|
January 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 |
89344 |
Basic benefit and medical policy
Assisted reproductive techniques
Selected assisted reproductive techniques, or ART, are established and may be considered useful therapeutic options in the treatment of infertility.
When infertility is due to an underlying medical condition (for example, chronic infection, uterine fibroids, etc.), the treatment of that disorder is medically necessary and is covered under basic medical-surgical benefits.** When no medically correctable underlying medical condition is found (for example, low sperm count, anovulation), other options may be pursued. One option is ART — specific services that may be used to establish pregnancy. Assisted reproductive techniques are only available to members when the employer group has chosen to offer the services as additional or extra benefits through certificate benefit language or riders.
The focus of this policy is the use of ART in heterosexual couples who are infertile. Eligibility of same-sex couples or single individuals for ART is based on benefit coverage (the certificate of coverage or rider) and is beyond the scope of this medical policy.
**See the medical policy “Infertility Diagnosis.”
Procedure code *89344 was added as a covered service when billed with a diagnosis related to azoospermia, effective Sept. 1, 2022. The criteria was also updated to include elective single embryo transfer.
Basic benefit policy group variations
Inclusions:
Assisted reproductive techniques, or ARTs, aren’t general medical or surgical benefits. While the procedures listed in the inclusions are considered established, these services are available only as additional benefits, offered by a group or employer. The covered services and limitations are defined by the group or employer. The benefit plan, including the certificate of coverage or rider, determines the available coverage.
To access benefits for assisted reproductive techniques, the definition of infertility*** must be met. A benefit document (certificate of coverage or rider) may specify that the definition of infertility isn’t a requirement for ART services; it’s only in this case that the requirement of meeting the definition of infertility waived.
***Infertility: Failure to achieve pregnancy after 12 months of unprotected intercourse in women younger than 35 years of age, or after six months in women older than 35 years of age.
Inclusions:
- Artificial insemination
- Assisted reproductive technologies:
- In vitro fertilization, or IVF
- Gamete intrafallopian transfer, or GIFT
- Transuterine fallopian transfer, or TUFT
- Natural oocyte retrieval with intravaginal fertilization, or NORIF
- Pronuclear state tubal transfer, or PROST
- Tubal embryo transfer, or TET
- Zygote intrafallopian transfer, or ZIFT
- Embryo transfer
- Blastocyst transfer
- Intracytoplasmic sperm injection, or ICSI, for male factor infertility only
- Cryopreservation of embryos and sperm****
- Storage of embryos and sperm
- Thawing of embryos and sperm
- Assisted embryo hatching when one of the following criteria is met:
- The individual is 38 years of age or older.
- There have been two or more IVF failures related to failed implantation.
- Elective single-embryo transfer, or eSET
Exclusions:
- Intracytoplasmic sperm injection in the absence of male factor infertility
- Co-culture of embryos
- Cryopreservation of ovarian tissue or testicular tissue****
- Storage of ovarian tissue or testicular tissue
- Thawing of ovarian tissue or testicular tissue****
- All services related to gestational surrogacy, gestational parent, gestational carrier
- Time lapse monitoring or imaging of embryos (for example, EmbryoScope)
- Endometrial receptivity testing (for example, ERA®, or Endometrial Receptivity Analysis)
- ART services are excluded when there has been a voluntary sterilization procedure (for example, tubal ligation, vasectomy), including when there has been surgical reversal of the sterilization procedure, as this is not considered treatment of disease
- Reversal of prior sterilization procedure is excluded
****Cryopreservation and thawing of testicular tissue in adult men with azoospermia is considered medically necessary as part of the intracytoplasmic sperm injection procedure. |
| POLICY CLARIFICATIONS |
0002M, 0003M ,76391, 81596, 76981, 76982, 76983, 91200,
Experimental
0014M, 76498,** 81599,** 84999**
**Unlisted codes |
Basic benefit and medical policy
Noninvasive techniques for patients with chronic liver disease
The policy has been updated to cover procedure codes *0002M and *0003M when criteria are met, effective Sept. 1, 2022.
The safety and effectiveness of ultrasonic transient elastography (FibroScan®) for the evaluation or monitoring of patients with chronic liver disease have been established. It may be considered a useful diagnostic option when indicated.
Magnetic resonance elastography for the diagnosis and management of advanced hepatic fibrosis or cirrhosis has been established. It may be considered a useful option when indicated.
The use of other noninvasive imaging, including, but not limited to, acoustic radiation force impulse imaging, or ARFI, or real-time tissue elastography, is considered experimental for the evaluation or monitoring of patients with chronic liver disease. While these services may be safe, their clinical utility for this clinical indication hasn’t been determined.
The use of FibroSURE™ multianalyte assays (HCV FibroSURE, ASH FibroSURE, NASH FibroSURE) in chronic liver disease has been established. It may be considered a useful diagnostic option when indicated.
The peer-reviewed medical literature hasn’t demonstrated the clinical utility of other multianalyte assays with algorithmic analyses (for example, FIBROSpect II, Enhanced Liver Fibrosis Test) for the evaluation or monitoring of patients with chronic liver disease. Therefore, these services are considered experimental.
Inclusions:
Noninvasive imaging techniques:
- Ultrasound transient elastography (FibroSCAN®), using an FDA-approved probe (for example, S+ M+ or XL+ Probe), may be considered established for the evaluation or monitoring of chronic liver disease.
- Magnetic resonance elastography may be considered established for the diagnosis or management of advanced hepatic fibrosis or cirrhosis for one of the following:
- Individuals with nonalcoholic fatty liver disease who have high risk for cirrhosis due to advanced age, obesity, diabetes or alanine aminotransferase level more than twice the upper limit of normal
- Individuals with other established chronic liver diseases when ultrasound elastography cannot be performed or is nondiagnostic
Multianalyte assays:
- A FibroSURE™ multianalyte assay (either HCV FibroSURE™, ASH FibroSURE™ or NASH FibroSURE™) may be considered established for the evaluation or monitoring of chronic liver disease.
Exclusions:
Noninvasive imaging techniques:
- Ultrasound transient elastography in individuals with ascites
- Acoustic radiation force impulse imaging
- Real-time tissue elastography
- Use of ultrasound elastography to differentiate benign from malignant liver lesions
Multianalyte assays:
Multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease not listed above (for example, Fibrospect, ELF, etc. — not a complete list) |
0239U, 0242U, 81191-81194, 81210, 81235, 81275, 81276, 81404-81406, 81445, 81455, 81479,** 88346, 88350, 0179U
**Unlisted procedure code |
Basic benefit and medical policy
Circulating tumor DNA for non-small cell lung cancer
Payment policy:
Modifiers 26 and TC (TOS P and K) don’t apply to procedure codes *0239U and *0242U.
Not payable in an office location or ambulatory surgical facility, or ASF.
Payable to an M.D., D.O., and independent laboratory only.
Medical policy statement:
The effectiveness and clinical utility of circulating tumor DNA of individual genes, listed multiple gene panels when more than five genes are tested and FDA-approved companion diagnostic tests for the management of non-small cell lung cancer (liquid biopsy) have been established. They may be considered a useful therapeutic option when indicated.
Inclusionary guidelines have been updated. Procedure codes *0239U and *0242U being changed from experimental to payable effective date of Sept. 1, 2022.
Inclusions:
Analyzing cell-free/circulating tumor DNA (ctDNA) alterations in the ALK, EGFR, BRAF V600E, KRAS, ROS1, NTRK, MET exon14 skipping, PD-L1, ERBB2 (HER-2) and RET gene using one of the following methods:
- Individual genes
- Targeted multi-gene panels
- FDA approved companion diagnostic tests (for example, Cobas® EGFR, or Epidermal Growth Factor Receptor Mutation Test v.2, FoundationOne® Liquid CDx, Guardant360® CDx)
When all the following apply:
- Advanced stage III or IV non-small cell lung cancer
- Clinical circumstances reflect one of the following:
- Patient is medically unfit for invasive tissue sampling.
- Following pathologic (biopsy) confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis and follow-up tissue-based analysis is planned for all patients in which an oncogenic driver isn’t identified.
- Used to detect ctDNA for targeted therapy benefit or to identify patients who won’t benefit from further molecular testing.
Exclusions:
- Use of circulating tumor DNA (ctDNA) for any indications not mentioned above
- Cell-free testing when the patient already meets criteria for treatment based on known biomarker status. (for example, patient has already had testing or testing isn’t required).
|
J0179 |
Basic benefit and medical policy
Beovu (brolucizumab-dbll)
The FDA has updated the payable indications for Beovu (brolucizumab-dbll) effective May 27, 2022. The payable indications include diabetic macular edema. |
J9228 |
Basic benefit and medical policy
Yervoy (ipilimumab)
Yervoy (ipilimumab) is covered for the following updated FDA-approved indication, effective May 27, 2022:
- Esophageal cancer: Treatment of adult patients with unresectable advanced or metastatic esophageal squamous cell carcinoma as first-line treatment in combination with nivolumab.
Dosing information:
Esophageal squamous cell carcinoma: Yervoy 1 mg/kg every six weeks with nivolumab 3 mg/kg every two weeks or 360 mg every three weeks. |
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. |
