The Record - Billing chart: Blues highlight medical, benefit policy changes

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

0164T, 0165T, 22857, 22860, 22862, 22865

Basic benefit and medical policy

Artificial discs for lumbar spine

The insertion of artificial intervertebral discs in the lumbar spine is established. It may be considered a useful therapeutic option when indicated, effective Sept. 1, 2023.

Benefit payment policy:

Prior authorization is required from TurningPoint for the procedure codes listed when performed in Place of Service B (ambulatory surgical center), Place of Service 2 (outpatient hospital) and Place of Service 3 (office) for members with individual coverage and fully insured PPO, Traditional contracts.

Inclusions:

Lumbar disc replacement with a U.S. Food and Drug Administration-approved lumbar artificial intervertebral prosthesis** is considered medically appropriate for the treatment of discogenic low back pain related to a degenerated disc at one or two levels*** that meet all the following criteria:

Radiographic evidence of moderate to severe degeneration with modic changes at levels planned for replacement from L3 to S1, when compared to other normal or mildly degenerated levels.
Symptoms have been present for at least one year and interfere with daily activities.
Presence of chronic pain and functional impairment that has failed to improve with at least six months of non-operative treatment, including all the following:

Physical therapy or rehabilitation
Pain management (e.g., medication, injections)
Cognitive behavioral therapy, where indicated

Absence of a poorly treated psychiatric disorder.
Primary complaint of axial pain, with or without lower extremity pain.
Individual is skeletally mature and between the ages of 18 and 60.
There is no significant facet joint arthropathy at level planned for surgery.

**Only implants with FDA approval are considered established:

Prodisc L: L3-S1
Active-L: L4-S1

***All requests for two-level lumbar disc replacements will require review on an individual basis.

Exclusions:

Lumbar disc replacement isn’t considered medically
appropriate if the above criteria are not met, or if any of
the following contraindications are present:

Disease at a level superior to L3-L4
Planned disc replacement with a prior fusion or disc replacement at any other lumbar level
Presence of a neoplasm or infection (at surgical site or systemic)
Known hypersensitivity to implant materials (e.g., cobalt, chromium, polyethylene, titanium)
Age less than 18 or greater than 60
Radiographic evidence of facet joint degeneration or disease or pars defect
Radiographic evidence of multilevel degeneration or bony lumbar spinal stenosis
Disc replacement will be performed at the same time as lumbar fusion at another level
Osteoporosis or osteopenia (DEXA bone density T-score of less than -1.0)
Isolated radicular compression syndromes (including central or far-lateral disc herniation)
Traumatic injury at affected level resulting in compromised vertebral bodies
Degenerative or lytic spondylolisthesis greater than Grade 1
Presence of a poorly treated psychiatric disorder
BMI greater than 40

TurningPoint Healthcare Solutions LLC is an independent company that manages prior authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan.

UPDATES TO PAYABLE PROCEDURES

0364U, 81479**

**Not otherwise classified procedure

Basic benefit and medical policy

NGS to assess measurable residual disease

The efficacy of next-generation sequencing (e.g., clonoSEQ^®) to detect measurable residual disease has been established. It may be considered a useful option when specific criteria are met.

Additional payable diagnoses have been added, effective Nov. 1, 2023.

Payment policy:

Payable diagnoses:

C90.00, C90.01, C90.02, C91.00, C91.01, C91.02, C91.10, C91.11, C91.12, C91.30, C91.31, C91.32, C91.A0, C91.A1, C91.A2

Inclusions:

Next-generation sequencing (e.g., clonoSEQ) to detect measurable residual disease, or MRD, in any one of the following hematologic malignancies:

B-cell acute lymphoblastic leukemia
Chronic lymphocytic leukemia
Multiple myeloma

Exclusions:

Next-generation sequencing (e.g., clonoSEQ) to detect MRD in all other situations.

POLICY CLARIFICATIONS

0829

Basic benefit and medical policy

Revenue code 0829

Revenue code 0829 is an outpatient dialysis code and will reject as provider liable when reported on an inpatient claim. Make sure to reference a coding authority, such as the Centers for Medicare & Medicaid Services or the National Uniform Billing Committee, for the appropriate inpatient renal dialysis revenue code range.

A list of acceptable outpatient dialysis revenue codes and condition codes can be found in the “Dialysis” chapter of the provider manual. You can also find a complete list of acceptable codes for reporting outpatient dialysis services in our provider portal, availity.com.**

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

0089U

Experimental
81479, **81529, 81599, **84999, **0314U

**Unlisted procedure codes

Basic benefit and medical policy

Gene expression profiling for cutaneous melanoma

This policy was updated to cover procedure code *0089U when criteria are met, effective Sept. 1, 2023.

The safety and effectiveness of pigmented lesion assay for the diagnosis of cutaneous melanoma have been established. It may be considered a useful diagnostic option when indicated.

Gene expression profile, or GEP, tests that provide a numerical score to assess the likelihood of melanoma are experimental. The technology hasn’t been demonstrated to improve net health outcomes.

GEP tests that classify lesions as having low risk or high risk for metastasis or for locoregional recurrence are experimental. The technology hasn’t been demonstrated to improve net health outcomes.

All other GEP tests are experimental.

The medical policy statement and inclusionary and exclusionary criteria have been updated, effective Sept. 1, 2023.

Inclusions:

The use of the PLA (DermTech Pigmented Lesion Assay) is considered established when ordered by a dermatologist to help inform a biopsy decision when all the following conditions are met:

When the lesion size is 5 to 19 mm.
When the lesion meets one or more Asymmetry, Border, Color, Diameter, Evolving, or ABCDE, criteria with suspicion of melanoma or the individual has pigmented skin making the dermatologist’s visual inspection using the ABCDE checklist less reliable.
When the skin is intact (non-ulcerated or non-bleeding lesions).
When the lesion is free of psoriasis, eczema and other similar skin conditions.
When the lesion does not contain a scar or when the location of the lesion is on fragile skin (for example, the dorsum of the hand) or in a location where scarring should be minimized (for example, on the face) or the location isn’t conducive for biopsy (back of the ear).
When the lesion has not been previously biopsied.
When the PLA test was not used for the same lesion before.
When the lesion is not already clinically diagnosed as benign or melanoma.
When the lesion is not located on the palms of hands, soles of feet, nails, mucous membranes, or hair-covered areas that can’t be trimmed.
When the ordering dermatologist has a plan at the time of ordering the test to continue to monitor the skin lesion for changes if the test is negative.
Only one test may be used per patient per clinical encounter, in most cases. In roughly 10% of patients, a second test may be indicated for the same clinical encounter. For rare cases where more than two tests are indicated in a single clinical encounter, an appeal with supporting documentation may be submitted for additional tests.

Exclusions:

Pigmented Lesion Assay testing when the above criteria aren’t met.
MyPath Melanoma testing
DecisionDx-Melanoma testing
All other gene expression profile testing for cutaneous melanoma

C9399
J3490
J3590
J9999

Basic benefit and medical policy

Aphexda^® (motixafortide)

Aphexda (motixafortide) is considered established when criteria are met, effective Sept. 11, 2023.

Aphexda, a hematopoietic stem cell mobilizer, is indicated in combination with filgrastim (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma.

Dosage and administration:

Initiate Aphexda treatment after filgrastim has been administered daily for four days.
Recommended dosage is 1.25 mg/kg actual body weight by subcutaneous injection 10 to 14 hours before initiation of apheresis.
A second dose of Aphexda can be administered 10 to 14 hours before a third apheresis.

Dosage forms and strengths:

For injection: 62 mg as a lyophilized powder in a single-dose vial for reconstitution.

Aphexda (motixafortide) isn’t a benefit for URMBT.

C9399
J3490
J3590
J9999

Basic benefit and medical policy

Epkinly^® (epcoritamab-bysp)

Effective May 19, 2023, Epkinly (epcoritamab-bysp) is covered for the following FDA-approved indications:

Epkinly (epcoritamab-bysp) 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, or DLBCL, not otherwise specified, including DLBCL arising from indolent lymphoma and high-grade B-cell 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 a confirmatory trial or trials.

Dosage and administration:

For subcutaneous injection only.
Recommended dosage:

Treatment Cycle 1

Day 1 ̶ Step-up dose 1 = Dose 0.16 mg
Day 8 ̶ Step-up dose 2 = Dose 0.8 mg
Day 15 ̶ First full dose = Dose 48 mg
Day 22 – Dose 48 mg

Treatment cycles 2 and 3

Days 1, 8, 15 and 22 = Dose 48 mg

Treatment cycles 4 to 9

Days 1 and 15 = Dose 48 mg

Treatment Cycle 10 and beyond

Day 1 = Dose 48 mg

Cycle = 28 days

Patients should be hospitalized for 24 hours after administration of the Cycle 1 Day 15 dosage of 48 mg.
Administer premedications and prophylaxis as recommended.
Dosages of Epkinly (epcoritamab-bysp) 0.16 mg and 0.8 mg require dilution before administration.

Dosage forms and strengths:

Injection: 4 mg/0.8 mL in a single-dose vial. Dilute before use.
Injection: 48 mg/0.8 mL in a single-dose vial

Epkinly (epcoritamab-bysp) isn’t a benefit for URMBT.

C9399
J9999

Basic benefit and medical policy

Elrexfio^® (elranatamab-bcmm)

Effective Aug. 14, 2023, Elrexfio (elranatamab-bcmm) is covered for its FDA-approved indications.

Coverage of Elrexfio (elranatamab-bcmm) is provided when all the following are met:

FDA-approved indication
FDA-approved age
Prescribed by or in consultation with an oncologist
Treatment of patients with relapsed or refractory multiple myeloma after at least four prior lines of therapy
Patients must have been treated with all of the following:

An immunomodulatory agent
A proteasome inhibitor
An anti-CD38 antibody

Must have active disease defined by at least one of the following:

Serum M-protein greater or equal to 1.0 g/dL
Urine M-protein greater or equal to 200 mg/24 h
Serum free light chain, or FLC, assay greater or equal to 10 mg/dL provided the baseline serum FLC ratio is abnormal

Patients must meet all the following:

ECOG performance status of 0-2
No known central nervous system involvement with myeloma
Alanine aminotransferase, or ALT, and aspartate aminotransferase, or AST, less than or equal to three times the upper limit of normal, or ULN
Creatinine clearance greater than or equal to 40 mL/min
No detectable hepatitis B or C viral load
No infection that is uncontrolled or requires IV or long-term oral antimicrobial therapy
Left ventricular ejection fraction greater than or equal to 40%
No stroke event within six months of therapy administration
No pulmonary disease requiring oxygen dependence
No seizures within six months of therapy administration
No active autoimmune disease except vitiligo, Type 1 diabetes mellitus or prior autoimmune thyroiditis

Haven’t received prior treatment with any bispecific B-cell maturation antigen-directed CD3 T-cell engager therapy
Trial and failure, contraindication or intolerance to the preferred drugs as listed in Blue Cross Blue Shield of Michigan or Blue Care Network’s utilization management medical drug list

Quantity limitations, authorization period and renewal criteria:

Quantity limits: Align with FDA-recommended dosing
Authorization period: Aligns with FDA-recommended or guideline-supported treatment duration and provided for at least 60 days and up to six months at a time
Renewal criteria: Treatment may be continued until disease progression or until unacceptable toxicity occurs

This drug isn’t a benefit for URMBT.

J0896

Basic benefit and medical policy

Reblozyl^® (luspatercept-aamt)

Reblozyl (luspatercept-aamt) is payable for the following indications, effective Aug. 28, 2023:

Reblozyl is an erythroid maturation agent indicated for the treatment of anemia without previous erythropoiesis stimulating agent use (ESA-naïve) in adult patients with very low- to intermediate-risk myelodysplastic syndromes, or MDS, who may require regular red blood cell transfusions.

J1439

Basic benefit and medical policy

Injectafer^® (ferric carboxy-maltose injection)

Injectafer (ferric carboxy-maltose injection) is covered for the following updated FDA-approved indications:

Injectafer (ferric carboxy-maltose injection) is an iron replacement product indicated for the treatment of iron deficiency in adult patients with heart failure and New York Heart Association class II/III to improve exercise capacity.

J3490
J3590

Basic benefit and medical policy

Izervay^® (avacincaptad pegol)

Effective Aug. 8, 2023, Izervay (avacincaptad pegol) is covered for its FDA-approved indications:

Coverage of Izervay (avacincaptad pegol) is provided when all the following are met:

FDA-approved indication
FDA-approved age
Must not have geographic atrophy, or GA, secondary to a condition other than dry AMD
Must have a visual acuity in the affected eyes or eyes of 20/320 or better
Must not be used in combination with Syfovre or any other medication for GA
Trial and failure, contraindication or intolerance to the preferred drugs as listed in Blue Cross or BCN’s utilization management medical drug list

Quantity limitations, authorization period and renewal criteria:

Quantity limit: Align with FDA-recommended dosing
Initial authorization period: One year at a time and align with FDA-recommended duration of treatment
Renewal criteria: Clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit.

This drug isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Penbraya^® (meningococcal groups A, B, C, W and Y vaccine)

Penbraya (meningococcal groups A, B, C, W and Y vaccine) is considered established, effective Oct. 20, 2023.

Penbraya is indicated for active immunization to prevent invasive disease caused by Neisseria meningitidis serogroups A, B, C, W and Y. Penbraya is approved for use in individuals 10 through 25 years of age.

Dosage and administration:

For intramuscular use only.
Administer two doses (approximately 0.5 mL each) of Penbraya six months apart.
To prepare Penbraya, reconstitute the Lyophilized MenACWY component with the MenB component.

Dosage forms and strengths:

Penbraya is a suspension for injection. A single dose after reconstitution is approximately 0.5 mL.

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 2023 American Medical Association. All rights reserved.