The Record - Blues highlight medical, benefit policy changes

Billing chart: Blues highlight 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.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

Click on BCBSM Provider Publications & Resources.

Click on Benefit Policy for a Code.

Click on Topic.

Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.

Enter the procedure code.

Click on Finish.

Click on Search.

Code*

BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines

NEW PAYABLE PROCEDURES

Occurrence code 56

Basic benefit and medical policy

New occurrence code 56 approved

The National Uniform Billing Committee approved the new occurrence code 56, effective Jan. 1, 2018. Blue Cross Blue Shield of Michigan will also accept this code for all claims processed on or after Jan. 1, 2018.

UPDATES TO PAYABLE PROCEDURES

20982, 32998, 50542, 50592, 58674

Basic benefit and medical policy

Radiofrequency ablation of miscellaneous solid tumors, excluding liver tumors

The criteria have been updated for the radiofrequency ablation of miscellaneous solid tumors, excluding liver tumors policy. This policy is effective March 1, 2018.

Inclusions:
Radiofrequency ablation is appropriate to palliate pain in patients with osteolytic bone metastases for those who have failed or are poor candidates for standard treatments such as radiation or opioids.

Radiofrequency ablation is appropriate for osteoid osteomas for those who can’t be managed successfully with medical treatment.

Radiofrequency ablation is appropriate to treat localized renal cell carcinoma that is no more than 4 cm in size when any of the following criteria are met:

It is necessary to preserve kidney function in patients with significantly impaired renal function (i.e., the patient has one kidney or renal insufficiency defined by a glomerular filtration rate [GFR] of less than 60 mL/min/m2).
The standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen existing kidney function.
The patient isn’t considered a surgical candidate.

Radiofrequency ablation is appropriate to treat an isolated peripheral non-small cell lung cancer lesion that is no more than 3 cm in size when all of the following criteria are met:**

Surgical resection or radiation treatment with curative intent is considered appropriate based on stage of disease, however, medical co-morbidity renders the individual unfit for those interventions.
The tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.

Radiofrequency ablation is appropriate to treat malignant non-pulmonary tumors metastatic to the lung that are no more than 3 cm in size when all of the following criteria are met:**

It is necessary to preserve lung function when surgical resection or radiation treatment is likely to substantially worsen pulmonary status.
The patient isn’t considered a surgical candidate.
There is no evidence of extrapulmonary metastases.
The tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.

** Additional criteria that have been developed by clinical judgment/consensus and existing guidelines for the use of radiofrequency ablation in metastatic tumors to the lung are as follows:

No more than three tumors per lung should be ablated.
Tumors should be amenable to complete ablation.
Twelve months should elapse before a repeat ablation is considered.

Radiofrequency ablation may be appropriate to treat uterine fibroids (refer to “Myolysis of Uterine Fibroids using Laparoscopic, Percutaneous, or Transcervical Techniques” for criteria)

Exclusions:

Breast tumors
Lung cancer not meeting the criteria above
Renal cell cancer not meeting the criteria above
Osteoid osteomas that can be managed with medical treatment
Initial treatment of painful bony metastases
All indications and tumor types not specifically noted in the inclusion section of this policy

32701, 77529, 77522, 77523, 77525

Basic benefit and medical policy

Charged-particle (proton or helium ion) radio therapy for neoplastic conditions

The criteria have been updated for the charged-particle (proton or helium ion) radio therapy for neoplastic conditions. This policy is effective March 1, 2018.

Inclusions:**
Charged-particle irradiation with proton or helium ion beams is established for the following indications:

In the treatment of intracranial arteriovenous malformation not amenable to surgical excision or other conventional forms of treatment or adjacent to critical structures such as the optic nerve, brain stem or spinal cord.
Primary or metastatic central nervous system malignancies, such as gliomas, when adjacent to critical structures such as the optic nerve, brain stem, or spinal cord and when other standard radiation techniques such as IMRT or standard stereotactic modalities would not reduce the risk of radiation damage to the critical structure.
Post-operative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II), chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma), cervical spine or sacral/lower spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height, and particularly when plaque brachytherapy is not a feasible option.
In the treatment of all pediatric tumor types, through 21 years of age.

** Use of proton beam therapy may require prior authorization to verify that Blue Cross Blue Shield of Michigan and Blue Care Network criteria are met and, where appropriate, to explore the appropriateness of using alternative therapeutic modalities such as IMRT and 3-dimensional conformal radiation therapy.

Exclusions:

All other applications of charged-particle irradiation including, but not limited to, clinically localized prostate cancer, non-small-cell lung cancer at any stage or for recurrence, breast cancer, pancreatic cancer and hepatocellular carcinoma are experimental.
Proton beam therapy for the treatment of macular degeneration or choroidal neovascularization and hemangiomas.

43201, 43210, 43212, 43236, 43257, 43499

Basic benefit and medical policy

Transesophageal endoscopic therapies GERD are still experimental
The transesophageal endoscopic therapies for gastroesophageal reflux disease (Transoral Incisionless Fundoplication) policy was reviewed in December 2017. The decision is to maintain the experimental status.

Transesophageal endoscopic therapies are considered experimental as a treatment of gastroesophageal reflux disease. These procedures include, but are not limited to, the following:

Transesophageal endoscopic gastrolatry (gastroplication or transoral incisionless fundoplication) procedures including, but not limited to, the EndoCinch™ procedure, the EsophyX® procedure, the Syntheon ARD Plicator, the Bard™ Endoscopic Suturing System (also known as BESS), StomaphyX™, and the Endoscopic Plication System.
Transesophageal radiofrequency to create submucosal thermal lesions of the gastroesophageal junction (i.e., the Stretta™ procedure).
Endoscopic submucosal implantation of a prosthesis or injection of a bulking agent (e.g., polymethylmethacrylate beads, zirconium oxide spheres).

These procedures haven’t been scientifically demonstrated to be as safe and effective for the treatment of GERD as conventional medical or surgical management.

This policy is effective March 1, 2018.

52441, 52442

Basic benefit and medical policy

Prostatic urethral lift for the treatment BPH
The safety and efficacy of the prostatic urethral lift procedure for the treatment of benign prostatic hypertrophy, known as BPH, have been established. It’s a useful therapeutic option for men with symptomatic BPH who have failed conventional pharmacologic therapy.

Inclusionary criteria have been updated, effective March 1, 2018.

Inclusions:
Candidates for the prostatic urethral lift procedure must meet all of the following guidelines:

Age 50 or older
A documented diagnosis of symptomatic benign prostatic hypertrophy of the lateral lobes of the prostate including, but not limited to, the following symptoms:

Difficulty starting and stopping urination (hesitancy and straining).
Decreased strength of the urine stream (weak flow).
Dribbling after urination.
Feeling that the bladder is not completely empty.
An urge to urinate again soon after urinating (urgency).
Pain during urination (dysuria).
Nocturia – waking up several times during the night with the urge to urinate.
Frequent urinary tract infections secondary to urinary obstruction.

Documented failure of, inability to tolerate, or undesirable side effects of pharmacologic interventions for BPH including, but not limited to:

Alpha blockers such as Uroxatral, Cardura, Rapaflo, Flomax or Hytrin.
5-Alpha Reductase Inhibitors for BPH, such as Avodart or Proscar.
Combination drugs using both an alpha blocker and a 5-alpha reductase inhibitor.

Exclusions:
Patients not meeting the patient selection criteria above.

69930, 92601- 92607, 92618

Device/DME codes:

L7510, L8614- L8619, L8621- L8624, L8627- L8629

Basic benefit and medical policy

Bilateral and unilateral cochlear implants and associated hybrid cochlear implant devices

The safety and effectiveness of U.S. Food and Drug Administration-approved bilateral and unilateral cochlear implants and associated hybrid cochlear implant devices have been established. The implants may be considered useful therapeutic options when indicated. Inclusionary and exclusionary criteria have been updated, effective March 1, 2018.

Inclusions:
Unilateral or bilateral cochlear implantation is considered an established, safe and effective therapy if all of the following criteria are met:

FDA-approved cochlear implant
12 months of age or older**
Bilateral severe to profound pre- or post-lingual (sensorineural) hearing loss

Defined as a hearing threshold of pure-tone average of 70 dB hearing loss or greater at 500, 1000, 2000 Hz

Replacement of internal or external components in a small subset of members may be considered established when all of the following are met:

There is an inadequate response to existing components to the point of one of the following:

Interfering with the individual’s activities of daily living.
The component is no longer functional and can’t be repaired.

Copies of original medical records must be submitted either by hard copy or electronically to support medical necessity.

Cochlear implant with a hybrid device that includes the hearing aid integrated into the external sound processor of the cochlear implant (e.g., the Nucleus^® Hybrid L24 Cochlear Implant System) may be considered established for patients 18 years and older who meet all of the following criteria:

Bilateral severe-to-profound high frequency sensorineural hearing loss with residual low-frequency hearing sensitivity.
Receive limited benefit from appropriately fit bilateral hearing aids.
Have all of the following hearing thresholds:

Low frequency hearing thresholds no poorer than 60 dB hearing level up to and including 500 Hz (averaged over 125, 250 and 500 Hz) in the ear selected for implantation.
Severe to profound mid-to-high frequency hearing loss (threshold average of 2000, 3000 and 4000 Hz ≥75 dB hearing level) in the ear to be implanted.
Moderately severe to profound mid-to-high frequency hearing loss (threshold average of
2000, 3000 and 4000 Hz ≤ 60 dB hearing level) in the contralateral ear.
Aided consonant-nucleus-consonant word recognition score from 10 percent to 60 percent in the ear to be implanted in the preoperative aided condition and in the contralateral ear will be equal to or better than that of the ear to be implanted but not more than 80 percent correct.

In certain situations, implantation may be considered before 12 months of age. One scenario post meningitis when cochlear ossification may preclude implantation. Another is in cases with a strong family history because establishing a precise diagnosis is less uncertain.

Contraindications to cochlear implantation may include deafness due to lesions of the eighth cranial (acoustic) nerve, central auditory pathway or brainstem; active or chronic infections of the external or middle ear; and mastoid cavity or tympanic membrane perforation. Cochlear ossification may prevent electrode insertion, and the absence of cochlear development as demonstrated on computed tomography scans remains an absolute contraindication.

Exclusions:

Cochlear implantation as a treatment for patients with unilateral hearing loss with or without tinnitus.
Upgrades of an existing, functioning external system to achieve aesthetic improvement, such as smaller profile components or a switch from a body-worn, external sound processor to a behind-the-ear model.
Replacement of internal or external components solely for the purpose of upgrading to a system with advanced technology or to a next-generation device.
Non-FDA approved devices.

77058, 77059

Basic benefit and medical policy

MRI for detection and diagnosis of breast cancer

The criteria have been updated for the magnetic resonance imaging for detection and diagnosis of breast cancer policy. This policy is effective March 1, 2018.

Inclusions:
Note: All the following policy statements refer to performing MRI of the breast with a breast coil and the use of contrast. MRI of the breast without the use of a breast coil, regardless of the clinical indication, is considered experimental.

MRI of the breast may be considered medically appropriate for screening for breast cancer in patients at high risk of breast cancer.

High-risk considerations
There is no standardized method for determining a woman’s risk of breast cancer that incorporates all possible risk factors. There are validated risk prediction models, but they are based primarily on family history.

Some known individual risk factors confer a high risk by themselves. The following list includes factors known to indicate a high risk of breast cancer:

Lobular carcinoma in situ.
A known BRCA1 or BRCA2 variant.
Another gene variant associated with high risk, e.g., TP53 (Li-Fraumeni syndrome), PTEN (Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome), CDH1, and STK11, ATM, CHEK2 and PALB2
High risk (lifetime risk about 20 percent or greater) of developing breast cancer as identified by models that are largely defined by family history
Received radiotherapy to the chest between 10 and 30 years of age.

A number of other factors may increase the risk of breast cancer but don’t by themselves indicate high risk. It’s possible that combinations of these factors may be indicative of high risk, but it isn’t possible to give quantitative estimates of risk. As a result, it may be necessary to individualize the estimate of risk, whereby one would need to take into account the numerous risk factors. A number of risk factors, not individually indicating high risk, are included in the National Cancer Institute Breast Cancer Risk Assessment Tool (also called the Gail model). Risk factors in the model can be accessed online at cancer.gov/bcrisktool/Default.aspx.

National Cancer Care Network guidelines state there is insufficient evidence for any recommendations for breast MRI for patients with the following variants: BARD1, FANCC, MRE11A, MUTYH, NF1, NBN, RAD50, SMARCA, or XRCC2. Moreover, there are conflicting data regarding risks associated with MLH1, MSH2, MSH6, PMS2 and EPCAM gene deletion.

MRI of the breast is medically appropriate for the following indications:

Detection of a suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma (i.e., negative mammography and physical exam)
Presurgical planning in patients with locally advanced breast cancer (before and after completion of neoadjuvant chemotherapy) to permit tumor localization and characterization
Determining the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumor
Evaluation of the contralateral breast in those patients with a new diagnosis of breast cancer when clinical and mammographic findings are normal
Preoperative tumor mapping of the involved (ipsilateral) breast to evaluate the presence of multicentric disease in patients with clinically localized breast cancer who are candidates for breast-conservation therapy
Evaluation of a documented abnormality of the breast prior to obtaining an MRI-guided biopsy when there is documentation that other methods, such as palpation or ultrasound, aren’t able to localize the lesion for biopsy.

Exclusions:

Screening technique in average-risk patients.
Screening technique for the detection of breast cancer when the sensitivity of mammography is limited (i.e., dense breasts).
Diagnosis of low-suspicion findings on conventional testing not indicated for immediate biopsy and referred for short-interval follow-up.
Diagnosis of a suspicious breast lesion in order to avoid biopsy.

81219, 81270, 81402, 81403

Basic benefit and medical policy

JAK 2, MPL and CALR testing for myeloproliferative neoplasms

The criteria have been updated for the genetic testing – JAK 2, MPL and CALR testing for myeloproliferative neoplasms policy. This policy is effective March 1, 2018.

Inclusions:
JAK2 testing as a diagnostic option for patients presenting with clinical, laboratory or pathologic findings suggesting polycythemia vera, essential thrombocythemia or primary myelofibrosis.

MPL and CALR testing as diagnostic options for patients presenting with clinical, laboratory or pathologic findings suggesting essential thrombocythemia or primary myelofibrosis.

Based on World Health Organization criteria, in the case of suspected polycythemia vera, documentation of serum erythropoietin level below the reference range for normal is recommended prior to JAK2 testing.

Exclusions:
JAK2, MPL and CALR testing in other circumstances including, but not limited to, the following:

Diagnosis of nonclassic forms of myeloproliferative neoplasms, known as MPNs.
Molecular phenotyping of patients with MPNs.
Monitoring, management or selecting treatment in patients with MPNs.

81220

Basic benefit and medical policy

Cystic fibrosis

Code 81220 — cystic fibrosis transmembrane conductance regulator (e.g., cystic fibrosis) gene analysis — is payable once per lifetime.

81479, 88271

Basic benefit and medical policy

Genetic testing for the evaluation of early pregnancy loss and intrauterine fetal demise

The criteria have been updated for the genetic testing – for the evaluation of early pregnancy loss and intrauterine fetal demise policy.

The safety and effectiveness of chromosomal microarray analysis of fetal tissue have been established. It’s a useful diagnostic option for the evaluation of pregnancy loss and intrauterine fetal demise when indicated.

Inclusions:

In cases of pregnancy loss at 20 weeks of gestation or earlier when there is a maternal history of recurrent miscarriage (defined as a history of >2 failed pregnancies).
In all cases of pregnancy loss after 20 weeks of gestation.

This policy is effective March 1, 2018.

90636, 90740, 90743, 90744, 90746, 90747

Basic benefit and medical policy

Hepatitis B vaccines

Hepatitis B vaccines are payable when administered by a retail pharmacy.

A9587, 78607

Basic benefit and medical policy

Dopamine transporter imaging with single photon emission computed tomography (DaTscan™)

The safety and effectiveness of dopamine transporter imaging with single photon emission computed tomography have been established for patients meeting specified criteria. It may be considered a useful diagnostic option when specific clinical criteria are met.

Inclusionary criteria have been updated, effective
March 1, 2018.

Inclusions:

To aid in the diagnosis of a parkinsonian syndrome (e.g., essential tremor versus Parkinson’s disease).
To distinguish drug-induced parkinsonism versus degenerative parkinsonism or idiopathic Parkinson’s disease.
To discriminate psychogenic parkinsonism from neurologically based parkinsonism.
To be used prior to DBS surgery for intractable tremor of uncertain etiology to determine the appropriate site of DBS stimulation (e.g., VIM stimulation for essential tremor versus STN or GPi stimulation for Parkinson’s disease).
To distinguish between dementia with Lewy bodies and Alzheimer disease.
DaTscan™ should only be ordered by a board-certified neurologist who has evaluated the patient.

Exclusions:

As a screening or confirmatory test and for monitoring disease progression or response to therapy.
Serial DaTscan studies.

EXPERIMENTAL PROCEDURES

27446, 27447

Basic benefit and medical policy

Custom implants or patient-specific instrumentation for joint arthroplasty

Use of custom implants or patient-specific instrumentation (e.g., cutting guides) for joint arthroplasty including, but not limited to, use in unicompartmental or total knee arthroplasty, is considered experimental. There is insufficient evidence in the peer-reviewed medical literature to determine the effects of the technology on health outcomes. This policy is effective March 1, 2018.

33999**

**Unlisted procedure code used to represent this surgical service

Basic benefit and medical policy

Transmyocardial closure of ventricular septal defects

Transmyocardial closure of ventricular septal defects is considered experimental. The safety and effectiveness have not been established, effective March 1, 2018.

96365, 96366, J2001, J3490**

**When used for the indications listed in this policy

Basic benefit and medical policy

Intravenous infusion of anesthetics for treatment of chronic pain

Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of chronic pain including, but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia, depression and other mood disorders is considered experimental/investigational. It hasn’t been scientifically demonstrated to improve patient clinical outcomes, effective March 1, 2018.

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 2017 American Medical Association. All rights reserved.