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November 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
|
| UPDATES TO PAYABLE PROCEDURES |
81450, 81455 |
Basic benefit and medical policy
Updated medical policies
Updates have been made to the covered conditions for a panel test that evaluates hematolymphoid neoplasms or disorders, and another test that evaluates both hematolymphoid and solid organ tumors. These changes were made to align the payable diagnoses with various criteria outlined in several policies. The changes were effective March 1, 2023.
The following medical policies can be viewed on the Medical Policy Router or Benefit Explainer:
- Genetic Testing – Next Generation Sequencing of Multiple Genes (Panel) for Malignant Conditions
- Genetic Testing – JAK2, MPL and CALR Testing for Myeloproliferative Neoplasms
- Genetic Testing for FMR1 and FMR2 variants (Including Fragile X and Fragile XE Syndromes)
- Genetic Testing for FLT3, NPM1, CEBPA, IDH1 and IDH2 Variants in Acute Myeloid Leukemia
- Genetic Testing – BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
Payable diagnoses:
D61.818, D72.824, D75.81 and E88.09, plus the range of malignant conditions
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J9035
Q5107
Q5118
Q5126 |
Basic benefit and medical policy
Off-label use of Avastin (bevacizumab)
Blue Cross Blue Shield of Michigan has approved payment for the off-label use of Avastin (bevacizumab). The listed procedure codes are payable for off-label use to treat endometrial cancer.
URMBT groups are excluded from this change. |
| POLICY CLARIFICATIONS |
20930, 22533, 22558
|
Basic benefit and medical policy
Bone morphogenetic protein
The safety and effectiveness of the use of recombinant human bone morphogenetic protein-2 (Infuse™) have been established in skeletally mature patients, effective Sept. 1, 2023.
Inclusions:
The use of recombinant human bone morphogenetic protein-2 (Infuse™) is indicated in skeletally mature patients when used as described per FDA approval (one of the following criteria must apply):
- For spinal indications when used with the appropriate FDA-approved cage and all the following criteria are met:
- Surgery is planned for one level from L2-S1 for the treatment of degenerative disc disease through an anterior, oblique or direct lateral approach.
- There’s a high risk for failure of fusion (prior failed spinal fusion, recent history of smoking, presence of diabetes or renal disease, alcoholism, long-term steroid use or osteoporosis).
- Autologous bone or marrow isn’t feasible** or not expected to promote fusion.
- For use in tibia trauma indications when the following criterion is met:
- For the treatment of acute, open fracture of the tibial shaft when the use of autograft is not feasible.**
**Use of autologous (iliac crest bone) graft may be considered not feasible due to situations that may include, but aren’t limited to, prior harvesting of iliac crest bone graft or need for a greater quantity of iliac crest bone graft than available (for example, for multilevel fusion).
Exclusions:
The use of recombinant human bone morphogenetic protein-2 is considered experimental for all other indications not listed above including, but not limited to, spinal fusion when the use of autograft is feasible and craniomaxillofacial surgery, or when any of the following are present:
- Planned posterior approach fusion
- Cervical or thoracic indications
- Known sensitivity to implant material or bovine type I collagen, or with an allergy to titanium (including alloys) or polyetheretherketone
- Use near the site of extant or resected tumor, or for patients with active malignancy or receiving treatment for cancer
- Infection at the planned operative site
- Pediatric patients younger than 18, or skeletal immaturity
- Female patients who are pregnant or those planning to become pregnant within one year of placement
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89253 |
Basic benefit and medical policy
*89253 removed from Physician Office Laboratory List
Procedure code *89253 was removed from the Physician Office Laboratory List. This procedure can no longer be performed in a physician’s office. |
C9399
J3490
J3590
J9999 |
Basic benefit and medical policy
Columvi (glofitamab-gxbm)
Effective June 15, 2023, Columvi (glofitamab-gxbm) is considered established when criteria are met.
Columvi (glofitamab-gxbm) is a bispecific CD20-directed CD3 T-cell engager indicated for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified, or DLBCL, NOS, or large B-cell lymphoma, known as LBCL, arising from follicular lymphoma, after two or more lines of systemic therapy.
This indication is approved under accelerated approval based on response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.
Dosage and administration:
- Pretreat with a single 1,000 mg dose of obinutuzumab intravenously seven days before initiation of Columvi (glofitamab-gxbm); Cycle 1, Day 1.
- Administer premedications as recommended.
- Administer only as an intravenous infusion.
- Recommended dosage:
Treatment Cycle 1
Day 1 – Obinutuzumab 1,000 mg
Day 8 – Step-up dose 1 2.5 mg
Day 15 – Step-up dose 2 10 mg
Treatment Cycle 2-12
Day 1 – 30 mg
Cycle = 21 days
- Administer in a facility equipped to monitor and manage CRS.
- Patients should be hospitalized for the 2.5 mg step-up dose and for subsequent infusions as recommended.
Dosage forms and strengths:
Injection:
- 2.5 mg/2.5 mL (1 mg/mL) in a single-dose vial.
- 10 mg/10 mL (1 mg/mL) in a single-dose vial.
Columvi (glofitamab-gxbm) isn’t covered for URMBT. |
J0172
J1427
J1428 |
Basic benefit and medical policy
Aduhelm (aducanumab-avwa), Viltepso (viltolarsen) and Exondys 51 (eteplirsen)
The medical drugs Aduhelm (aducanumab-avwa), Viltepso (viltolarsen) and Exondys 51 (eteplirsen) are considered experimental. This change is effective Oct. 1, 2023. |
J0565 |
Basic benefit and medical policy Zinplava (bezlotoxumab)
Effective May 26, 2023, Zinplava (bezlotoxumab) is covered for the following FDA-approved indication:
Zinplava (bezlotoxumab) is a human monoclonal antibody that binds to Clostridioides difficile toxin B, used to reduce recurrence of clostridioides difficile infection, or CDI, in adults and pediatric patients 1 year and older who are receiving antibacterial drug treatment for CDI and are at a high risk for CDI recurrence. |
J3490
J3590 |
Basic benefit and medical policy
Lantidra (donislecel-jujn)
Lantidra (donislecel-jujn) is considered established, effective June 29, 2023.
Lantidra is an allogeneic pancreatic islet cellular therapy indicated for the treatment of adults with Type 1 diabetes who are unable to approach target HbA1c because of current repeated episodes of severe hypoglycemia despite intensive diabetes management and education. Use in conjunction with concomitant immunosuppression.
Dosage and administration:
For infusion into the hepatic portal vein only
- Don’t irradiate.
- Don’t use leukodepleting filters.
- Don’t use if product time exceeds six hours post-product release or if temperature isn’t maintained between 15 and 25 degrees Celsius.
- The recommended minimum dose is 5,000 equivalent islet number, or EIN, per kg patient body weight for initial infusion (transplant) and 4,500 EIN/kg for subsequent infusions (same recipient).
- Administer cells through the hepatic portal vein. The estimated tissue volume shouldn’t exceed 10 cc per transplant infusion.
Dosage forms and strengths:
The dosage form is a cellular suspension. Dosage strength depends on the total number of islets packaged for infusion, which is reported on the container label and associated documents.
This drug isn’t a benefit for URMBT. |
J3490
J3590 |
Basic benefit and medical policy Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)
Effective June 20, 2023, Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) is covered for the following FDA-approved indications:
Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) is a combination of efgartigimod alfa, a neonatal Fc receptor blocker, and hyaluronidase, an endoglycosidase, indicated for the treatment of generalized myasthenia gravis, or gMG, in adult patients who are anti-acetylcholine receptor, or AChR, antibody positive.
Dosage and administration:
- Evaluate the need to administer age-appropriate vaccines according to immunization guidelines before initiation of a new treatment cycle with Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc).
- Administer by a health care professional only.
- For subcutaneous use with a winged infusion set.
- The recommended dose is 1,008 mg / 11,200 units (1,008 mg efgartigimod alfa and 11,200 units hyaluronidase) administered subcutaneously over approximately 30 to 90 seconds in cycles of once-weekly injections for four weeks.
- Administer subsequent treatment cycles based on clinical evaluation; the safety of initiating subsequent cycles sooner than 50 days from the start of the previous treatment cycle hasn’t been established.
Dosage forms and strengths:
Injection: 1,008 mg efgartigimod alfa and 11,200 units hyaluronidase per 5.6 mL (180 mg/2,000 units per mL) in a single-dose vial
Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) isn’t a benefit for URMBT. |
J9271 |
Basic benefit and medical policy
Keytruda (pembrolizumab)
Effective April 3, 2023, Keytruda (pembrolizumab) is no longer payable for the following indication and usage.
The following statement has been removed from the Urothelial Carcinoma Indication:
- Patients whose tumors express PD-L1 (Combined Positive Score ≥10) as determined by an FDA-approved test, or in patients who aren’t eligible for any platinum-containing chemotherapy regardless of PD-L1 status.
The following limitation of use statement has been removed from the Microsatellite Instability-High Cancer or Mismatch Repair Deficient Cancer Indication:
- The safety and effectiveness of Keytruda in pediatric patients with MSI-H central nervous system cancers haven’t been established.
|
J9309 |
Basic benefit and medical policy
Polivy (polatuzumab vedotin-piiq)
Effective April 19, 2023, Polivy® (polatuzumab vedotin-piiq) is indicated for the following new FDA-approved indication:
In combination with a rituximab product, cyclophosphamide, doxorubicin and prednisone, or R-CHP, for the treatment of adult patients who have previously untreated diffuse large B-cell lymphoma, not otherwise specified, or high-grade B-cell lymphoma and who have an International Prognostic Index score of 2 or greater. |
Condition Code 45 |
Basic benefit and medical policy
Revised nomenclature of Condition Code 45
The National Uniform Billing Committee revised the nomenclature/description of Condition Code 45 to Gender Incongruence, effective July 1, 2023. |
Value Code 42 |
Basic benefit and medical policy Revised nomenclature of Value Code 42
The National Uniform Billing Committee revised the nomenclature of Value Code 42 to VA or PACE retroactively for an effective date of July 1, 2023. |
| EXPERIMENTAL PROCEDURES |
98978, A9291 |
Basic benefit and medical policy
Digital health therapies for substance use
Digital health therapies for individuals with substance use disorders are considered experimental.
Procedure code *98978 was originally loaded as payable but was considered experimental as of Aug. 1, 2023.
Inclusionary guidelines and exclusionary guidelines:
Not applicable |
| GROUP BENEFIT CHANGES |
Lacks Enterprises, Inc. |
Lacks Enterprises, Inc., group number 000071855, is returning to Blue Cross Blue Shield of Michigan, effective Jan. 1, 2024.
Group number: 000071855
Alpha prefix: A4F
Platform: NASCO
Plans offered:
HDHP-PPO Standard Blue Cross PPO Network
Medical
Virtual Care by Teladoc Health™ (formerly Blue Cross Online Visits℠)
Advocate (formerly known as Navigator)
Pharmacy is carved out to Magellan.
Lacks offers near-site clinics managed by Trinity Health
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Teladoc Health is an independent company that provides virtual care solutions for Blue Cross Blue Shield of Michigan.
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. |
