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May 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 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. Under Topic Criteria, click on the circle for 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 |
90626, 90627 |
Basic benefit and medical policy
Ticovac
Ticovac™ is a vaccine indicated for active immunization to prevent tick-borne encephalitis. Ticovac is FDA approved for use in individuals ages 1 year and older. This policy is effective Aug. 13, 2021 (FDA approval).
Basic benefit policy group variations:
Note: Coverage is based on the member’s certificate benefits and may not be covered on all contracts. Reference member benefits before administering procedure. |
| POLICY CLARIFICATIONS |
78608, 78609, 78811, 78812, 78813,
78814, 78815, 78816, 78999, G0235,
A9593, A9594, A9595, A9800
Not covered:
G0219, G0252 |
Basic benefit and medical policy
PET for oncologic conditions
The safety and effectiveness of PET scanning for select oncologic applications have been established. It’s a useful diagnostic option for individuals meeting patient selection criteria.
Inclusionary criteria for the following conditions have been updated, effective March 1, 2023:
- Anal cancer
- Bladder cancer
- Bone cancer/sarcoma
- Brain cancer
- Colorectal cancer
- Head and neck cancer
- Penile cancer
- Soft tissue sarcoma
- Testicular cancer
- Vaginal/vulvar cancers
Inclusions:
All inclusionary and exclusionary statements apply to both positron emission tomography, or PET, scans and PET/CT scans, i.e., PET scans with or without PET/CT fusion.
A PET or PET/CT may be appropriate for a patient with known diagnosis of a malignancy in order to determine the optimal anatomic site for a biopsy or other invasive diagnostic procedure if standard imaging is equivocal. It also may replace conventional imaging when conventional imaging would be inadequate for accurate staging, and when clinical management will depend upon the stage of disease. In general, for most solid tumors, a tissue diagnosis is made before the performance of PET scanning. PET scans following a tissue diagnosis are performed for staging, not diagnosis. If the results of the PET scan won’t influence treatment decisions, these situations would be considered not medically necessary.
PET scans may be considered appropriate for the following oncologic conditions:
Anal cancer
Inclusions:
- For the diagnosis when standard imaging can’t be performed or is nondiagnostic for metastatic disease.
- Indicated in either of the following:
- Radiation planning for definitive treatment only
- Standard imaging can’t be performed or is nondiagnostic for recurrent or progressive disease
- For locally progressive or recurrent cancer with evidence of progression found on digital rectal exam.
Exclusions:
- Conditions not listed above
Bladder cancer
Inclusions:
- Diagnostic workup:
- Evaluation of stage II or stage III bladder cancer prior to definitive treatment when standard imaging can’t be performed or is nondiagnostic for metastatic disease
- When bone metastasis is suspected based on signs and symptoms and standard imaging can’t be performed or is nondiagnostic
- Management:
- Standard imaging can’t be performed or is nondiagnostic for recurrent or progressive disease.
Exclusions:
- Conditions not listed above
Bone cancer/sarcoma
Inclusions:
- Diagnostic workup (indicated in any of the following scenarios [all tumor types]):
- Initial workup of Ewing sarcoma and osteosarcoma if curative treatment planned
- Standard imaging can’t be performed or is nondiagnostic for metastatic disease
- Standard imaging suggests a resectable solitary metastasis
- Baseline study prior to neoadjuvant chemotherapy
- Management:
- Indicated following completion of neoadjuvant chemotherapy
Exclusions:
- Conditions not listed above
Brain cancer
Inclusions:
- Diagnostic workup:
- Evaluation of possible systemic disease in proven CNS lymphoma
- For staging, where lesions metastatic from the brain are identified
- For restaging, to distinguish recurrent tumor from radiation necrosis
Exclusions:
- Conditions not listed above
Colorectal cancer
Inclusions:
- Diagnostic workup:
- Indicated when standing imaging (CT chest, abdomen and pelvis) can’t be performed or isn’t diagnostic for surgically curable metastatic disease
- Management:
- Indicated in any of the following scenarios:
- CT is equivocal for metastatic disease and lesion are greater than 1 cm in diameter.
- CT demonstrates recurrence that is potentially curable with surgery.
- CT doesn’t demonstrate a focus of recurrence but carcinoembryonic antigen, or CEA, level is rising.
- Signs or symptoms are suggestive of recurrence and CT is contraindicated.
Exclusions:
- When used as a technique to assess the presence of scarring versus local bowel recurrence in individuals with previously resected colorectal cancer
- When used as a technique contributing to radiotherapy treatment planning
Head and neck cancer
Inclusions:
- For the evaluation of the head and neck in the initial diagnosis of suspected head and neck cancer
- For the initial staging of the disease
- For restaging of residual or recurrent disease during follow up
- Evaluation of response to treatment
Exclusions:
- Conditions not listed above
Penile cancer
Inclusions:
- Diagnostic workup:
- Indicated in either of the following scenarios:
- Standard imaging can’t be performed or is nondiagnostic for metastatic disease.
- Staging of penile cancer when pelvic lymph nodes are enlarged on CT or MRI and needle biopsy isn’t technically feasible
- Management:
- Indicated in any of the following scenarios:
- Radiation planning for preoperative or definitive treatment only
- Standard imaging can’t be performed or is nondiagnostic for recurrent or progressive disease
- Restaging of local recurrence when pelvic exenteration surgery is planned
Exclusions:
Soft tissue sarcoma
Inclusions:
- Diagnostic workup:
- Indicated in any of the following scenarios (excluding desmoid tumors):
- Standard imaging can’t be performed or is nondiagnostic for metastatic disease
- Standard imaging suggests a resectable solitary metastasis
- Baseline study prior to neoadjuvant chemotherapy
- Initial staging for rhabdomyosarcoma
- Determination of response to therapy, gastrointestinal stromal tumor for initial staging and re-staging when there is documented recurrence
- Management:
- Indicated following completion of neoadjuvant chemotherapy
Exclusions:
- When used in evaluation of soft tissue sarcoma including, but not limited to, the following applications:
- Distinguishing between low grade and high-grade soft tissue sarcoma
- Detecting locoregional recurrence
- Detecting distant metastasis
Testicular cancer
Inclusions:
- Diagnostic workup:
- Indicated when standard imaging can’t be performed or is nondiagnostic for metastatic disease
- Management:
- Standard imaging can’t be performed or is nondiagnostic for recurrent or progressive disease
- Residual mass greater than 3 cm and normal tumor markers after completion of chemotherapy
Exclusions:
Vaginal/vulvar cancers
Inclusions:
- Diagnostic workup:
- Indicated in either of the following scenarios:
- Standard imaging can’t be performed or is nondiagnostic for metastatic disease
- Staging of penile cancer when pelvic lymph nodes are enlarged on CT or MRI and needle biopsy isn’t technically feasible
- Management:
- Indicated in any of the following scenarios:
- Radiation planning for preoperative or definitive treatment only
- Standard imaging can’t be performed or is nondiagnostic for recurrent or progressive disease
- Restaging of local recurrence when pelvic exenteration surgery is planned
Exclusions:
Note: This notification doesn’t include all the conditions addressed in the medical policy because of the lengthy list. Reference the policy itself if a condition isn’t addressed here.
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89344 |
Basic benefit and medical policy
*89344 on Physician Office Laboratory List
Procedure code *89344 has been added to the Physician Office Laboratory List. It can be performed in a physician’s office. |
90715 |
Basic benefit and medical policy
Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed)
Effective Oct. 10, 2022, Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) is covered for the following FDA-approved indications:
Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) is a vaccine indicated for the following:
- Active booster immunization against tetanus, diphtheria and pertussis in individuals ages 10 and older
- Immunization during the third trimester of pregnancy to prevent pertussis in infants younger than 2 months of age
Dosage and administration:
For intramuscular use only.
- Each dose of Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) is administered as a 0.5-mL injection.
- An initial dose of Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) is administered five years or more after the last dose of the diphtheria and tetanus toxoids and acellular pertussis, or DTaP, series or five years or more after a dose of tetanus and diphtheria toxoids adsorbed, or Td. Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) may be administered as an additional dose nine years or more after the initial dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed, or Tdap.
- Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) may be administered for tetanus prophylaxis for wound management. For management of a tetanus-prone wound, a dose of Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) may be administered if at least five years have elapsed since previous receipt of a tetanus toxoid-containing vaccine.
- To provide protection against pertussis in infants younger than 2 months of age, administer Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) during the third trimester of pregnancy.
|
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. |
J0224 |
Basic benefit and medical policy
Oxlumo (lumasiran)
Effective Oct. 6, 2022, Oxlumo (lumasiran) is covered for the following FDA-approved indications:
- Oxlumo is a HAO1-directed small interfering ribonucleic acid, or siRNA, indicated for the treatment of primary hyperoxaluria type 1 to lower urinary and plasma oxalate levels in pediatric and adult patients.
Dosage and administration:
The recommended dose of Oxlumo by subcutaneous injection is based on body weight.
Body weight less than 10 kg: Loading dose is 6 mg/kg once monthly for three doses. Maintenance dose is 3 mg/kg once monthly, beginning one month after the last loading dose.
Body weight of 10 kg to less than 20 kg: Loading dose is 6 mg/kg once monthly for three doses. Maintenance dose is 6 mg/kg once every three months quarterly, beginning one month after the last loading dose.
Body weight of 20 kg and above: Loading dose is 3 mg/kg once monthly for three doses. Maintenance dose is 3 mg/kg once every three months quarterly, beginning one month after the last loading dose. |
J3490
J3590 |
Basic benefit and medical policy
Briumvi (ublituximab-xiiy)
Briumvi (ublituximab-xiiy) is considered established effective Dec. 28, 2022.
Briumvi is a CD20-directed cytolytic antibody indicated for the treatment of relapsing forms of multiple sclerosis to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease in adults.
Dosage and administration:
- Hepatitis B virus screening and quantitative serum immunoglobulin screening are required before first dose.
- Pre-medicate with methylprednisolone (or an equivalent corticosteroid) and an antihistamine (e.g., diphenhydramine) prior to each infusion.
- Administer Briumvi by intravenous infusion:
- First infusion: 150 mg intravenous infusion
- Second infusion: 450 mg intravenous infusion two weeks after the first infusion
- Subsequent Infusions: 450 mg intravenous infusion 24 weeks after the first infusion and every 24 weeks thereafter
- Must be diluted in 0.9% sodium chloride Injection, USP prior to administration.
- Monitor patients closely during and for at least one hour after the completion of the first two infusions. Post-infusion monitoring of subsequent infusions is at physician discretion unless infusion reaction and/or hypersensitivity has been observed.
Dosage forms and strengths:
Injection: 150 mg/6 mL (25 mg/mL) in a single-dose vial
Coverage of Briumvi is provided when all the following are met:
- Won’t be used in combination with other disease-modifying treatments of multiple sclerosis
- Trial and failure, contraindication, or intolerance to the preferred drugs as listed in Blue Cross Blue Shield of Michigan’s utilization management medical drug list and/or Blue Cross’ prior authorization and step therapy documents
This drug isn’t a benefit for URMBT. |
J3490
J3590 |
Basic benefit and medical policy
Iheezo (chloroprocaine hydrochloride)
Effective Sept. 27, 2022, Iheezo (chloroprocaine hydrochloride) is covered for the following FDA-approved indications:
- Iheezo (chloroprocaine hydrochloride) is an ester anesthetic indicated for ocular surface anesthesia.
Dosage and administration:
The recommended dose of Iheezo (chloroprocaine hydrochloride) is three drops applied topically to the ocular surface in the area of the planned procedure.
Iheezo (chloroprocaine hydrochloride) may be reapplied as needed to maintain anesthetic effect.
Dosage forms and strengths:
Iheezo (chloroprocaine hydrochloride ophthalmic gel) 3% contains 24 mg of chloroprocaine hydrochloride per vial (800 mg). Clear, colorless to light yellow gel in single-patient-use vial.
Iheezo (chloroprocaine hydrochloride) isn’t a benefit for URMBT. |
J3490
J3590 |
Basic benefit and medical policy
Sunlenca (lenacapavir)
Sunlenca (lenacapavir) is considered established, effective Dec. 22, 2022.
Sunlenca, a human immunodeficiency virus type 1, or HIV-1, capsid inhibitor, in combination with other antiretrovirals, is indicated for the treatment of HIV-1 infection in heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance or safety considerations.
Dosage and administration:
Recommended dosage: Initiation with one of two options followed by once every six-months maintenance dosing. Tablets may be taken without regard to food.
Initiation Option 1
Day 1: 927 mg by subcutaneous injection (2 x 1.5 mL injections) 600 mg orally (2 x 300 mg tablets)
Day 2: 600 mg orally (2 x 300 mg tablets)
Initiation Option 2
Day: 1 600 mg orally (2 x 300 mg tablets)
Day 2: 600 mg orally (2 x 300 mg tablets)
Day 8: 300 mg orally (1 x 300 mg tablet)
Day 15: 927 mg by subcutaneous injection (2 x 1.5 mL injections)
Maintenance
927 mg by subcutaneous injection (2 x 1.5 mL injections) every six months (26 weeks) from the date of the last injection +/-2 weeks.
- Missed dose: If more than 28 weeks since last injection and clinically appropriate to continue Sunlenca, restart initiation from Day 1, using either Option 1 or Option 2.
- Two 1.5 mL subcutaneous injections are required for complete dose.
Dosage forms and strengths:
Tablets: 300 mg Injection: 463.5 mg/1.5 mL (309 mg/mL) in single-dose vials
Coverage of Sunlenca is provided when all the following are met:
- Will be used in combination with other anti-retroviral therapy for the treatment of human immunodeficiency virus type 1, or HIV-1.
- Patient is heavily treatment-experienced with multidrug resistant HIV-1 infection based on the following:
- Documented resistance to at least one antiretroviral medication from three different classes of drugs.
- Patient is failing their current antiretroviral regimen.
- Trial and failure, contraindication, or intolerance to the preferred drugs as listed in Blue Cross Blue Shield of Michigan’s utilization management medical drug list and/or Blue Cross’ prior authorization and step therapy documents.
This drug isn’t a benefit for URMBT. |
J3490
J3590 |
Basic benefit and medical policy Xenoview (xenon Xe 129 hyperpolarized)
Effective Dec. 23, 2022, Xenoview (xenon Xe 129 hyperpolarized) is covered for the following FDA-approved indications:
- Xenoview, prepared from the Xenon Xe 129 Gas Blend, is a hyperpolarized contrast agent indicated for use with an MRI for evaluation of lung ventilation in adults and pediatric patients aged 12 and older.
Limitations of use:
Xenoview hasn’t been evaluated for use with lung perfusion imaging.
Dosage and administration:
- The recommended target dose of Xenoview for adult and pediatric patients ages 12 and older is 75 mL to 100 mL dose equivalent, or DE, of hyperpolarized xenon Xe 129 by oral inhalation of the entire contents of one Xenoview Dose Delivery Bag.
- Each bag contains at least 75 mL DE of hyperpolarized xenon Xe 129 with a recommended target DE range of 75 mL to 100 mL measured within five minutes of administration, in a volume of 250 mL to 750 mL total xenon with additional nitrogen, NF (99.999% purity) added to reach a total volume of 1,000 mL.
- Administer dose within five minutes of DE measurement.
- Initiate imaging immediately after inhalation.
Dosage forms and strengths:
- Xenoview is a clear, colorless, odorless gas contained in a 1,000 mL Xenoview Dose Delivery Bag. The bag contains at least 75 mL DE of hyperpolarized xenon Xe 129 in a volume of 250 mL to 750 mL total xenon.
- The strength is DE per 1,000 mL administered. The minimum DE for a dose of Xenoview is 75 mL with a recommended DE target range of 75 to 100 mL. DE of greater than 100 mL is acceptable.
Xenoview (xenon Xe 129 hyperpolarized) isn’t a benefit for URMBT.
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J9047 |
Basic benefit and medical policy
Kyprolis (carfilzomib)
Effective Aug. 1, 2022, Kyprolis (carfilzomib) is covered for the following FDA-approved indications:
- Kyprolis (carfilzomib) is a proteasome inhibitor indicated for the treatment of adult patients with relapsed or refractory multiple myeloma who have received one to three lines of therapy in combination with isatuximab and dexamethasone.
Dosage and administration:
Regimen: Kyprolis and dexamethasone (Kd) or Kyprolis, Daratumumab and Dexamethasone (DKd) or Kyprolis, Daratumumab and hyaluronidase-fihj and Dexamethasone (DKd) or Kyprolis, Isatuximab and Dexamethasone (Isa-Kd) or Kyprolis Monotherapy.
Dosage: 20/56 mg/m2 twice weekly
Infusion time: 30 minutes |
J9358 |
Basic benefit and medical policy
Enhertu (fam-trastuzumab deruxtecan-nxki)
Enhertu (fam-trastuzumab deruxtecan-nxki) is payable for the updated FDA indications, effective Nov. 4, 2022:
- Adult patients with unresectable or metastatic HER2-low (IHC 1+ or IHC 2+/ISH-) breast cancer, as determined by an FDA-approved test, who have received a prior chemotherapy in the metastatic setting or developed disease recurrence during or within six months of completing adjuvant chemotherapy.
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None of the information included in this billing chart is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations. |
