Billing chart: Blue Cross highlights medical, benefit policy changes

11920,*** 11921,*** 11922,*** 17380,*** 19325,*** 21120,*** 21121,*** 21122,*** 21123,*** 21125,*** 21127,*** 21137,*** 21138,*** 21209,*** 30400,*** 30410,*** 30420, 15769, 15771, 15772, 15773, 15774, 17999,** 19303, 19318, 19350, 31599,** 31899,** 54520, 55970, 55980, 56805, 57291, 57292, 57335, 58150, 58152, 58180, 58260, 58262, 58275, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554

Diagnosis codes
F64.0, F64.8, F64.9, Z87.890

**Unlisted codes
***Payable with listed diagnoses

Experimental/non-payable

Basic benefit and medical policy

Gender affirming services

The gender affirming services policy has been updated to cover additional procedure codes, update established codes with additional payable diagnoses and add non-payable diagnoses for specific procedure codes when criteria are met, effective Jan. 1, 2023.

The safety and effectiveness of select medical and surgical treatments for gender dysphoria have been established. The established treatments for gender dysphoria include:

• Puberty suppression in adolescents
• Hormone therapy (for masculinization/feminization) for adolescents who meet criteria and adults
• Medically necessary gender affirming surgery:**
• Genitalia reconstruction
• Mastectomy for a transgender man (a person who has a gender identity as a man and who was assigned female at birth) 
• Augmentation mammoplasty (implants) for transgender women (a person who has a gender identity as a woman and who was assigned male at birth)
• Thyroid reduction chondroplasty (tracheal shave)
• Facial feminization
• Facial masculinization

**Gender-affirming surgery may require prior authorization.

Gender-specific services may be medically necessary for transgender and gender-diverse people appropriate to their anatomy. Examples include:

• Breast cancer screening in transgender and gender-diverse people with breasts from natal puberty who haven’t undergone gender-affirming chest surgery and for transgender and gender diverse people who have received estrogens, taking into account the length of time of hormone use, dosing, current age and age at which the hormones were initiated
• Prostate cancer screening for transgender and gender diverse people who have retained their prostate
• Cervical screening for transgender and gender diverse people who currently have or previously had a cervix following local guidelines for cisgender women.
• Obvstetric services for transgender and gender diverse people when they are pregnant
• To guide preventive medical care, any anatomical structure present that warrants screening should be screened, regardless of gender identity.

Inclusions:

Gender-affirming surgery may be indicated for members who meet all the following inclusionary criteria:

1. Chest surgery***
1. Mastectomy is considered reconstructive when all the following criteria have been met:
• The individual is at least 18 years of age.
• The individual has been diagnosed with gender dysphoria (see Description/Background section for diagnostic criteria).
• Gender dysphoria is marked and sustained.
• The individual has capacity to make fully informed decisions and consent for treatment.
• One letter of assessment as indicated below****
• Other possible causes of apparent gender incongruence have been identified and excluded.
• Mental health and physical conditions that could negatively affect the outcome of gender-affirming medical treatments have been assessed, with the risks and benefits discussed, before a decision is made regarding treatment.
• Hormone therapy prior to mastectomy isn’t required, as the aim of hormone therapy before facial surgery or gonadectomy is primarily to introduce a period of reversible testosterone or estrogen suppression before the individual undergoes irreversible surgical intervention.
• Living in a gender role congruent with gender identity for 12 continuous months isn’t required prior to a mastectomy.
• Pre-operative and post-operative care that addresses both surgical results and possible behavioral health results is highly recommended.

Nipple reconstruction, including tattooing, following a gender affirming mastectomy that meets the reconstructive criteria above is considered reconstructive.

2. Breast augmentation is considered reconstructive when all the following criteria have been met:
• The individual is at least 18 years of age.
• The individual has been diagnosed with gender dysphoria (see Description/Background section for diagnostic criteria).
• Gender dysphoria is marked and sustained.
• The individual has capacity to make fully informed decisions and consent for treatment.
• One letter of assessment as indicated below****
• Other possible causes of apparent gender incongruence have been identified and excluded.
• Mental health and physical conditions that could negatively affect the outcome of gender-affirming medical treatments have been assessed, with the risks and benefits discussed, before a decision is made regarding treatment.
• The individual is stable on their gender-affirming hormonal treatment regimen for at least 12 months, unless a rationale is provided by the HCP that indicates that hormone treatment is either contraindicated or not necessary for the individual’s clinical situation.
• Living in a gender role congruent with gender identity for 12 continuous months isn’t required prior to breast augmentation.
• Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender.
• Pre-operative and post-operative care that addresses both surgical results and possible behavioral health results is highly recommended.

***The procedures needed to reconstruct a feminine/masculine appearance can only be performed once per lifetime.

2. Facial surgery***^† is considered reconstructive when all the following criteria have been met: 
• The individual is at least 18 years of age.
• The individual has been diagnosed with gender dysphoria (see Description/Background section for diagnostic criteria).
• Gender dysphoria is marked and sustained.
• The individual has capacity to make fully informed decisions and consent for treatment.
• Other possible causes of apparent gender incongruence have been identified and excluded.
• One letter of assessment as indicated below****
• Mental health and physical conditions that could negatively affect the outcome of gender-affirming medical treatments have been assessed, with the risks and benefits discussed, before a decision is made regarding treatment.
• The individual is stable on their gender-affirming hormonal treatment regimen for at least 12 months, unless a rationale is provided by the HCP that indicates that hormone treatment is either contraindicated or not necessary for the individual’s clinical situation.
• The new gender identity should be present for at least 12 months.
• The member has a consistent stable gender identity that is well documented by their treating providers and, when possible, lives as their affirmed gender in places where it is safe to do so.
• Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender.
• The procedure directly addresses variation from normal appearance for the experienced gender (Note: Each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive).
• Pre-operative and post-operative care that addresses both surgical results and possible behavioral health results is highly recommended.

***The procedures needed to reconstruct a feminine/masculine appearance can only be performed once per lifetime.
^†List of procedures included in this group is thyroid reduction chondroplasty (tracheal shave), genioplasty (repositioning or reshaping of the chin), mandible augmentation (jawline contouring/reconstruction), facial bone reduction, forehead reduction/contouring, rhinoplasty (reshaping/contouring of the nose).

3. Genital surgery is considered medically necessary when all the following criteria have been met: 
• The individual is at least 18 years of age.
• The individual has been diagnosed with gender dysphoria (see Description/Background section for diagnostic criteria).
• Gender dysphoria is marked and sustained.
• The individual has capacity to make fully informed decisions and consent for treatment.
• Other possible causes of apparent gender incongruence have been identified and excluded.
• One letter of assessment as indicated below****
• Mental health and physical conditions that could negatively affect the outcome of gender-affirming medical treatments have been assessed, with the risks and benefits discussed, before a decision is made regarding treatment.
• The individual is stable on their gender affirming hormonal treatment regimen for at least 12 months, unless a rationale is provided by the HCP that indicates that hormone treatment is either contraindicated or not necessary for the individual’s clinical situation.
• The new gender identity should be present for at least 12 months.
• The member has a consistent stable gender identity that is well documented by their treating providers and, when possible, lives as their affirmed gender in places where it is safe to do so.
• Pre-operative and post-operative care that addresses both surgical results and possible behavioral health results is highly recommended.

These criteria don’t apply to patients who are having these surgical procedures for medical indications other than gender dysphoria.

****Letter requirements:

1. Required for hormone therapy for adolescents
2. Required for facial, pelvic, gonadal and/or genital surgery for adults

Adolescents

One letter of assessment from the multidisciplinary team (or in situations where a multidisciplinary team isn’t available, a professional from one of the multiple disciplines who are experts in transgender health and in the management of the care required for transgender and gender-diverse adolescents who is taking care of the individual) is required for adolescents receiving gender-affirming medical treatment.

This letter needs to reflect the assessment and opinion from the team, which involves both medical HCPs and mental health professionals, supporting that the individual meets the criteria for gender dysphoria. The detailed assessment must have been performed within 12 months of the requested submission. 

The HCP assessing and working with the adolescent should meet all the following criteria:

1. Are licensed by their professional body and hold a postgraduate degree or its equivalent in a clinical field related to transgender health granted by a nationally accredited institution.
2. Receive theoretical and evidenced-based training and have expertise in general child, adolescent and family mental health across the developmental spectrum.
3. Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent and possess general knowledge of gender diversity across the lifespan.
4. Continue engaging in professional development in all areas relevant to gender-diverse children, adolescents and families.

Adults

One letter of assessment from an HCP who has competencies in the assessment of transgender and gender diverse people, documenting that the individual meets the criteria for gender dysphoria, is required for transgender and gender diverse adults who meet the below criteria for gender-affirming medical and surgical treatments. The detailed assessment must have been performed within 12 months of the requested submission. 

The HCP should meet all the following criteria:

1. Are licensed by their professional body and hold, at a minimum, a master’s degree (or equivalent training in a clinical field related to transgender health or equivalent further clinical training in this area) that’s  granted by a nationally accredited institution
2. Should be competent using the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, for diagnosis
3. Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence and diversity
4. Are able to assess capacity to consent for treatment
5. Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence and diversity
6. Undergo continuing education in health care relating to gender dysphoria, incongruence and diversity.

Exclusions:

• Transgender services aren’t covered if contract or certificate language contains specific exclusion of these services.
• Reversal of transgender surgical procedures.
• All procedures that are primarily cosmetic and not reconstructive or not medically necessary including, but not limited to:
• Abdominoplasty
• Blepharoplasty
• Brow lift
• Calf implants
• Cheek/malar implants
• Chin/nose implants
• Collagen injections
• Drugs for hair loss or growth
• Forehead lift
• Hair removal (for exception: see Inclusions, Electrolysis)
• Hair transplantation
• Injectable dermal fillers (i.e. Sculptra, Radiesse)
• Lip reduction
• Liposuction
• Mastopexy
• Neck tightening
• Otoplasty
• Pectoral implants
• Removal of redundant skin
• Rhytidectomy
• Speech-language therapy

80305-80307, G0480-G0483, G0659

Not medically necessary/not covered:

Basic benefit and medical policy

Drug testing in pain management and substance use disorder treatment

Presumptive and definitive drug testing in the outpatient setting may be considered established when criteria are met. 

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

Note: This policy addresses drug testing in an outpatient setting. The policy doesn’t apply to drug testing in emergency department, acute inpatient medical or behavioral health facility settings, or testing ordered by or on behalf of a health care provider or facility that receives per-diem reimbursement that includes clinical diagnostic laboratory testing (skilled nursing facility).

Inclusions:

1. Presumptive drug testing
• For outpatient pain management, presumptive drug testing is considered established in:
• Baseline screening at the initiation of treatment
• Subsequent monitoring of treatment at an appropriate frequency based on the risk level of the individual, including assessment of aberrant behavior
• For outpatient substance use disorder treatment, presumptive drug testing is considered established in:
• Baseline screening at the initiation of treatment
• Subsequent screening is based on the risk level of the individual and the substance being used
• For an individual not participating in outpatient pain management or outpatient substance use disorder treatment:
• When a clinical evaluation suggests use of non-prescribed medications, illegal or other substances
• When testing for drug or alcohol exposure during pregnancy
• To rule out a fetal withdrawal syndrome by testing the mother for drug use

2. Definitive/confirmatory drug testing
• Definitive drug testing is considered established for one of the following:
• When immunoassays for the relevant drugs are not commercially available
• In situations where definitive drug levels are required for clinical decision making (e.g., unexpected positive test that is inadequately explained by the patient, unexpected negative test, quantitative levels are needed to determine clinical treatment)

Exclusions:

• Drug testing as a third-party requirement (e.g., for employment, licensing, court order)
• Simultaneously testing for the same drug with two specimens from different sources (e.g., blood and urine)

Policy guidelines:

One presumptive and one definitive test code may be billed per date of service.

Billing guidelines for definitive drug testing:

Bill G0480-G0483 and G0659 as appropriate, for the number of drug classes tested.

Bill *80XXX and *83992 to report the appropriate drug or metabolite testing. The codes are no longer individually reimbursed for the purpose of this policy; however, we request that they be reported with the appropriate G code.

Contracted laboratories:

Providers should select contracted laboratories for the processing of drug tests. Referring a member to a non-participating laboratory may result in unnecessary services (such as processing tests not originally ordered) and greater financial liability for the member. The referring provider may be held accountable for any inappropriate behavior on the part of the non-participating laboratory.

J3490, J3590

Basic benefit and medical policy

Daxxify (daxibotulinumotoxina-lanm)

Daxxify (daxibotulinumotoxina-lanm) is considered established when criteria are met, effective Sept. 7, 2022.

Daxxify (daxibotulinumtoxinA-lanm) is an acetylcholine release inhibitor and neuromuscular blocking agent indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator or procerus muscle activity in adult patients.
 
Dosage and administration:

Glabellar lines: 0.1 mL (8 units) by intramuscular injection into each of five sites, for a total dose of 40 units.

Dosage forms and strengths:

For injection: 50 units or 100 units sterile lyophilized powder in a single-dose vial

Daxxify (daxibotulinumotoxina-lanm) isn’t a benefit for URMBT.

J3490, J3590

Basic benefit and medical policy

NexoBrid (anacaulase-bcdb)

Effective Dec. 28, 2022, NexoBrid (anacaulase-bcdb) is covered for the following FDA-approved indications:

NexoBrid contains proteolytic enzymes and is indicated for eschar removal in adults with deep partial thickness or full thickness thermal burns.

Limitations of use:

The safety and effectiveness of NexoBrid haven’t been established for treatment of:

• Chemical or electrical burns
• Burns on the face, perineum or genitalia
• Burns on the feet of patients with diabetes mellitus or on the feet of patients with occlusive vascular disease
• Circumferential burns
• Burns in patients with significant cardiopulmonary disease, including inhalation injury

NexoBrid isn’t recommended for wounds contaminated with radioactive and other hazardous substances to avoid unforeseeable reactions with the product and an increased risk of spreading the noxious substance.

Dosage and administration:

• For topical use only.
• NexoBrid may be applied in up to two applications of four hours each.
• A first application may be applied to an area of up to 15% body surface area, or BSA.
• A second application may be applied 24 hours later. The total treated area for both applications must not exceed 20% BSA.
• Use 1.94 g of anacaulase-bcdb in 2 g powder mixed with 20 g gel per 1% BSA, or 4.85 g of anacaulase-bcdb in 5 g powder mixed with 50 g gel per 2.5% BSA.
• Prepare NexoBrid at patient’s bedside within 15 minutes of intended application.
• Apply NexoBrid to a clean, moist wound bed free of burned epidermis layer and blisters, and cover with an occlusive film dressing for four hours.

Dosage forms and strengths:

• For topical gel: 8.8%.

NexoBrid (anacaulase-bcdb) isn’t a benefit for URMBT.

J3490, J3590

Basic benefit and medical policy

Sezaby (phenobarbital sodium)

Effective Nov.17, 2022, Sezaby (phenobarbital sodium) is covered for the following FDA-approved indications:

Sezaby is a barbiturate indicated for the treatment of neonatal seizures in term and preterm infants.

Dosage and administration:

• Loading dose: 20 mg/kg is administered by intravenous infusion over 15 minutes into a large peripheral vein. If clinically indicated, at least 15 minutes after completion of the initial loading dose, a second loading dose may be administered over the subsequent 15 minutes as 20 mg/kg for term infants or 10 mg/kg or 20 mg/kg for preterm infants. The maximum total loading dose is 40 mg/kg.
• Maintenance dosage: Starting 8 to 12 hours after first loading dose: 4.5 mg/kg/day given in 2 or 3 divided doses (e.g., 1.5 mg/kg every eight hours or 2.25 mg/kg every 12 hours) up to five days.
• Must be reconstituted with 10 mL 0.9 % sodium chloride Injection, USP prior to administration.

Dosage forms and strengths:

For injection: 100 mg of phenobarbital sodium lyophilized powder in a single-dose vial for reconstitution

Sezaby (phenobarbital sodium) isn’t a benefit for URMBT.

J7297

Basic benefit and medical policy

Liletta (levonorgestrel-releasing intrauterine system)

Effective Nov. 10, 2022, Liletta (levonorgestrel-releasing intrauterine system) is covered for the following FDA-approved indications:

Liletta is a progestin-containing intrauterine system indicated for prevention of pregnancy for up to eight years.

Dosage and administration:

• The initial release rate of levonorgestrel is approximately 20 mcg/day and declines progressively to approximately 6.5 mcg/day after eight years; Liletta can be removed at any time but must be removed by the end of the eighth year.
• To be inserted into the uterine cavity with the provided inserter by a trained health care professional using strict aseptic technique. Follow insertion instructions exactly as described.

Re-examination and evaluation should be considered 4 to 6 weeks after insertion and during routine care, or more often if clinically indicated.

36836, 36837

Basic benefit and medical policy

Endovascular percutaneous device

The use of an endovascular percutaneous device for the creation of an arteriovenous fistula, or pAVF, for hemodialysis access is considered experimental, effective May 1, 2023.

K1016, K1017

Basic benefit and medical policy

eTNS for ADHD

External trigeminal nerve stimulation, or eTNS, for the management of attention deficit hyperactivity disorder is considered experimental (e.g., MonarchM^® eTNS System). There is insufficient evidence in the peer-reviewed medical literature to determine the effects of the technology on health outcomes, effective May 1, 2023.