The Record - Billing chart: 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

J3490
J3590

Basic benefit and medical policy

Onpattro (patisiran)

Onpattro (patisiran) is considered established, effective Aug. 10, 2018.

Onpattro (patisiran) is covered when all the following criteria are met:

Age 18 or older
Must have diagnosis of peripheral nerve disease caused by hATTR (formerly known as familial amyloidosis polyneuropathy or FAP) with documented TTR mutation
Must not include signs and symptoms of ocular or cerebral area involvement (ocular amyloidosis or primary/leptomeningeal amyloidosis)
Documentation of clinical signs and symptoms of peripheral neuropathy (such as tingling or increased pain in the hands, feet and/or arms, loss of feeling in the hands and/or feet, numbness or tingling in the wrists, carpal tunnel syndrome, loss of ability to sense temperature, difficulty with fine motor skills, weakness in the legs, difficulty walking) or documentation of clinical signs and symptoms of autonomic neuropathy symptoms (such as orthostasis, abnormal sweating, dysautonomia [constipation and/or diarrhea, nausea, vomiting, anorexia, early satiety])
Must have polyneuropathy disability score ≤ IIIb
Must have baseline FAP Stage 1 or 2

Onpattro won’t be used in combination with any of the following:

Oligonucleotide agents (such as inotersen)
TTR stabilizers (such as tafamidis)
No prior liver transplant or planning to undergo liver transplant
Must not have New York Heart Association heart failure classification > 2

Dosing is in accordance with the FDA-labeled prescribing information with a maximum of 30 mg every three weeks.

Quantity limitations, authorization period and renewal criteria

Quantity limit: Maximum 30 mg every three weeks

Initial authorization period: One year

Renewal criteria: Renewal based on clinical response yearly and must have all the following:

Stabilization or improvement of PND score from baseline and score remains less than or equal to IIIb
Stabilization or improvement of FAP stage from baseline and staging remains at 1 or 2
Documentation of positive clinical response (such as improved neurological impairment, motor function, cardiac function, quality of life assessment, stabilization or improvement in serum TTR levels, etc.)

Onpattro won’t be used in combination with any of the following drug classes:

Oligonucleotides (such as inotersen)
TTR stabilizers (such as tafamidis)

Renewal authorization period: One year

Onpattro (patisiran) is considered investigational when used for all other conditions including, but not limited to, any condition that isn’t polyneuropathy of hATTR.

Onpattro (patisiran) isn’t a benefit for URMBT.

Prior authorization is required effective Dec. 1, 2018.

NDC: 71336-1000-01.

UPDATES TO PAYABLE PROCEDURES

J3490

Basic benefit and medical policy

Xerava (eravacycline)

Effective Aug. 27, 2018, Xerava (eravacycline) is payable for its FDA-approved indications for the treatment of complicated intra-abdominal infections in patients aged 18 and older.

Administer 1 mg/kg as an intravenous infusion over approximately 60 minutes every 12 hours for a total duration of four to 14 days. It’s not indicated for the treatment of complicated urinary tract infections.

URMBT groups are excluded from coverage of this drug.

J3590

Basic benefit and medical policy

Poteligeo (mogamulizumab-kpkc)

Poteligeo (mogamulizumab-kpkc) is payable for its FDA-approved indications, effective Aug. 8, 2018, for the treatment of adult patients with relapsed or refractory mycosis fungoides or Sézary syndrome after at least one prior systemic therapy.

Administer 1 mg/kg as an intravenous infusion over at least 60 minutes on days 1, 8, 15, and 22 of the first 28-day cycle and on days 1 and 15 of each subsequent cycle.

URMBT groups are excluded from coverage of this drug.

POLICY CLARIFICATIONS

J9271

Basic benefit and medical policy

Keytruda (pembrolizumab)

Keytruda (pembrolizumab) is payable for the following new FDA indications:

Cervical cancer

For the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS ≥ 1) as determined by an FDA-approved test

Urothelial carcinoma

For the treatment of patients with locally advanced or metastatic urothelial carcinoma who aren’t eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 (Combined Positive Score [CPS] ≥ 10), or in patients who aren’t eligible for any platinum-containing chemotherapy regardless of PD-L1 status
For the treatment of patients with locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy

Primary mediastinal large b-cell lymphoma

For the treatment of adult and pediatric patients with refractory PMBCL, or who have relapsed after two or more prior lines of therapy. Limitation of use: Keytruda isn’t recommended for treatment of patients with PMBCL who require urgent cytoreductive therapy

Dosage information

Cervical cancer: 200 mg every three weeks
Urothelial carcinoma: 200 mg every three weeks
PMBCL: 200 mg every three weeks for adults; 2 mg/kg (up to 200 mg) every three weeks for children

NDCs: 00006 3026 01 and 00006 3026 02

Pharmacy doesn’t require preauthorization of this drug.

J9305

Basic benefit and medical policy

Alimta (pemetrexed)

Alimta (pemetrexed) is payable for the following FDA indications:

In combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer, or NSCLC
In combination with carboplatin and pembrolizumab for the initial treatment of patients with metastatic, non-squamous NSCLC. This indication is approved under accelerated approval based on tumor response rate and progression-free survival. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.
As a single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease hasn’t progressed after four cycles of platinum-based first-line chemotherapy
As a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC after prior chemotherapy. Limitations of use: ALIMTA^® isn’t indicated for the treatment of patients with squamous cell, non-small cell lung cancer.
Initial treatment, in combination with cisplatin, of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery

NDCs: 00002 7640 01 and 00002 7623 01

Pharmacy doesn’t require preauthorization of this drug.

Note: The Federal Employee Program^® follows its own criteria related to procedure codes J3490, J3590, J9271 and J9305.

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 2018 American Medical Association. All rights reserved.