or a single and a tandem transplant per patient for the same condition
  • The routine harvesting or storage of an individual’s umbilical cord blood for possible use at some unspecified time in the future

POEMS syndrome

Inclusions:

Autologous hematopoietic cell transplantation to treat disseminated POEMS syndrome

Exclusions:

Allogeneic and tandem hematopoietic cell transplantation to treat POEMS syndrome

65756, 65757

Experimental:
66999**

**Not otherwise classified code

Basic benefit and medical policy

Endothelial keratoplasty

Endothelial keratoplasty for the treatment of endothelial dysfunction is established. It may be considered a useful treatment option for selected indications, effective Jan. 1, 2023.

The femtosecond laser, and femtosecond and excimer laser, for use in endothelial disease of the cornea is experimental. Further studies are needed to evaluate the clinical utility and long-term health implications of this technology.

Inclusions:

Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty, Descemet membrane endothelial keratoplasty or Descemet membrane automated endothelial keratoplasty may be medically necessary for the treatment of endothelial dysfunction including:

  • Ruptures in Descemet membrane
  • Endothelial dystrophy
  • Aphakic and pseudophakic bullous keratopathy
  • Iridocorneal endothelial syndrome
  • Corneal edema attributed to endothelial failure
  • Failure or rejection of a previous corneal transplant
  • Anterior corneal disease when endothelial disease is the primary cause of the decrease in vision

Exclusions:

  • Endothelial keratoplasty when endothelial dysfunction isn’t the primary cause of decreased corneal clarity
  • Endothelial keratoplasty used in place of penetrating keratoplasty for conditions with concurrent endothelial disease and anterior corneal disease, including any of the following:
    • Concurrent anterior corneal dystrophies
    • Anterior corneal scars from trauma or prior infection
    • Ectasia after previous laser vision correction surgery
  • Femtosecond laser-assisted endothelial keratoplasty

Femtosecond and excimer laser-assisted endothelial keratoplasty

66179, 66180, 66183, 66184, 66185

Experimental:

66999, 0253T

    

Basic benefit and medical policy

Aqueous shunts and stents

The safety and effectiveness of the insertion of U.S. FDA-approved aqueous shunts and stents have been established. They are useful therapeutic options for reducing intraocular pressure in individuals with glaucoma in whom medical therapy has failed to adequately control intraocular pressure.

Insertion of ab externo aqueous shunts approved by the FDA is established as a method to reduce intraocular pressure in individuals with glaucoma in whom medical therapy has failed to adequately control intraocular pressure.

Use of an ab externo aqueous shunt for all other conditions, including in individuals with glaucoma when intraocular pressure is adequately controlled by medications, is considered experimental.

Insertion of ab interno aqueous stents approved by the FDA as a method to reduce intraocular pressure in individuals with glaucoma in whom medical therapy has failed to adequately control intraocular pressure, is considered established.

Implantation of one or two FDA-approved microstents in conjunction with cataract surgery may be considered established in individuals with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication.

The use of ab interno stents for all other conditions is considered experimental.

Inclusionary and exclusionary critertia have been updated, effective Jan. 1, 2023.

Inclusions:

Insertion of FDA-approved aqueous shunts is considered established as a method to reduce intraocular pressure in patients with mild to moderate open-angle glaucoma when conventional pharmacologic treatments have failed to control intraocular pressure adequately. 

Currently available FDA-approved shunts include:
•           Ahmed™ glaucoma implant
•           Baerveldt® seton
•           Ex-PRESS® mini glaucoma shunt
•           Glaucoma pressure regulator
•           Krupin-Denver valve implant
•           Molteno® implant
•           Schocket shunt
•           Xen Gel Stent
•           CyPass® Micro-Stent (recalled)a
•           iStent®a
•           iStent inject®ab
•           Hydrus™a

aThese stents are indicated for use in conjunction with cataract surgery for the reduction of IOP in adult patients with mild to moderate primary open-angle glaucoma.
abThe iStent Inject® comes pre-loaded with two stents.

Exclusions:

  • The use of an aqueous shunt for all other conditions, including patients with glaucoma when intraocular pressure is controlled by medications
  • Insertion of aqueous shunts that aren’t FDA approved
  • For the Trabecular Micro-Bypass iStent and the iStent Inject, patients with the following conditions aren’t appropriate candidates and the insertion of this stent would be considered experimental:
    • Quick or sudden increase in eye pressure
    • Inflammation of the eye tissue (uvea)
    • Neovascular glaucoma
    • Noticeable birth irregularities on the front of the eye
    • Orbital tumor
    • Thyroid eye disease
    • Sturge-Weber syndrome
    • Any other type of condition that may cause elevated pressure in the veins of the eye
  • For the Hydrus Microstent, patients with the following conditions aren’t appropriate candidates and the insertion of this stent would be considered experimental:
    • When the colored part of the eye (iris) is pushed up against the drainage pathway or when other material blocks the drainage pathway
    • Traumatic glaucoma, malignant glaucoma or inflammation of the eye tissue
    • Glaucoma associated with the growth of abnormal blood vessels in the eye
    • Noticeable birth irregularities of the anterior chamber angle

81313, 81479, 81539, 81551, 81599, 84153, 84154, 86316, 0005U, 0113U

Experimental
81229, 81599,** 0021U, 0228U

**Unlisted codes

Basic benefit and medical policy

Early detection of prostate cancer: Biomarkers

For the purpose of early detection of prostate cancer, testing of genetic and protein biomarkers prior to an initial or repeat biopsy is considered established when criteria are met.

Procedure codes *0005U and *0113U were added as payable for all groups, effective July 1, 2022.

Inclusions:

  1. Genetic and protein biomarkers for early detection of prostate cancer are established prior to an initial biopsy:
    • In individuals 45 to 75 years of age who are considered average risk and all the following:
      • Have a PSA level > 3 ng/mL and/or have a very suspicious digital rectal examination, or DRE
      • Have been evaluated for benign prostate disease

Or

    • In individuals 40 to 75 years of age who have one of the following:
      • Are Black/African American
      • Have germline mutations that increase the risk of prostate cancer
      • Have a suspicious family history

And

      • Have a PSA level > 3 ng/mL and/or
      • Have a very suspicious digital rectal examination (DRE), and
      • Have been evaluated for benign prostate disease

Biomarkers that improve the specificity of cancer detection include percent-free PSA; Prostate Health Index, or PHI; SelectMDx®; 4Kscore®; ExoDx™ (EPI); MyProstateScore, or MPS; and IsoPSA.

  1. Genetic and protein biomarkers for early detection of prostate cancer are established prior to a repeat biopsy in individuals who had an initial biopsy with one of the following results:
    • Atypia, suspicious for cancer
    • High-grade prostatic intraepithelial neoplasia, or PIN
    • A negative prostate biopsy and clinical suspicion of cancer persists

Biomarkers that improve specificity in the post-biopsy setting include percent-free PSA, Prostate Health Index, or PHI; 4Kscore®; Progensa® PCA3; ConfirmMDx®; MyProstateScore, or MPS; IsoPSA and ExoDx™ (EPI).

Exclusions:

    • Biomarkers aren’t covered if criteria above are not met.
    • Biomarkers that aren’t covered include:
      • Biomarkers not identified or discussed by the National Comprehensive Cancer Network
      • Mitochondrial DNA mutation testing (for example, Prostate Core Mitomic Test™)
      • PanGIA Prostate

Biomarker testing isn’t expected to be performed more frequently than every three to five years.

98975, 98976, 98977, 98980, 98981

    

Basic benefit and medical policy

Remote therapeutic monitoring

The use of remote therapeutic monitoring, or RTM, in the medical management of an individual’s respiratory or musculoskeletal treatment plan is considered established when criteria are met, effective Jan. 1, 2023.

Inclusions:

Remote therapeutic monitoring, or RTM, is approved when there is an order written by a physician or qualified health care practitioner that specifies the medical condition and the length of time for RTM, up to 90 days.

Policy guidelines:

RTM data

  • Data may be self-reported by the individual or may be electronically captured by a device.
  • Data is for a respiratory or musculoskeletal condition. 

RTM device guidance (when a device is used)**

  • The device used for data collection must be a medical device, as defined by the FDA.
  • The device used must provide secure, HIPAA-compliant transmission of the data.

** Examples: Devices may include wearable, hand-held and digital interfaces.

Services included in RTM

  • Initial set-up and patient instruction of the monitoring device
  • RTM for up to 90 days
  • For RTM services beyond 90 days (all the following):
    • There is a physician/QHP order for the continuation of RTM
    • The medical record contains documentation that includes all the following:
      • Supports the medical necessity for continued RTM
      • Reflects that the results of the monitoring are used in clinical decision-making and intervention
    • RTM (after the first 90 days) is billed with modifier KX (the provider attests that requirements specified in the medical policy have been met).

Each 30-day billing cycle must include at least 16 days of monitoring.

Reimbursement for remote therapeutic monitoring is driven by current Blue Cross Blue Shield of Michigan payment policy

Exclusions:

The RTM device itself (including any additional apps, software, digital interfaces, etc.) is generally not covered.

B4157, B4162

Basic benefit and medical policy

Medical formula

The safety and effectiveness of oral medical formula for individuals with inborn errors of metabolism have been established. Oral medical formula is considered an established treatment option when policy criteria are met.

Inclusionary and exclusionary guidelines have been updated, effective Jan. 1, 2023. 

Inclusions:

Oral medical formula (metabolic formula for consumption by mouth) for individuals of any age is considered established when all of the following are met:

  • The individual has a diagnosis of an inborn error of metabolism that requires oral medical formula; or
  • The individual has an inherited condition that is proven to be treated by oral medical formula; and
  • The oral medical formula is labeled and used for nutritional management of an inborn error of metabolism that interferes with the metabolism of specific nutrients (for example, Phenylketonuria, Homocystinuria, Maple Syrup Urine Disease, etc.); and
  • The oral medical formula nutrition is ordered by a clinical or medical biochemical geneticist or by other qualified medical professionals in consultation with a clinical or medical biochemical geneticist.

Exclusions:

  • Formula for any condition other than an inborn error of metabolism (for example, diabetes, hypercholesterolemia, etc.)
  • Formula not specifically used for the nutrition of an individual with an inborn error of metabolism
  • Medical food product that isn’t formula (for example, food modified to be low in protein [meat or cheese substitutes, pasta, etc.])
  • Nutrition by tube feeding (refer to the Enteral Nutrition policy for guidelines)

J3490
J3590

Basic benefit and medical policy

Spevigo (spesolimab-sbzo)

Spevigo (spesolimab-sbzo) is payable for its FDA-approved indications, effective Sept. 1, 2022.

Spevigo is an interleukin-36 receptor antagonist indicated for the treatment of generalized pustular psoriasis flares in adults.

Dosage and administration:

  • Administer as a single 900 mg dose by intravenous infusion over 90 minutes. If flare symptoms persist, may administer an additional intravenous 900 mg dose one week after the initial dose.
  • Must be diluted before use. See full prescribing information for preparation and administration instructions and storage of the diluted solution.

Dosage forms and strengths:

Injection: 450 mg/7.5 mL (60 mg/mL) solution in a single-dose vial

Spevigo (spesolimab-sbzo) isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Zynteglo (betibeglogene autotemcel)

Effective Aug. 17, 2022, Zynteglo (betibeglogene autotemcel) is covered for the following FDA-approved indications:

Zynteglo is an autologous hematopoietic stem cell-based gene therapy indicated for the treatment of adult and pediatric patients with β-thalassemia who require regular red blood cell transfusions.

Dosage administrations:

For autologous use only. For intravenous use only.

  • Patients are required to undergo hematopoietic stem cell mobilization followed by apheresis to obtain CD34+ cells for Zynteglo manufacturing.
  • Dosing of Zynteglo is based on the number of CD34+ cells in the infusion bags per kg of body weight.
  • The minimum recommended dose is 5.0 × 106 CD34+ cells/kg.
  • Full myeloablative conditioning must be administered before infusion of Zynteglo.
  • Prophylaxis for hepatic veno-occlusive disease (VOD) is recommended. Prophylaxis for seizures should be considered.
  • Verify that the patient’s identity matches the unique patient identification information on the Zynteglo infusion bags prior to infusion.
  • Don’t sample, alter or irradiate Zynteglo. 
  • Don’t use an in-line blood filter or an infusion pump.
  • Administer each infusion bag of Zynteglo via intravenous infusion over a period of less than 30 minutes.

Dosage forms and strengths:

  • Zynteglo is a cell suspension for intravenous infusion.
  • A single dose of Zynteglo contains a minimum of 5.0 × 106 CD34+ cells/kg of body weight in one or more infusion bags. 

J9358

Basic benefit and medical policy

Enhertu (fam-trastuzumab deruxtecan-nxki)

Enhertu (fam-trastuzumab deruxtecan-nxki) is payable for the updated FDA-approved indications, effective Aug. 5, 2022.

  • Adult patients with unresectable or metastatic HER2-low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received a prior chemotherapy in the metastatic setting or developed disease recurrence during or within six months of completing adjuvant chemotherapy.
  • Adult patients with unresectable or metastatic non-small cell lung cancer whose tumors have activating HER2 (ERBB2) mutations, as detected by an FDA-approved test, and who have received a prior systemic therapy.
  • This indication is approved under accelerated approval based on objective response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

S2053-S2055, 44120, 44121, 44132,
44133, 44135, 44136, 44715, 44720,
44721, 44799,** 47133, 47135, 47140-47147, 47399**

**Unlisted code used to report not otherwise classified procedures

Basic benefit and medical policy

Transplantation: small bowel, liver, multi-visceral

The safety and effectiveness of a small bowel/liver and/or multivisceral transplant have been established.  It may be considered a useful therapeutic option when indicated in adult and pediatric individuals with intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte or micronutrient balance) who have been managed with long-term total parenteral nutrition, or TPN, and who have developed evidence of impending end-stage liver failure.

A small bowel/liver transplant or multivisceral retransplant may be considered established for individuals following a failed primary small bowel/liver transplant or multivisceral transplant.

A modified multivisceral transplantation may be considered established for individuals requiring only one or two organs (for example, stomach, liver, duodenum, pancreas, intestine) to be transplanted.

A small bowel/liver transplant or multivisceral transplant is considered experimental in all other situations.
This policy has been updated regarding modified multi-visceral transplantation, effective Jan. 1, 2023.

Inclusions:

The individual selected for small bowel/liver, small/bowel multivisceral transplant and/or modified multivisceral transplant must meet the transplanting institution’s protocol eligibility criteria. These criteria should include:

  • Documentation of patient compliance with medical management
  • Adequate cardiopulmonary status

HIV-positive individuals who meet the following criteria, as stated in the 2001 guidelines of the American Society of Transplantation, could be considered candidates for small bowel/liver or multivisceral transplantation:

  • CD4 count greater than 200 cells per cubic millimeter for greater than six months
  • HIV-1 RNA undetectable
  • On stable anti-retroviral therapy >3 months
  • No other complications from AIDS (for example, opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm), and meeting all other criteria for transplantation.

Small bowel/liver specific

Inclusions:

Evidence of intolerance of total parenteral nutrition includes, but isn’t limited to, multiple and prolonged hospitalizations to treat TPN-related complications, or the development of progressive but reversible liver failure. In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.

Exclusions:

Potential contraindications to solid organ transplant are subject to the judgment of the transplant center:

  • Known current malignancy, including metastatic cancer
  • Recent malignancy with high risk of recurrence
  • History of cancer with a moderate risk of recurrence
  • Systemic disease that could be exacerbated by immunosuppression
  • Untreated systemic infection making immunosuppression unsafe, including chronic infection
  • Other irreversible end-stage disease not attributed to intestinal failure
  • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Contraindications:

Absolute and relative contraindications represent situations where proceeding with transplant may not be advisable in the context of limited organ/tissue availability. Contraindications may evolve over time as transplant experience grows in the medical community. Clinical documentation supplied to the health plan must demonstrate that attending staff at the transplant center have considered all contraindications as part of their overall evaluation of potential organ transplant recipients and have decided to proceed.

Relative contraindications:

The selection process for approved organ transplants is designed to obtain the best result for each patient.  Therefore, relative contraindications to small bowel/liver or multivisceral transplant may include, but aren’t limited to:

  • Poor cardiac function: Ejection fraction should be greater than 45% with no overt symptoms of congestive heart failure.
  • Poor pulmonary function: Pulmonary function tests must be greater than or equal to 50% of predicted value.
  • Poor renal function: Renal creatinine clearance should be greater than 40 ml/min or creatinine must be less than or equal to 2mg/dl.
  • Poor liver function: There should be no history of severe chronic liver disease
  • Presence of uncontrolled HIV or an active form of hepatitis B, hepatitis C or human T-cell lymphotropic virus

Note: There is a separate liver transplantation policy.

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.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2022 American Medical Association. All rights reserved.