Billing chart: Blues highlight medical, benefit policy changes

J1559

Basic benefit and medical policy

Primary immunodeficiency

J1559 is payable for its new U.S. Food and Drug Administration-approved indications. Effective March 19, 2018, it’s approved for the treatment of primary immunodeficiency in adults and pediatric patients ages 2 and older and maintenance therapy in adults with chronic inflammatory demyelinating polyneuropathy.

Procedure code J1559 requires preauthorization.

J3490

Basic benefit and medical policy

Approved indications for Xgeva

Starting Jan. 4, 2018, Blue Cross Blue Shield of Michigan considered Xgeva (injection, denosumab, 1 milligram) established for the following indications:

• Prevention of skeletal-related events in patients with multiple myeloma and in patients with bone metastases from solid tumors.
• Treatment of adults and skeletally mature adolescents with giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity.
• Treatment of hypercalcemia of malignancy refractory to bisphosphonate therapy.

J3590

Basic benefit and medical policy

Andexxa (coagulation factor Xa [recombinant] inactivated-zhzo)

Effective May 3, 2018, Andexxa (coagulation factor Xa [recombinant] inactivated-zhzo) is covered for the following FDA-approved indications:

Andexxa (coagulation factor Xa [recombinant] inactivated-zhzo) is a recombinant modified human Factor Xa (FXa) protein indicated for patients treated with rivaroxaban and apixaban, when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding. Andexxa (coagulation factor Xa [recombinant], inactivated-zhzo) hasn’t been shown to be effective for, and isn’t indicated for, the treatment of bleeding related to any FXa inhibitors other than apixaban and rivaroxaban.

• Dose Andexxa based on the specific FXa inhibitor, dose of FXa inhibitor and time since the patient’s last dose of FXa inhibitor.
• Administer as an intravenous bolus, with a target rate of 30 mg/min, followed by continuous infusion for up to 120 minutes.

There are two dosing regimens:

• Low dose 400 mg at a target rate of 30 mg/min 4 mg/min for up to 120 minutes
• High dose 800 mg at a target rate of 30 mg/min 8 mg/min for up to 120 minutes

NDC: 69853-0101-01

Pharmacy doesn’t require preauthorization of this drug.

Andexxa (coagulation factor Xa [recombinant] inactivated-zhzo) isn’t a benefit for URMBT.

S9473, G0237, G0238, G0239, G0302, G0303, G0304, G0424

Not covered:
G0305

Basic benefit and medical policy

Pulmonary rehabilitation

The safety and effectiveness of pulmonary rehabilitation have been established. It may be considered a useful therapeutic option when indicated. Inclusionary criteria have been updated, effective Sept. 1, 2018.

Inclusionary guidelines:
The outpatient program generally includes team assessment, patient training, psychosocial intervention, supervised exercise and follow-up. Participation in pulmonary rehabilitation generally occurs for a period of four to six hours per week for eight to 12 weeks. The program must have active medical supervision that includes, at a minimum, either a registered nurse, respiratory therapist or exercise physiologist providing direct supervision and a physician available on-site.

Inclusions:
Pulmonary rehabilitation is considered established for:

1. Preoperative conditioning before one of the following:
• Lung volume reduction surgery
• Lung transplantation
2. Postoperative rehabilitation following lung transplantation
3. Individuals with chronic respiratory diseases, with medical documentation of all the following:
• A diagnosis of a chronic but stable respiratory system impairment that is under medical management.
• A pulmonary function test within the past year that shows forced vital capacity, forced expiratory volume in one second or diffusing capacity of the lungs for carbon monoxide) (uncorrected for volume) less than 65 percent of predicted normal.
• Disabling symptoms that significantly impair the individual’s level of function.

Note: Respiratory diseases may include: COPD (chronic bronchitis, emphysema), asthma, bronchiectasis, cystic fibrosis, interstitial lung disease, restrictive chest wall disease, pulmonary hypertension, lung cancer, respiratory impairment from neuromuscular disease, etc.

In addition to the above, there is medical documentation that the individual is all the following:

• Physically able, motivated and willing to participate in a pulmonary rehabilitation program
• A nonsmoker, has quit smoking or is enrolled in a smoking cessation program
• Expected to show measurable improvement in a reasonable and predictable time frame

Candidates for pulmonary rehabilitation should be medically stable and not limited by another serious or unstable medical condition. Contraindications to pulmonary rehabilitation may include:

• Ischemic cardiac disease
• Acute cor pulmonale
• Severe pulmonary hypertension
• Significant hepatic dysfunction
• Metastatic cancer
• Renal failure
• Severe cognitive deficit
• Psychiatric disease that interferes with memory and compliance
• Substance abuse
• Disabling stroke

Exclusions:

• Multiple courses of pulmonary rehabilitation, either as maintenance therapy in patients who initially respond or in patients who fail to respond or whose response to an initial rehabilitation program has diminished over time
• Home-based pulmonary rehabilitation programs
• Pulmonary rehabilitation following lung surgeries other than lung transplant (e.g., lung volume reduction surgery and surgical resection of lung cancer)

20983, 32994**, 50250, 50542, 50593

Not covered:
19105, 32999***, 48999***

**Procedure code 32994 has been added to the covered procedures to reflect the updated policy criteria, effective May 1, 2018.

***Used to report not otherwise classified procedures

Basic benefit and medical policy

Cryosurgical ablation

The safety and effectiveness of cryosurgical ablation to treat the following have been established:

• Localized renal cell carcinoma
• Lung cancer
• Osteoid osteoma

The safety and effectiveness of cryosurgical ablation to palliate pain in patients with osteolytic bone metastases have been established.

It may be considered a useful therapeutic option when indicated.

Cryosurgical ablation as a treatment of benign or malignant tumors of the breast or pancreas is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Inclusions:
Renal cell carcinoma with no evidence of metastasis and when either of the following criteria is met:

• The tumor is no more than 4 centimeters in its greatest dimension, preservation of kidney function is necessary (i.e., the patient has one kidney or renal insufficiency defined by a glomerular filtration rate [GFR] of less than 60 mL/min per m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function.
• The tumor is no more than 4 centimeters in its greatest dimension and the patient isn’t considered a surgical candidate.

Cryosurgical ablation to treat lung cancer when either of the following criteria is met:

• The patient has early-stage non-small cell lung cancer and is a poor surgical candidate.
• The patient requires palliation for a central airway obstructing lesion.

Cryosurgical ablation to palliate pain in patients with osteolytic bone metastases when all the following criteria are met:

• Patient ≥ age 18 years.
• One or two painful bone metastasis lesions, 1-11 cm in size.
• Patient has failed or is a poor candidate for standard treatments such as radiation or opioids.
• Patient has pain score ≥ 4 on scale 0-10.
• Life expectancy is > 2 months.
• The lesion is > 1 cm away from the spinal cord, brain, other critical nerve structure, large abdominal vessel such as the aorta or inferior vena cava, bowel or bladder.
• The coagulation profile is normal (platelets > 50,000 and INR > 1.5).
• The site of the lesion isn’t at imminent risk of fracture.
• Patient must not have a primary musculoskeletal malignancy, lymphoma or leukemia.

Cryosurgical ablation to treat osteoid osteoma when any of the following criteria are met:

• Those who have failed medical therapy
• Those being considered for surgical resection
• Those who have failed previous surgical therapy and have recurrent symptoms and/or pain

Exclusions:
Other indications not noted in the policy inclusions.

Q0138, Q0139

Basic benefit and medical policy

Procedure codes Q0138, Q0139

Procedure codes Q0138 and Q0139 are payable for the following diagnosis codes:

• D50.0
• D50.1
• D50.8
• D50.9

Feraheme™ (ferumoxytol) is indicated for the treatment of iron deficiency anemia in adult patients who have one of the following:

• Intolerance to oral iron or who have had unsatisfactory response to oral iron
• Chronic kidney disease

27415, 27416, 28446, 29866, 29867

Not covered:
29999**, 27899**

**Unlisted procedures for arthroscopy
 of leg and ankle

Basic benefit and medical policy

Autografts and allografts in the treatment of focal articular cartilage lesions

This is an update to recently published information on autografts and allografts in the treatment of focal articular cartilage lesions. The subsection below has been added to the medical policy statement, effective Sept. 1, 2018.

In addition, osteochondral allografting and autografting are approved for both the knee and talus. For more policy information, see the July billing chart.

Microfracture technique
The safety and effectiveness of microfracture surgery in joints (e.g., knee, hip, shoulder) for the treatment of osteochondritis dissecans, known as OCD, have been established in patients where OCD is proven.

92585, 92586, 95829, 95967, 95868, 95925, 95926, 95927, 95938, 95940, 95955, G0453

Note: CPT codes 95940 or G0453 should be used to report intraoperative neurophysiological monitoring regardless of the specific test that is performed.

Not covered:

Basic benefit and medical policy

Intraoperative neurophysiologic monitoring

Intraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG and electrocorticography, is established during spinal, intracranial or vascular procedures.

Intraoperative neurophysiologic monitoring of the recurrent laryngeal nerve is established for patients meeting inclusionary guidelines.

Intraoperative monitoring of visual-evoked potentials is considered experimental.

Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental.

Criteria have been updated, effective Sept. 1, 2018.

Inclusions:
The following types of intraoperative monitoring are appropriate when performed during spinal, intracranial or vascular surgeries or procedures:
Note: Only a qualified person can perform this type of monitoring.

• Somatosensory-evoked potentials
• Motor-evoked potentials using transcranial electrical stimulation
• Brainstem auditory-evoked potentials
• Electromyogram of cranial nerves
• Electroencephalogram
• Electrocorticography

Intraoperative neurophysiologic monitoring of the recurrent laryngeal nerve is established in patients undergoing the following:

• High risk thyroid or parathyroid surgery, including:
• Total thyroidectomy
• Repeat thyroid or parathyroid surgery
• Surgery for cancer
• Thyrotoxicosis
• Retrosternal or giant goiter
• Thyroiditis

• Anterior cervical spine surgery associated with any of the following increased risk situations:
• Prior anterior cervical surgery, particularly revision anterior cervical discectomy and fusion, revision surgery through a scarred surgical field, reoperation for pseudarthrosis or revision for failed fusion
• Multilevel anterior cervical discectomy and fusion
• Time consuming anterior cervical discectomy and fusion (e.g., tumor)
• Preexisting recurrent laryngeal nerve pathology, when there is residual function of the recurrent laryngeal nerve

Exclusions:

• Intraoperative monitoring of visual-evoked potentials
• Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation
• Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves
• Intraoperative neurophysiologic monitoring of the recurrent laryngeal nerve during anterior cervical spine surgery not meeting the criteria above or during esophageal surgeries
• Intraoperative monitoring performed during any surgical procedure not specified in the inclusions

Q4128

Basic benefit and medical policy

Skin and tissue substitutes

The safety and effectiveness of skin and tissue substitutes approved by the FDA and the Centers for Medicare & Medicaid Services have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Procedure code Q4128 has been added as an established procedure under this policy.

64912, 64913

Basic benefit and medical policy

Nerve allografts

81479**, 81599***

**Unlisted procedure for Percepta^®
***Unlisted procedure for Xpresys^® Lung

Basic benefit and medical policy

Molecular testing (proteomic and gene expression) in the management of pulmonary nodules

Plasma-based proteomic screening, including but not limited to Xpresys® Lung, in patients with undiagnosed pulmonary nodules detected by computed tomography is considered experimental.

Gene expression profiling on bronchial brushings, including but not limited to Percepta^® Bronchial Genomic Classifier, in patients with indeterminate bronchoscopy results from undiagnosed pulmonary nodules is considered experimental.

The policy is effective Sept. 1, 2018.

Partner Solutions

Partner Solutions is adding a new plan option effective September 1, 2018.

Group Number: 71594

The following lines of business will be added to the plan

• PPO with HSA
• Pharmacy 1 plan
• Vision 1 plan