Billing chart: Blue Cross highlights medical, benefit policy changes

0421T, C2596

Basic benefit and medical policy

Aquablation of the prostate

Aquablation (transurethral waterjet ablation) of the prostate is considered established as an alternative to open prostatectomy or transurethral resection of the prostate for the treatment of benign prostatic hyperplasia.

Procedure codes *0421T and C2596 were added as payable for all groups, effective of May 1, 2023.

Inclusions:
 
Aquablation (transurethral waterjet ablation) for the treatment of urinary outlet obstruction due to benign prostatic hyperplasia, or BPH, is considered established once per lifetime when all the following criteria are met:

• The individual is age 80 years or younger with prostate volume of 30 to 150 cc by transrectal ultrasound, or TRUS, and persistent moderate to severe symptoms despite maximal medical management, including all the following attributed to BPH:
• The individual has an International Prostate Symptom Score, or IPSS, of equal to or greater than 12.
• The individual has a peak urine flow rate (Qmax) of less than or equal to 15mL/sec on a voided volume that is greater than 125 cc.
• The individual has had a failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH (e.g., alpha-blocker, PDE5 Inhibitor, finasteride/dutasteride).

Exclusions:

• The individual has none of the following:
• Severe obesity (BMI ≥ 42kg/m2)
• Known or suspected prostate cancer or a prostate specific antigen, or PSA, >10 ng/mL unless there has been a negative prostate biopsy within the past six months
• Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum
• Damaged external urinary sphincter
• Treatment for chronic prostatitis
• Diagnosis of urethral stricture, meatal stenosis or bladder neck contracture
• Active urinary tract or systemic infection
• Known allergy to device materials
• Inability to safely stop anticoagulants or antiplatelet agents preoperatively

81225, 81226, 81227, 81418    

Not  covered/experimental:
81230, 81231, 81401, 81402, 81404, 81405, 0380U

Basic benefit and medical policy

Cytochrome P450 testing

The safety and effectiveness of Cytochrome P450, or CYP450, genotyping for the purpose of aiding in the choice of clopidogrel versus alternative antiplatelet agents or determining drug metabolizer status for patients with multiple sclerosis, Gaucher and Huntington’s disease have been established. It may be considered a useful diagnostic option for patients who meet specific patient selection criteria.

Procedure code *81227 is being added as a payable service, and inclusionary criteria have been updated, effective May 1, 2023.

Inclusions (one of the following):

• CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative anti-platelet agents
• CYP450 genotyping for the purpose of aiding in decisions on the optimal dosing for clopidogrel
• CYP2D6 genotyping to determine drug metabolizer status for patients with one of the following:
• Gaucher disease being considered for treatment with eliglustat
• Huntington’s disease being considered for treatment with tetrabenazine in a dosage greater than 50 mg per day
• Relapsing forms of multiple sclerosis to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease, being considered for treatment with siponimod (See the pharmacy policy on Genetic Testing for dosage information.)

Exclusions:

CYP450 genotyping for the purpose of aiding in the choice of drug or dose to increase efficacy or avoid toxicity for all other drugs. This includes, but isn’t limited to, CYP450 genotyping for the following applications (list may not be all-inclusive):

• Selection or dosing of codeine
• Dosing of efavirenz and other antiretroviral therapies for HIV infection
• Dosing of immunosuppressant for organ transplantation
• Selection or dose of beta-blockers (e.g., metoprolol)
• Dosing and management of antituberculosis medicines

The use of genetic testing panels that include multiple CYP450 mutations is considered experimental.

J3490

Basic benefit and medical policy

Qalsody (tofersen)

Qalsody (tofersen) is considered established, effective April 25, 2023.

Coverage of Qalsody (tofersen) is provided when all the following are met:

• FDA-approved indication: For the treatment of amyotrophic lateral sclerosis in adults who have a mutation in the superoxide dismutase 1, or SOD1, gene. This indication is approved under accelerated approval based on reduction in plasma neurofilament light chain observed in patients treated with Qalsody™. Continued approval for this indication may be contingent upon verification of clinical benefit in confirmatory trial or trials.
• FDA-approved age.
• Confirmed superoxide dismutase 1, or SOD1, mutation.
• Vital capacity greater than 50% predicted.
• Submission of a baseline metrics from the ALSFRS-R.
• Currently receiving treatment and will continue to receive treatment with riluzole, if tolerated.
• Trial and failure, intolerance or a contraindication to the preferred products as specified in the Blue Cross Blue Shield of Michigan or Blue Care Network medical utilization management drug list.

Quantity limitations, authorization period and renewal criteria:

• Quantity limits: Align with the FDA’s recommended dosing.
• Authorization period: One year at a time.
• Renewal criteria: Continuation of coverage requires submission of patient assessments using the ALSFRS-R or other clinical documentation to determine if Qalsody is slowing the progression of ALS.

This drug isn’t a benefit for URMBT.

J9035
Q5107
Q5118
Q5126

Basic benefit and medical policy

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 malignant neoplasm of the uterus.

URMBT groups are excluded from this change.