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

POLICY CLARIFICATIONS

87634

Basic benefit and medical policy

Procedure code *87634

Procedure code *87634 is payable in an office setting — location 3 — in addition to any existing locations already payable. This code has been added to the Physician Office Laboratory List.

A9270

Basic benefit and medical policy

A9270 isn’t a covered service

We’d like to remind all providers and facilities that HCPCS procedure code A9270 isn’t a covered service.

J0714

Basic benefit and medical policy

Avycaz (ceftazidime and avibactam)

Effective March 18, 2019, Avycaz (ceftazidime and avibactam) is covered for the following updated FDA-approved indications.

Avycaz (ceftazidime and avibactam) is indicated for the treatment of the following infections caused by designated susceptible Gram-negative microorganisms:

Complicated intra-abdominal infections, known as cIAI, used in combination with metronidazole, in adult and pediatric patients 3 months and older
Complicated urinary tract infections, known as cUTI, including pyelonephritis, in adult and pediatric patients 3 months and older
Hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia, known as HABP and VABP, in patients 18 years and older

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Avycaz and other antibacterial drugs, Avycaz should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria.

Avycaz (ceftazidime and avibactam) is a combination of ceftazidime, a cephalosporin, and avibactam, a beta-lactamase inhibitor.

Dosing information:

Dosage of Avycaz in adult patients with creatinine clearance, known as CrCl, greater than 50 mL/min.

Infection: cIAI, cUTI including pyelonephritis, hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia
Dose: Avycaz 2.5 grams (ceftazidime 2 grams and avibactam 0.5 grams)
Frequency: Every eight hours
Infusion time: Two hours

Dosage of Avycaz in pediatric patients age 2 to less than 18 years old with estimated glomerular filtration rate, known as eGFR, greater than 50 mL/min/1.73 m2 and 3 months to less than 2 years without renal impairment

Infection: cIAI and cUTI including pyelonephritis

Age range: Ages 2 to less than 18 years old
Dose: Avycaz 62.5 mg/kg to a maximum of 2.5 grams (ceftazidime 50 mg/kg and avibactam 12.5 mg/kg to a maximum dose of ceftazidime 2 grams and avibactam 0.5 grams)
Infusion time/frequency: Two hours/every eight hours

Age range: 6 months to less than 2 years old
Dose: Avycaz 62.5 mg/kg (ceftazidime 50 mg/kg and avibactam 12.5 mg/kg)
Infusion time/frequency: Two hours/every eight hours

Age range: 3 months to less than 6 months
Dose: Avycaz 50 mg/kg (ceftazidime 40 mg/kg and avibactam 10 mg/kg)
Infusion time/frequency: Two hours/every eight hours

For treatment of cIAI, metronidazole should be given concurrently.
Recommended duration of treatment:
- cIAI: Five to 14 days
- cUTI including pyelonephritis: Seven to 14 days
- HABP/VABP: Seven to 14 days (adults only)
Dosage in adult patients with renal impairment

Dosage of Avycaz in adult patients with renal impairment

Estimated creatinine clearance (mL/min):^a 31 to 50
Dose:^b Avycaz 1.25 grams (ceftazidime 1 gram and avibactam 0.25 grams)
Frequency: Every eight hours

Estimated creatinine clearance (mL/min):^a 16 to 30
Dose:^b Avycaz 0.94 grams (ceftazidime 0.75 grams and avibactam 0.19 grams)
Frequency: Every 12 hours

Estimated creatinine clearance (mL/min):^a 6 to 15^c
Dose:^b Avycaz 0.94 grams (ceftazidime 0.75 grams and avibactam 0.19 grams)
Frequency: Every 24 hours

Estimated creatinine clearance (mL/min):^a Less than or equal to 5^c
Dose:^b Avycaz 0.94 grams (ceftazidime 0.75 grams and avibactam 0.19 grams)
Frequency: Every 48 hours

^aAs calculated using the Cockcroft-Gault formula.
^bAll doses of Avycaz are administered over 2 hours
^cBoth ceftazidime and avibactam are hemodialyzable; thus, administer Avycaz after hemodialysis on hemodialysis days.

Pharmacy doesn’t require prior authorization of this drug.

NDCs:

00456-2700-01
00456-2700-10

J1599

Basic benefit and medical policy

Panzyga (immune globulin intravenous human-ifas)

Panzyga (immune globulin intravenous human-ifas) is considered established, effective Aug. 2, 2018.

Panzyga (immune globulin intravenous human-ifas) is considered covered when all the criteria below are met.

Panzyga (immune globulin intravenous human-ifas) is an immune globulin intravenous (human) – ifas 10% liquid preparation indicated for the treatment of:

Primary humoral immunodeficiency in patients age 2 and older
Chronic immune thrombocytopenia in adults

Dosage information:
Primary humoral immunodeficiency

Dose: 300-600 mg/kg (3-6 mL/kg) every three to four weeks
Initial infusion rate: 1 mg/kg/min (0.01 mL/kg/min)
Maximum infusion rate in PANZYGA New Patients (as tolerated): 1 mg/kg/min (0.01 mL/kg/min)
Maximum infusion rate in PANZYGA Experienced patients (as tolerated): 12 or 14 mg/kg/min (0.12 or 0.14 mL/kg/min)

Chronic immune thrombocytopenia (ITP) in adults

Dose: 1 g/kg (10 mL/kg) daily for two consecutive days
Initial infusion rate: 1 mg/kg/min (0.01 mL/kg/min)
Maximum infusion rate in PANZYGA new patients (as tolerated): 8 mg/kg/min (0.08 mL/kg/min)

This drug isn’t a benefit for URMBT.

Prior authorization is required for this drug.

NDCs:

68982-0820-01
68982-0820-02
68982-0820-03
68982-0820-04
68982-0820-05
68982-0820-06
68982-0820-81
68982-0820-82
68982-0820-83
68982-0820-84
68982-0820-85
68982-0820-86

J3490

Basic benefit and medical policy

Esperoct [antihemophilic factor (recombinant), glycopegylated-exei]

Esperoct [antihemophilic factor (recombinant), glycopegylated-exei] is considered established, effective Feb. 19, 2019.

Esperoct [antihemophilic factor (recombinant), glycopegylated-exei] is considered covered when the criteria below are met.

Esperoct [antihemophilic factor (recombinant), glycopegylated-exei] is a coagulation Factor VIII concentrate indicated for use in adults and children with hemophilia A for:

On-demand treatment and control of bleeding episodes
Perioperative management of bleeding
Routine prophylaxis to reduce the frequency of bleeding episodes

Esperoct [antihemophilic factor (recombinant), glycopegylated-exei] isn’t indicated for the treatment of von Willebrand disease.

Dosage information:
For intravenous infusion after reconstitution only.

Each vial label for Esperoct states the actual Factor VIII activity in international units.
On-demand treatment/control of bleeding episodes: In adolescents and adults, 40 IU/kg body weight for minor or moderate bleeds and 50 IU/kg body weight for major bleeds; children (younger than age 12), 65 IU/kg body weight for minor, moderate or major bleeds.
Perioperative management: For minor or major surgery — In adolescents and adults: pre-operative dose of 50 IU/kg body weight; in children (younger than age 12), pre-operative dose of 65 IU/kg body weight. Frequency of administration is determined by the treating physician.
Routine prophylaxis: In adolescents and adults, 50 IU/kg every four days; in children (younger than age 12), 65 IU/kg twice weekly. A regimen may be individually adjusted to less or more frequent dosing based on bleeding episodes.
Esperoct also may be dosed to achieve a specific target Factor VIII activity level, depending on the severity of hemophilia, for on-demand treatment or control of bleeding episodes or perioperative management. To achieve a specific target Factor VIII activity level, use the following formula: Dosage (IU) = body weight (kg) × desired Factor VIII increase (IU/dL or % normal) × 0.5 (IU/kg per IU/dL).

This drug isn’t a benefit for URMBT.

Prior authorization isn’t required for this drug.

NDCs:

00169-8500-01
00169-8100-01
00169-8150-01
00169-8200-01
00169-8300-01

J9305

Basic benefit and medical policy

Alimta (pemetrexed)

Effective Jan. 30, 2019, Alimta (pemetrexed) is covered for the following updated FDA-approved indications: In combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous non-small cell lung cancer, with no estimated glomerular filtration rate or ALK genomic tumor aberrations.

Alimta (pemetrexed) is a folate analog metabolic inhibitor.

Dosing information:

The recommended dose of Alimta administered with pembrolizumab and platinum chemotherapy in patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes, administered after pembrolizumab and prior to platinum chemotherapy, on Day 1 of each 21-day cycle.
Initiate folic acid 400 mcg to 1,000 mcg orally, once daily, beginning seven days prior to the first dose of Alimta and continue until 21 days after the last dose of Alimta.
Administer vitamin B12, 1 mg intramuscularly, one week prior to the first dose of Alimta and every three cycles.
Administer dexamethasone 4 mg orally, twice daily the day before, the day of, and the day after Alimta administration.

Pharmacy doesn’t require prior authorization of this drug.

NDCs:

00002 7640 01
00002 7623 01

EXPERIMENTAL PROCEDURES

81400-81407, 81479, 87798,** 87801

Basic benefit and medical policy

Polymerase chain reaction testing in the diagnosis of onychomycosis

Polymerase chain reaction for the diagnosis of onychomycosis is experimental. There is insufficient scientific evidence in the current medical literature to indicate that this technology is as beneficial as the established alternatives. This policy became effective Jan. 1, 2019.

Payment policy
**Effective March 1, 2019, not otherwise classified procedure *87798 will change from payable to individual consideration, requiring documentation and medical consultant review.

GROUP BENEFIT CHANGES

DTE Energy Company

Starting Jan. 1, 2020, DTE Energy Company is adding the following group numbers:

DTE Electric — 71785
DTE Merc — 71786
DTE Gas — 71787
DTE Citizens Gas — 71788
DTE LLC — 71789
DTE Non-regulated Affiliates — 71790

Alpha prefixes — PPO (DTI)
Benefits platform — NASCO hybrid
Membership platform — Members Edge

Plans offered:
PPO, medical/surgical
Vision (VSP)

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.