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May 2024
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
|
| POLICY CLARIFICATIONS |
C9290
J3490
J3590 |
Basic benefit and medical policy
Exparel (bupivacaine liposome injectable suspension)
Effective Nov. 9, 2023, the U.S. Food and Drug Administration has updated the indications for Exparel (bupivacaine liposome injectable suspension) to include usage for the following treatment:
Exparel (bupivacaine liposome injectable suspension) contains bupivacaine, an amide local anesthetic, and is indicated to produce postsurgical regional analgesia via:
- A sciatic nerve block in the popliteal fossa in adults.
- An adductor canal block in adults.
Dosage and administration
The recommended dose of Exparel (bupivacaine liposome injectable suspension) for:
- Sciatic nerve block in the popliteal fossa in adults is 133 mg.
- Adductor canal block in adults is 133 mg (10 mL) admixed with 50 mg (10 mL) 0.5% bupivacaine HCl, for a total volume of 20 mL.
|
J0638 |
Basic benefit and medical policy
Ilaris (canakinumab)
Ilaris (canakinumab) is covered for the following updated FDA-approved indication, effective Aug. 25, 2023.
- Gout flares in adults in whom non-steroidal anti-inflammatory drugs, or NSAIDs, and colchicine are contraindicated, aren’t tolerated or don’t provide an adequate response, and in whom repeated courses of corticosteroids aren’t appropriate.
Dosage and administration:
Recommended dosage is 150 mg subcutaneously. In patients who require re-treatment, there should be an interval of at least 12 weeks before a new dose of Ilaris may be administered. |
J3490, J3590 |
Basic benefit and medical policy
Casgevy (exagamglogene autotemcel)
Casgevy (exagamglogene autotemcel) is payable for its FDA-approved indications. This was effective Dec. 8, 2023.
Coverage of Casgevy (exagamglogene autotemcel) is provided when all the following are met:
- FDA-approved indication
- FDA-approved age
- Prescribed by or in consultation with a hematologist
- Sickle cell disease, or SCD
- Genetic test confirming a diagnosis of SCD
- Must have experienced at least four severe vaso-occlusive crises in the past 24 months
- Trial and failure, contraindication, or intolerance to hydroxyurea
- Must not have any of the following:
- Positive presence of HIV-1 or HIV-2, hepatitis B or hepatitis C
- White blood cell count less than 3 × 109/L or platelet count less than 50 × 109/L not related to hypersplenism
- Advanced liver disease defined as alanine transferase greater than three times the upper limit of normal, total bilirubin greater than two times the upper limit of normal, baseline prothrombin time 1.5 times the upper limit of normal, or history of cirrhosis, any evidence of bridging fibrosis, or active hepatitis
- Prior treatment with an allogenic stem cell transplant
- Prior or current malignancy or immunodeficiency disorder
- Must not have received prior treatment with any gene therapy for sickle cell disease or are being considered for treatment with any other gene therapy for sickle cell disease
- Transfusion dependent β-thalassemia
- Genetic testing confirming diagnosis of β-thalassemia
- Must not have α-thalassemia
- Must be considered transfusion dependent with a history of at least 100 mL/kg/year of packed red blood cells, or pRBC, in the previous two years or be managed under standard thalassemia guidelines with ≥ 8 transfusions of pRBCs per year in the previous two years
- Must not have:
- A prior hematopoietic stem cell transplant, or HSCT, or currently be eligible for a HSCT with an HLA-matched family donor
- Presence of HIV-1 or HIV-2 infection
- Current immunodeficiency disorder or malignancy
- Uncorrected bleeding disorder
- Advanced liver disease defined as one of the following:
- Alanine transferases or direct bilirubin greater than three times the upper limit of normal, or ULN
- Baseline prothrombin time or partial thromboplastin time greater than 1.5 times the ULN suspected of arising from liver disease
- Magnetic resonance imaging of the liver demonstrating clear evidence of cirrhosis
- Haven’t received prior treatment with any gene therapy or are being considered for treatment with any other gene therapy for beta-thalassemia
Quantity limitations, authorization period and renewal criteria:
- Quantity limits: Align with FDA-recommended dosing.
- Authorization period: Six months with the allowance of only one dose per lifetime.
- Renewal criteria: Not applicable as no further authorization will be provided.
This drug isn’t a benefit for URMBT.
|
J1833 |
Basic benefit and medical policy
Cresemba (Isavuconazonium sulfate)
Effective Dec. 3, 2023, Cresemba (Isavuconazonium sulfate) is covered for the following FDA-approved indications:
As an azole antifungal indicated for the treatment of invasive aspergillosis and invasive mucormycosis for adults and pediatric patients 1 year of age and older. |
J3490, J3590 |
Basic benefit and medical policy
Wezlana (ustekinumab-auub)
Effective Oct. 31, 2023, Wezlana (ustekinumab-auub) is covered for the FDA-approved indications below.
Wezlana is a human interleukin -12 and -23 antagonist indicated for the treatment of:
Adult patients with:
- Moderate to severe plaque psoriasis, or Ps, who are candidates for phototherapy or systemic therapy.
- Active psoriatic arthritis, or PsA.
- Moderately to severely active Crohn’s disease, or CD.
- Moderately to severely active ulcerative colitis.
Pediatric patients 6 years and older with:
- Moderate to severe plaque psoriasis, who are candidates for phototherapy or systemic therapy.
- Active psoriatic arthritis.
Dosage and administration:
Psoriasis adult subcutaneous recommended dosage
- Weight range (kilograms): Less than or equal to 100 kg
- Dosage regimen: 45 mg administered subcutaneously initially and four weeks later, followed by 45 mg administered subcutaneously every 12 weeks
- Weight range (kilograms): Greater than 100 kg
- Dosage regimen: 90 mg administered subcutaneously initially and four weeks later, followed by 90 mg administered subcutaneously every 12 weeks
Psoriasis pediatric patients (6 to 17 years) subcutaneous recommended dosage:
Weight-based dosing is recommended at the initial dose, four weeks later, then every 12 weeks thereafter.
- Weight range (kilograms): Less than 60 kg
- Dosage regimen: 0.75 mg/kg
- Weight range (kilograms): 60 kg to 100 kg
- Dosage regimen: 45 mg
- Weight range (kilograms): Greater than 100 kg
- Dosage regimen: 90 mg
Psoriatic arthritis adult subcutaneous recommended dosage:
- The recommended dosage is 45 mg administered subcutaneously initially and four weeks later, followed by 45 mg administered subcutaneously every 12 weeks.
- For patients with co-existent moderate-to-severe plaque psoriasis weighing greater than 100 kg, the recommended dosage is 90 mg administered subcutaneously initially and four weeks later, followed by 90 mg administered subcutaneously every 12 weeks.
Psoriatic arthritis pediatric (6 to 17 years old) subcutaneous recommended dosage:
Weight-based dosing is recommended at the initial dose, four weeks later, then every 12 weeks thereafter.
- Weight range (kilograms): Less than 60 kg
- Dosage regimen: 0.75 mg/kg
- Weight range (kilograms): 60 kg or more
- Dosage regimen: 45 mg
- Weight range (kilograms): Greater than 100 kg with co-existent moderate-to-severe plaque psoriasis
- Dosage regimen: 90 mg
Crohn’s disease and ulcerative colitis initial adult intravenous recommended dosage:
A single intravenous infusion using weight-based dosing:
- Weight range (kilograms): Up to 55 kg
- Recommended dosage: 260 mg (two vials)
- Weight range (kilograms): Greater than 55 kg to 85 kg
- Recommended dosage: 390 mg (three vials)
- Weight range (kilograms): Greater than 85 kg
- Recommended dosage: 520 mg (four vials)
Crohn’s disease and ulcerative colitis maintenance adult subcutaneous recommended dosage:
A subcutaneous 90 mg dose eight weeks after the initial intravenous dose, then every eight weeks thereafter.
Dosage forms and strengths:
Subcutaneous Injection
- Injection: 45 mg/0.5 mL or 90 mg/mL solution in a single-dose prefilled syringe
- Injection: 45 mg/0.5 mL solution in a single-dose vial
Intravenous Infusion
- Injection: 130 mg/26 mL (5 mg/mL) solution in a single-dose vial
Wezlana (ustekinumab-auub) isn’t a benefit for URMBT. |
J3490, J3590 |
Basic benefit and medical policy
Combogesic IV (acetaminophen and ibuprofen)
Effective Oct. 17, 2023, Combogesic IV (acetaminophen and ibuprofen) is covered for the following FDA-approved indications below.
Combogesic IV (acetaminophen and ibuprofen) is indicated in adults where an intravenous route of administration is considered clinically necessary for:
- The relief of mild to moderate pain
- The management of moderate to severe pain as an adjunct to opioid analgesics
Limitation of use: Combogesic IV (acetaminophen and ibuprofen) is indicated for short-term use of five days or less.
Dosage and administration:
- Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.
- Don’t exceed the maximum total daily dose of Combogesic IV (acetaminophen and ibuprofen) (4,000 mg acetaminophen and 1,200 mg ibuprofen) in 24 hours.
- Don’t exceed a total daily dose of 4,000 mg (4 g) of acetaminophen from all sources.
- Don’t administer with other acetaminophen-containing products.
- For adult patients weighing greater than or equal to 50 kg (actual body weight): The recommended dosage is 1,000 mg of acetaminophen and 300 mg of ibuprofen administered as a 15-minute infusion, every six hours, as necessary.
- For adult patients weighing less than 50 kg (actual body weight): The recommended dosage is 15 mg/kg acetaminophen and 4.5 mg/kg ibuprofen administered as a 15-minute infusion, every six hours, as necessary.
Dosage forms and strengths:
Injection: 1,000 mg/100 mL (10 mg/mL) of acetaminophen and 300 mg/100 mL (3 mg/mL) of ibuprofen in single-dose vial.
Combogesic IV (acetaminophen and ibuprofen) isn’t a benefit for URMBT. |
J3490, J3590 |
Basic benefit and medical policy
Adzynma (ADAMTS13, recombinant-krhn)
Adzynma (ADAMTS13, recombinant-krhn) is payable for the FDA-approved indications below, effective Nov. 9, 2023.
Coverage of Adzynma (ADAMTS13, recombinant-krhn) is provided when all the following are met:
- FDA-approved indication
- FDA-approved age
- Confirmation of diagnosis by serum assay showing less than 10% of normal ADAMTS13 enzyme activity and genetic testing showing a mutation in the ADAMTS13 gene
- Must not be used in combination with any other therapy for the treatment of congenital thrombotic thrombocytopenic purpura, or cTTP
- Trial and failure, contraindication or intolerance to the preferred drugs as listed in Blue Cross Blue Shield of Michigan and Blue Care Network’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.
- 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. |
J1930 |
Basic benefit and medical policy
Somatuline (lanreotide)
Blue Cross Blue Shield of Michigan has approved payment for the off-label use of Somatuline (lanreotide) in the treatment of malignant neoplasm of the adrenal gland.
URMBT is excluded from this benefit. |
J9271 |
Basic benefit and medical policy
Keytruda (pembrolizumab)
Effective Oct. 16, 2023, and Nov. 16, 2023, Keytruda (pembrolizumab) is covered for the FDA-approved indications below.
Keytruda is a programmed death receptor-1 (PD-1)-blocking antibody indicated for:
- Non-small cell lung cancer, or NSCLC: The treatment of patients with resectable (tumors ≥4 cm or node positive) NSCLC in combination with platinum-containing chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery (effective Oct. 16, 2023).
- Gastric cancer: When used in combination with fluoropyrimidine- and platinum-containing chemotherapy, for the first-line treatment of adults with locally advanced unresectable or metastatic HER2-negative gastric or gastroesophageal junction, or GEJ, adenocarcinoma (effective Nov. 16, 2023).
- Cervical cancer: When used in combination with chemoradiotherapy, for the treatment of patients with FIGO 2014 Stage III-IVA cervical cancer (effective Nov. 16, 2023).
|
Q5127 |
Basic benefit and medical policy
Stimufend (pegfilgrastim-fpgk)
Stimufend (pegfilgrastim-fpgk) is considered established when criteria are met, effective Sept. 29, 2023.
Stimufend (pegfilgrastim-fpgk) has been approved for the following updated indication: Increase survival in patients acutely exposed to myelosuppressive doses of radiation (hematopoietic subsyndrome of acute radiation syndrome). |
C9399, J3490, J3590, J9999 |
Basic benefit and medical policy
Ryzneuta (efbemalenograstim alfa-vuxw)
Ryzneuta (efbemalenograstim alfa-vuxw) is considered established, effective Nov. 16, 2023.
Ryzneuta is a leukocyte growth factor indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in adult patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.
Limitations of use:
Ryzneuta isn’t indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.
Dosage and administration:
- Recommended dose: 20 mg administered subcutaneously once per chemotherapy cycle.
- Administer approximately 24 hours after cytotoxic chemotherapy.
- Don’t administer between 14 days before and 24 hours after administration of cytotoxic chemotherapy.
Dosage forms and strengths:
- Injection: 20 mg/mL solution in a single-dose prefilled syringe.
This drug isn’t a benefit for URMBT.
|
J1599 |
Basic benefit and medical policy
Alyglo (immune globulin intravenous, human-stwk)
Alyglo (immune globulin intravenous, human-stwk) is considered established, effective Dec. 15, 2023.
Alyglo (immune globulin intravenous, human-stwk) is a 10% immune globulin liquid for intravenous injection, indicated for the treatment of primary humoral immunodeficiency, or PI, in adults.
Dosage and administration:
For intravenous use only.
Dose: 300 to 800 mg/kg body weight every 21 or 28 days.
- Infusion number: For the first infusion.
- Initial infusion rate: 1 mg/kg/min (0.01 mL/kg/min).
- Maintenance infusion rate: Double the infusion rate every 30 minutes (if tolerated) up to 8 mg/kg/min (0.08 mL/kg/min).
Dose: 300 to 800 mg/kg body weight every 21 or 28 days.
- Infusion number: From the second infusion.
- Initial infusion rate: 2 mg/kg/min (0.02 mL/kg/min).
- Maintenance infusion rate: Double the infusion rate every 15 minutes (if tolerated) up to 8 mg/kg/min (0.08 mL/kg/min).
Ensure that patients with pre-existing renal insufficiency aren’t volume-depleted; discontinue Alyglo if renal function deteriorates.
For patients at risk of renal dysfunction or thrombotic events, administer Alyglo at the minimum dose and infusion rate practicable.
Dosage forms and strengths:
Alyglo is a liquid solution containing 10% IgG (100 mg/mL) for intravenous infusion.
This drug isn’t a benefit for URMBT. |
Revenue codes:
0480, 0481, 0482, 0483
CPT codes:
92920, 92928, 92950, 92953, 92975, 92977, 92978, 92979, 93050, 93260, 93264, 93279, 93280, 93281, 93284, 93285, 93286, 93287, 93288, 93289, 93290, 93291, 93303, 93304, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93451, 93452, 93453, 93454, 93456, 93458, 93460, 93464, 93503, 93569, 93571, 93572, 93573, 93574, 93575, 93600, 93602, 93603, 93668, 93701, 93702, 93740, 93770, 93784, 93786, 93788, 93790
0501T, 0502T, 0503T, 0504T, 0518T, 0519T, 0520T, 0521T, 0522T, 0620T, 0650T, 0716T, 0742T, 0795T, 0796T, 0797T
1010F, 1011F, 1012F, 1460F, 1461F, 3117F
HCPCS codes:
C7553, C8921, C9600, C9602, C9786, G0166, G0248, G0249, G2066, Q0035, S3902, S9025 |
Basic benefit and medical policy
Blue Cross Blue Shield of Michigan has approved additional cardiology procedures (listed at the left) as eligible for reporting with revenue code 0480, 0481, 0482 and 0483, effective April 1, 2024. These services are considered safe and effective for performing in an ambulatory surgical facility setting. |
| GROUP BENEFIT CHANGES |
Meijer |
All plans for Meijer members, group number 72625, are part of the exclusive provider organization, or EPO, benefit design. In these types of plans, members are responsible for obtaining services from in-network providers and services obtained out-of-network aren’t a benefit (with some exceptions).
When identifying the network that the member has (PPO, HPN or Select Network), the below prefixes or the member’s ID card can be used for reference.
Group number: 72625
Alpha prefixes:
EPO PPO (MJE)
EPO WI Select Network (OLI)
EPO High Performance Network (MNK)
Platform: NASCO |
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. |
