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March 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.

We'll will publish information about new Blue Cross groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the Blue Cross' policies for these procedures, check under the Commercial Policy tab in Benefit Explainer on Availity®. To access this online information:

  1. Log in to availity.com.
  2. Click on Payer Spaces on the Availity menu bar.
  3. Click on the BCBSM and BCN logo.
  4. Click on Benefit Explainer on the Applications tab.
  5. Click on the Commercial Policy tab.
  6. Click on Topic.
  7. Unique Identifier and click the drop-down arrow next to Choose Identifier Type, then click on HCPCS Code.
  8. Enter the procedure code.
  9. Click on Finish.
  10. Click on Search.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
NEW PAYABLE PROCEDURES

Q4113     

Additional covered codes:
15271-15278, 15777, A2001, A2002, A2004-A2013, A4100, A6010, A6011, A6021-A6023, C9356, C9358, C9360, C9363, C9364, Q4101, Q4102 - Q4108, Q4110, Q4113, Q4114, Q4116 - Q4118, Q4121, Q4122, Q4124, Q4127, Q4128, Q4130, Q4135, Q4136, Q4147, Q4149, Q4158, Q4161, Q4164-Q4166, Q4182, Q4195, Q4196, Q4203

Experimental codes:
Q4111, Q4112, Q4115, Q4123, Q4125, Q4126, Q4134, Q4141-Q4143, Q4146, Q4152, Q4167, Q4175-Q4180, Q4193, Q4197, Q4200, Q4202, Q4220, Q4222,

Q4226, Q4238

Basic benefit and medical policy

Skin and tissue substitutes

The safety and effectiveness of skin and tissue substitutes approved by the FDA and the Centers for Medicare & Medicaid Services have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Human tissue products are subject to the rules and regulations of banked human tissue by the American Association of Tissue Banks and have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Updates were made to the criteria, and procedure code Q4113 is payable, effective Nov. 1, 2022.

Inclusions:

The following skin and tissue substitutes are considered established when used according to FDA guidelines and approval. This list may not be all-inclusive:

  • Apligraft®
  • Apis®
  • Atlas Wound Matrix
  • Biobrane®
  • Bio-conneKt® Wound Care Matrix
  • BTM Wound Dressing (aka NovoSorb® BTM)
  • Cytal® Burn Matrix
  • Cytal® MicroMatrix™
  • Cytal™ Wound Matrix (formerly MatriStem)
  • Cytal® Wound Sheet
  • Derma-Gide (aka Geistlich Derma-Gide™)
  • Dermagraft®
  • Endoform Dermal Template™
  • Epicel® has FDA humanitarian device approval
  • E-Z Derm™
  • Helicoll™
  • Hyalomatrix®
  • InnovaMatrix™ (also known as InnovaMatrix AC)
  • InnovaMatrix™ FS
  • Integra® Bilayer Matrix
  • Integra® Dermal Regeneration Template
  • Integra® Flowable Wound Matrix
  • Intregra® Matrix Wound Dressing (formerly known as Avagen)
  • Keratec Wound Dressings (Kermatrix®)
  • Keratec Keragel
  • Keraderm
  • Kerafoam
  • Kerecis™ Omega3 Wound (formerly known as MeriGen)
  • MediSkin®
  • Microlyte® Ag
  • MicroMatrix®
  • Mirragen™
  • Oasis® Burn Matrix
  • Oasis® Ultra Tri-Layer Wound Matrix
  • Oasis® Wound Matrix
  • Ologen™ Collagen Matrix
  • OrCel®
  • PELNAC™ Bilayer Wound Matrix
  • Permacol™ (Covidien)
  • Phoenix™ Wound Matrix
  • PriMatrix™ Dermal Repair Scaffold
  • Puracol® and Puracol® Plus Collagen Wound Dressings
  • PuraPly Wound Matrix (formerly known as FortaDerm)
  • PuraPly Antimicrobial Wound Matrix (formerly known as FortaDerm AM)
  • Restrata®
  • Strattice™
  • Suprathel®
  • SupraSDRM Biodegradable Matrix Wound Dressing
  • SurgiMend®
  • Symphony™
  • Talymed™
  • TenoGlide™
  • TheraSkin®
  • TransCyte®
  • XCelliStem® Wound Powder

Breast reconstructive surgery using allogeneic acellular dermal matrix products** (including each of the following: AlloDerm®, AlloMend®, Cortiva®, [AlloMax™], DermACELL™, DermaMatrix™, FlexHD®, FlexHD® Pliable™, Graftjacket®) are considered established when one of the following are met:

  • There is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required.
  • There is viable but compromised or thin postmastectomy skin flaps that are at risk of dehiscence or necrosis.
  • The inframammary fold and lateral mammary folds have been undermined during mastectomy and reestablishment of these landmarks is needed.

**Various acellular dermal matrix products used in breast reconstruction have similar efficacy. The products listed are those that have been identified for use in breast reconstruction. Additional acellular dermal matrix products may become available for this indication.

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers is established when using the following tissue engineered skin substitutes:

  • AlloPatch®a
  • Apligraft®b
  • Dermagraft®b
  • GraftJacket® Regenerative Tissue Matrix-Ulcer Repair
  • Integra®, Omnigraft™ Dermal Regeneration Matrix (also known as Omnigraft™) and Integra Flowable Wound Matrix
  • Theraskin®

Treatment of chronic, noninfected, partial- or full-thickness lower-extremity skin ulcers due to venous insufficiency, which have not adequately responded following a one-month period of conventional user therapy, is established when using the following tissue-engineered skin substitutes:

  • Aplifraf®b
  • Oasis™ Wound Matrixc
  • Theraskin®

OrCel™ is considered established when all the following criteria are met:

  • Used for the treatment of dystrophic epidermolysis bullosa
  • Used for the treatment of mitten-hand deformity
  • Standard would therapy has failed
  • Provided in accordance with the humanitarian device exemption, or HDE, specifications of the FDA

The following skin and tissue products and substitutes are considered established for use in the treatment of second- and third-degree burns:

  • Alloderm
  • Epicel® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA)d
  • Integra® Dermal Regeneration Templateb

aBanked human tissue
bFDA premarket approval
cFDA 510(k) clearance
dFDA-approved under an HDE

Exclusions:

All other uses of bioengineered skin and soft tissue substitutes listed above unless they meet one of the following criteria:

  • FDA approval and provided in accordance with the FDA guidelines
  • Covered by Centers for Medicare & Medicaid Services

All other skin and soft tissue substitutes, including, but not limited to:

  • ACell® UBM Hydrated/Lyophilized Wound Dressing
  • AlloSkin™
  • AlloSkin™ RT
  • Aongen™ Collagen Matrix
  • Architect® ECM, PX, FX
  • ArthroFlex™ (Flex Graft)
  • AxoGuard® Nerve Protector (AxoGen)
  • BellaCell HD or SureDerm®
  • CollaCare®
  • CollaCare® Dental
  • Collagen Wound Dressing (Oasis Research)
  • CollaGUARD®
  • CollaMend™
  • CollaWound™
  • Coll-e-Derm
  • Collexa®
  • Collieva®
  • Conexa™
  • Coreleader Colla-Pad
  • CorMatrix®
  • Cymetra™ (Micronized AlloDerm™)
  • Dermadapt™ Wound Dressing
  • DermaPure™
  • DermaSpan™
  • DressSkin
  • Durepair Regeneration Matrix®
  • ENDURAGen™
  • Excellagen
  • ExpressGraft™
  • FlexiGraft®
  • FlowerDerm®
  • GammaGraft
  • hMatrix®
  • InteguPly®
  • Keroxx™
  • MatriDerm®
  • Matrix HD™
  • MemoDerm™
  • Microderm® biologic wound matrix
  • Miroderm®
  • MyOwn Skin™
  • NeoForm™
  • Progenamatrix™
  • Puros® Dermis
  • RegenePro™
  • Repliform®
  • Repriza™
  • SkinTE™
  • SlimpliDerm®
  • StrataGraft®
  • TenSIX™ Acellular Dermal Matrix
  • TissueMend
  • TheraForm™ Standard/Sheet
  • TruSkin™
  • Veritas® Collagen Matrix
  • XCM Biologic® Tissue Matrix
  • XenMatrix™ AB
POLICY CLARIFICATIONS

83695, 81401, 81405, 81406, 82172, 84999,** 86141

Experimental
83297, 82610, 82664, 83520, 83700, 83701, 83704, 83718, 83719, 83722, 83880, 84181, 85384, 85385, 0052U

**Unlisted code

Basic benefit and medical policy

Novel biomarkers in risk assessment of cardiovascular disease

This policy has been updated to cover procedure code *83695 when criteria are met, effective Nov. 1, 2022.

The safety and effectiveness of measuring apolipoprotein B concentrations have been established. It may be a useful diagnostic option when indicated for individuals at intermediate or high risk for a cardiovascular event.

The safety and effectiveness of high sensitivity C-reactive protein, or hs-CRP, measurement have been established. It may be a useful diagnostic option when indicated for individuals at intermediate risk for a cardiovascular event.

The safety and effectiveness of lipoprotein(a) measurement have been established. It may be a useful diagnostic option in those who meet criteria.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of laboratory testing of other novel biomarkers to assess cardiovascular risk including, but not limited to, apolipoprotein AI, apolipoprotein E or APOE genotypes, brain natriuretic peptide, or BNP, cystatin C, fibrinogen, leptin, LDL subclass, HDL subclass and PULS cardiac. Therefore, these services are experimental.

Inclusions:

Apolipoprotein B (apo B)

Apolipoprotein B measurement is established for individuals who meet at least one of the following criteria:

  • Hypertriglyceridemia
  • Diabetes mellitus
  • Obesity
  • Metabolic syndrome
  • Other dyslipidemias (e.g., very low LDL-C)
  • On lipid therapy
  • To facilitate diagnosis of familial dysbetalipoproteinemia
  • To facility diagnosis of familial combined hyperlipidemia

High-sensitivity C-reactive protein, or hs-CRP

High-sensitivity C-reactive protein testing is established for individuals who meet the following:

  • After quantitative risk assessment using ACC/AHA Pooled Cohort Equations to calculate 10-year risk of CVD events,** a risk-based treatment decision is uncertain

**Several tools are available to calculate 10-year risk of atherosclerotic cardiovascular disease, or ASCVD. The following are examples:

Lipoprotein(a) (Lp[a])

Lipoprotein(a) measurement is established for individuals meet at least one of the following criteria:

  • Individuals with primary severe hypercholesterolemia (LDL cholesterol greater than or equal to 190 mg/dL) or suspected familial hypercholesterolemia
  • Individuals with premature atherosclerotic cardiovascular disease, or ASCVD (i.e., diagnosis of ASCVD in men younger than 55 and in women younger than 65)
  • Family history of first-degree relatives with premature ASCVD (i.e., first-degree male relative diagnosed with ASCVD before reaching age 55; first-degree female relative diagnosed with ASCVD before reaching age 65
  • Family history of first-degree relative with elevated Lp(a)
  • Individuals at very high risk** of ASCVD to better define those who are more likely to benefit from PCSK9 (proprotein convertase subtilisin/kexin type 9 serine protease) inhibitor therapy

**Very high-risk includes a history of more than one major ASCVD events (e.g., history of myocardial infarction, history of ischemic stroke, recent acute coronary syndrome) or one major ASCVD event and multiple high-risk conditions (e.g., older than 65, family history of hypercholesterolemia, diabetes mellitus, hypertension, chronic kidney disease, history of congestive heart failure, current smoker, etc.)

Exclusions:

  • Measurement of apolipoprotein B, high-sensitivity C-reactive protein, and lipoprotein(a) is excluded for all other indications, including use as a routine screening test and for monitoring response to therapy
  • Laboratory testing of other novel biomarkers to assess cardiovascular risk including, but not limited to, apolipoprotein AI, apolipoprotein E or APOE genotypes, brain natriuretic peptide, cystatin C, fibrinogen, leptin, LDL subclass, HDL subclass, and PULS cardiac

90671

    

Basic benefit and medical policy

Vaxneuvance (pneumococcal 15-valent conjugate vaccine)

Effective June 24, 2022, Vaxneuvance (pneumococcal 15-valent conjugate vaccine) is covered for the following FDA-approved indications:

Vaxneuvance is a vaccine indicated for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in individuals 6 weeks and older.

Dosage and administration:

For intramuscular injection only. Each dose of Vaxneuvance is 0.5 mL.

Children: Administer Vaxneuvance as a 4-dose series at 2, 4, 6 and 12 through 15 months of age

J0490

Basic benefit and medical policy

Benlysta (belimumab)

Effective July 26, 2022, Benlysta (belimumab) is covered for the following FDA-approved indications:

Benlysta is a B-lymphocyte stimulator (BLyS)-specific inhibitor indicated for the treatment of:

  • Patients 5 years and older with active lupus nephritis who are receiving standard therapy

Limitations of use: The efficacy of Benlysta hasn’t been evaluated in patients with severe active central nervous system lupus. Use of Benlysta isn’t recommended in this situation.

Dosage and administration:

Intravenous dosage for adult and pediatric patients with SLE or lupus nephritis:

  • 10 mg/kg at two-week intervals for the first three doses and at four-week intervals thereafter. Reconstitute, dilute, and administer as an intravenous infusion over a period of one hour.
  • Consider prophylactic premedication for infusion reactions and hypersensitivity reactions.

J3357

    

Basic benefit and medical policy

Stelara (ustekinumab)

Effective July 29, 2022, Stelara (ustekinumab) is covered for the following FDA-approved indications:

Stelara is a human interleukin-12 and -23 antagonist indicated for the treatment of pediatric patients 6 years and older with active psoriatic arthritis, or PsA.

Dosage and administration:

Psoriatic arthritis pediatric (6 to 17 years old) Subcutaneous recommended dosage:

Weight-based dosing is recommended at the initial dose, four weeks later, then every 12 weeks thereafter.

Weight range (kilograms) and dosage regimen:

Weight range: Less than 60 kg
Dosage regimen: 0.75 mg/kg

Weight range: 60 kg or more
Dosage regimen: 45 mg

Weight range: Greater than 100 kg with coexistent moderate-to-severe plaque psoriasis
Dosage regimen: 90mg

Dosage forms and strengths:

Subcutaneous injection

  • Injection: 45 mg/0.5 mL or 90 mg/mL solution in a single-dose prefilled syringe
  • Injection: 45 mg/0.5 mL solution in a single-dose vial

Intravenous infusion

  • Injection: 130 mg/26 mL (5 mg/mL) solution in a single-dose vial

J3490

J3590

Basic benefit and medical policy

Cimerli (ranibizumab-eqrn)

Effective Aug. 2, 2022, Cimerli (ranibizumab-eqrn) is covered for the following FDA-approved indications:

Cimerli (ranibizumab-eqrn), a vascular endothelial growth factor, or VEGF, inhibitor, is indicated for the treatment of patients with:

  • Neovascular (Wet) age-related macular degeneration, or AMD
  • Macular edema following retinal vein occlusion, or RVO
  • Diabetic macular edema, or DME
  • Diabetic retinopathy, DR
  • Myopic choroidal neovascularization, or mCNV

Dosage and administration:

For ophthalmic intravitreal injection only.

  • Neovascular (Wet) age-related macular degeneration: Cimerli 0.5 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days).
    • Although not as effective, patients may be treated with three monthly doses followed by less frequent dosing with regular assessment.
    • Although not as effective, patients may also be treated with one dose every three months after four monthly doses. Patients should be assessed regularly.
  • Macular edema following retinal vein occlusion: Cimerli 0.5 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days).
  • Diabetic macular edema and diabetic retinopathy: Cimerli 0.3 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days).
  • Myopic choroidal neovascularization: Cimerli 0.5 mg (0.05 mL) is recommended to be initially administered by intravitreal injection once a month (approximately 28 days) for up to three months. Patients may be retreated if needed.

Dosage forms and strengths:

  • Single-dose glass vial designed to provide 0.05 mL for intravitreal injections:
    • 10 mg/mL solution (Cimerli 0.5 mg)
    • 6 mg/mL solution (Cimerli 0.3 mg)

This drug isn’t a benefit for URMBT.

J3490

J3590

    

Basic benefit and medical policy

Rolvedon (eflapegrastim-xnst) 

Effective Sept. 9, 2022, Rolvedon (eflapegrastim-xnst) is covered for the following FDA-approved indications:

Rolvedon is a leukocyte growth factor used to decrease the incidence of infection, as manifested by febrile neutropenia, in adult patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with clinically significant incidence of febrile neutropenia.
 
Limitations of use:

Rolvedon isn’t indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.

J3490

J3590

Basic benefit and medical policy

Terlivaz (terlipressin)

Effective Sept. 14, 2022, Terlivaz (terlipressin) is covered for the following FDA-approved indications:

Terlivaz is a vasopressin receptor agonist indicated to improve kidney function in adults with hepatorenal syndrome with rapid reduction in kidney function.

Limitation of use:

Patients with a serum creatinine >5 mg/dL are unlikely to experience benefit.

Dosage and administration:

Prior to initial dosing, assess patients for ACLF Grade 3 and obtain patient baseline oxygenation level. Monitor patient oxygen saturation with pulse oximetry.

Recommended dosage regimen:

  • Days 1 to 3 – Administer Terlivaz 0.85 mg (1 vial) intravenously every six hours.
  • Day 4: Assess serum creatinine, or SCr, versus baseline.
  • If SCr has decreased by at least 30% from baseline, continue Terlivaz 0.85 mg (1 vial) intravenously every six hours.
  • If SCr has decreased by less than 30% from baseline, dose may be increased to Terlivaz 1.7 mg (2 vials) intravenously every six hours.
  • If SCr is at or above baseline value, discontinue Terlivaz.
  • Continue Terlivaz until 24 hours after two consecutive SCr ≤1.5 mg/dL values at least two hours apart or a maximum of 14 days.

Dosage forms and strengths:

For injection: Terlivaz 0.85 mg (1 vial) as a lyophilized powder in a single-dose vial for reconstitution

J3490

J3590

    

Basic benefit and medical policy

Tzield (teplizumab-mzwv)

Tzield (teplizumab-mzwv) is considered established, effective Oct. 6, 2022. 
 
Coverage of Tzield (teplizumab-mzwv) is provided when all the following are met:

Patient must be a nondiabetic at a high risk for developing clinical Type 1 diabetes as evidenced by all of the following:

  • Patient must have a direct relative with Type 1 diabetes.
    • If first-degree relative (parent, sibling, offspring), patient must be between 8 and 45 years old.
    • If a second- or third-degree relative (niece, nephew, aunt, uncle, cousin, grandchild), patient must be between 8 to 20 years old.
  • Documentation of abnormal glucose tolerance by oral glucose tolerance test, or OGTT, defined as any of the following occurring at least once for patients under 18  or on two occasions for patients 18  and older within the last two months:
    • Fasting blood glucose level of 110mg/dL to < 126 mg/dL, or
    • Two-hour postprandial glucose > 140 mg/dL and < 200 mg/dL, or
    • Postprandial glucose level at 30, 60, or 90 minutes > 200 mg/dL
  • Presence of at least two of the following diabetes-related autoantibodies on two occasions within the previous six months: anti-GAD65, anti-ICA512, anti-insulin (MIAA), ZnT8, and/or ICA.
    • Autoantibodies found on the second occasion do not need to involve the same autoantibodies found on the first occasion.
  • Prescribed by or in consultation with an endocrinologist.
  • Trial and failure, intolerance or a contraindication to the preferred products as specified in the Blue Cross Blue Shield of Michigan and Blue Care Network medical utilization management drug list.

Quantity limitations, authorization period and renewal criteria:

  • Quantity limit: Align with FDA-recommended dosing.
  • Initial authorization period: Align with FDA-recommended duration of treatment.
  • Renewal criteria: Not applicable as no further authorization will be provided.

This drug isn’t a benefit for URMBT.

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.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.