Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update December 31, 2020

Medical Guidelines Reason for Update
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse New code 30468 added to Billing/Coding section for effective date 1/1/2021. Noted that code C9749 is deleted effective 12/31/2020.
Advanced Illness/Advance Directives Routine policy review. Medical Director approved 12/2020. References updated. No changes to policy statement
Ambulatory Event Monitors The following codes were added to the Billing/Coding section effective 1/1/21: 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248.
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy Added HCPCS code C9071 to Billing/Coding section effective 1/1/2021.
Aqueous Shunts and Devices for Glaucoma Added CPT codes 0621T and 0622T to Billing/Coding section for effective date 1/1/2021.
Balloon Dilation of the Eustachian Tube Added new codes 69705 and 69706 to Billing/Coding section for effective date 1/1/2021. Noted code C9745 deleted 12/31/2020.
Belantamab mafodotin-blmf (BlenrepTM) New policy developed. Blenrep is considered medically necessary for the treatment of adult patients with multiple myeloma when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021. Added HCPCS code C9069 to Billing/Coding section effective 1/1/2021.
Botulinum Toxin Injection Added the following to "When Covered" section for blepharospasm, "if the request is for Botox and the patient is 18 years of age or older, the patient has tried and had an inadequate response to OR has a clinical contraindication or intolerance to Xeomin." Updated criteria for requirement of trial of CGRP product for chronic migraine for clarity with no change to policy intent. Added the following criteria requirement for Dystonia/Spasticity: "If the request is for Botox, the patient has tried and had an inadequate response to OR has a clinical contraindication or intolerance to Xeomin and Dysport." Updated "When Covered" section from "upper limb spasticity" to "spasticity" for consistency with FDA label. Updated indications in "Description" section for Dysport. Reference added. Medical Director review 10/2020. Specialty Matched Consultant Advisory Panel review 10/21/2020. Notification given 10/27/2020 for effective date 1/1/2021. Added the following indication to "When Covered" section: "Hirschsprung disease in patients who develop obstructive symptoms after a pull-through operation." Removed "Hirschsprung disease" from "When Not Covered" section. Reference added. Medical Director review 11/2020.
Breast Surgeries Removed deleted codes 19366 and 19324 from Section I, Reconstructive Breast Surgery, Billing/Coding/Physician Documentation Information section.
Bundling Guidelines Routine policy review. Medical Director approved 12/2020. No changes to policy statement. Deleted code 0396T was replaced with unlisted code 27599. New code 99439 and G2214 added to "Topics of Frequent Interest" section Care Management Services.
Canakinumab (Ilaris®) New policy developed. Ilaris is considered medically necessary for the treatment of patients with autoinflammatory periodic fever syndromes (CAPS, FCAS, MWS, TRAPS, HIDS, MKD, and FMF) and active Still’s disease (AOSD and SJIA) when specified medical criteria and guidelines are met. Added HCPCS code J0638 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021.
CAR-T Therapy Added HCPCS code C9073 to Billing/Coding section effective 1/1/2021.
Computed Tomography to Detect Coronary Artery Calcification The following codes were added to the Billing/Coding section, effective 1/1/21: 0623T, 0624T, 0625T, 0626T.
Consistency Guidelines Routine policy review. Medical Director approved 12/2020. No change to policy statement.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Routine review. Medical Director approved 12/2020. No change to policy statement
Daratumumab (Darzalex®) Added HCPCS code J9144 to Billing/Coding section effective 1/1/2021 and deleted code C9062 termed 12/31/2020.
Dental Reconstructive Services Code D6052 deleted from the Billing/Coding section effective 1/1/21
Developmental Delay Screening and Testing Guidelines Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Documentation Requirements for Treatment of End Stage Renal Disease Routine policy review. Medical Director approved 12/2020. No changes to policy statement
ECG Reimbursement Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Eculizumab (Soliris®) Added continuation criteria in "When Covered" section for all indications. For NMOSD, added the following criteria to "When Covered" section: "The patient will not receive eculizumab concurrently with other biologics used to treat NMOSD (e.g., inebilizumab, satralizumab)," and "the patient has tried and had an inadequate response to inebilizumab (Uplizna) AND satralizumab (Enspryng), OR the patient has a clinical contraindication or intolerance to both inebilizumab and satralizumab." For aHUS and PNH, added the following criteria: "The patient will not receive eculizumab concurrently with other complement inhibitors (e.g., ravulizumab)." Edits made throughout policy to clarify intent. Added reference to the following related medical and pharmacy policies: "Inebilizumab-cdon (Uplizna™)" and "Enspryng™". Medical Director review 10/2020. Policy notification given 10/27/2020 for effective date 1/1/2021.
Electromagnetic Navigation Bronchoscopy Within "When Covered" section, clarified standard methods with "(e.g. peripheral nodule)". Added "diagnosis" to "When Covered" sections 3rd bullet point. Medical Director review.
Esketamine (SpravatoTM) Nasal Spray Added HCPCS code S0013 to Billing/Coding section effective 1/1/2021.
Focal Treatments for Prostate Cancer Reference added. Deleted codes C9747 and C9748 removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Group Visit (Shared Medical Appointment) Guidelines Routine policy review. Medical Director approved 12/2020. No changes to policy statement
Growth Factors in Wound Healing Code C1734 added to Billing/Coding section. Notification given 10/27/2020 for effective date 12/31/2020. Specialty Matched Consultant Advisory Panel 11/18/20
Guidelines for Global Maternity Reimbursement Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Immunization Guidelines Routine policy review. Medical Director approved 12/2020. No changes to policy statement. New code 90377 added to Coding section
Immunoglobulin Therapy Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section for Cutaquig subcutaneous immunoglobulin therapy effective 1/1/2021. Policy notification given 10/1/2020 for effective date 1/1/2021.
Implantable Bone Conduction Hearing Aids Reference added. Description section updated. Policy Guidelines section updated
Inebilizumab-cdon (UpliznaTM) Added HCPCS code J1823 to Billing/Coding section effective 1/1/2021 and deleted codes C9399, J3490, and J3590 termed 12/31/2020.
Infertility Diagnosis and Treatment – B0006 Coding section updated by removing deleted code 0058T effective 1/1/2021
Injectable Clostridial Collagenase for Fibroproliferative Disorders Updated Policy Guidelines with additional clinical evidence summary for Peyronie’s disease. Reference added. Specialty Matched Consultant Advisory Panel (Urology) review 11/18/2020. No change to policy statements.
Interleukin-5 Antagonists Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statements.
Isatuximab-irfc (Sarclisa®) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statements.
Laboratory Procedures Reimbursement Policy AHS - R2162 Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Lurbinectedin (ZepzelcaTM) Added HCPCS code J9223 to Billing/Coding section effective 1/1/2021 and deleted codes C9399, J3490, J3590, and J9999 termed 12/31/2020.
Minimal Residual Disease (MRD) AHS-M2175 New policy developed. Reviewed by Avalon 3rd Quarter 2020 CAB. BCBSNC will provide coverage for minimal residual disease (MRD) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 10/2020. Notification given 11/10/2020 for effective date 1/1/2021
Modifier Guidelines Routine policy review. Medical Director approved 12/2020. No changes to policy statement. Deleted code 99201 removed.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Deleted CPT code 81545 from Billing/Coding section effective 1/1/2021
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added following requirements to "When Covered" section: "If the request is for rituximab (Rituxan) or non-preferred rituximab biosimilars, then both of the following criteria are met: patient has a documented serious adverse event that required medical intervention to both preferred rituximab biosimilar products [rituximab-abbs (Truxima), rituximab-pvvr (Ruxience)] that is not anticipated with the requested product AND prescriber has completed and submitted an FDA MedWatch Adverse Event Reporting Form." Minor typographical and formatting changes made throughout for clarity. Medical Director review 10/2020. Policy notification given 10/27/2020 for effective date 1/1/2021
Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures Routine policy review. Medical Director approved 12/2020. New codes 92229, 93241, 93242, 93243, 93245, 93246, and 93247 added to Coding section. No changes to policy statement.
Multiple Surgical Procedure Guidelines for Professional Providers Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Nonpayment for Serious Adverse Events Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Observation Room Services Corrected code in Billing/Coding section to read G0378
Oncologic Uses of Bevacizumab (Avastin®) and Bevacizumab Biosimilars Added the following indication to "When Covered" section: unresectable or metastatic hepatocellular carcinoma when used in combination with atezolizumab in patients who have not received prior systemic chemotherapy. Removed statement regarding off-label use of bevacizumab biosimilars for epithelial ovarian, fallopian tube, or primary peritoneal cancer. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Orthopedic Applications of Stem Cell Therapy Codes 0627T, 0628T, 0629T, and 0630T added to Billing/Coding section for effective date 1/1/2021.
Outpatient Code Editor (OCE) Edits Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (PhesgoTM) New policy developed. Phesgo is considered medically necessary for the treatment of HER2-positive breast cancer when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021. Added HCPCS code J9316 to Billing/Coding section effective 1/1/2021 and deleted C9399, J3490, J3590, and J9999 termed 12/31/2020.
Pricing and Adjudication Principles for Professional Providers Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Prostatic Urethral Lift Investigational statements added in the When Not Covered section for use of Urolift in a patient previously treated for prostate cancer, and for use of more than 7 implants. Policy noticed 10/13/2020 for effective date 12/31/2020
Radiology Services Reimbursement Policy Routine policy review. Coding section updated with new code 71271. Medical Director approved 12/2020. No changes to policy statement.
Removal of Impacted Cerumen Routine policy review. Medical Director approved 12/2020. No changes to policy statement.
Rituximab for the Treatment of Rheumatoid Arthritis Added the following requirements to "When Covered" section: "If the request is for rituximab (Rituxan) or non-preferred rituximab biosimilars, then both of the following criteria are met: patient has a documented serious adverse event that required medical intervention to both preferred rituximab biosimilar products [rituximab-abbs (Truxima), rituximab-pvvr (Ruxience)] that is not anticipated with the requested product AND prescriber has completed and submitted an FDA MedWatch Adverse Event Reporting Form." Medical Director review 10/2020. Policy remains on notice for effective date 1/1/2021.
Sacituzumab govitecan-hziy (TrodelvyTM) Added HCPCS code J9317 to Billing/Coding section effective 1/1/2021 and deleted codes C9066, C9399, J3490, J3590, and J9999 termed 12/31/2020.
Skin and Soft Tissue Substitutes When not covered section revised for clarification. Added "The Plan may compare the cost -effectiveness of alternatives when determining which products will be covered" to When not covered section. Medical Director review.
Tafasitamab-cxix (Monjuvi®) New policy developed. Monjuvi is considered medically necessary for the treatment of adult patients with diffuse large B-cell lymphoma (DLBCL) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 9/2020. Policy notification given 10/1/2020 for effective date 1/1/2021. Added HCPCS code C9070 to Billing/Coding section effective 1/1/2021.
Telehealth Routine policy review. Medical Director approved 12/2020. References updated. No changes to policy statement.
Testosterone Pellet Implantation for Androgen Deficiency Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statements.
Trastuzumab (Herceptin®) and Trastuzumab Biosimilars Added the following requirements to "When Covered" section: "Trastuzumab (Hereptin) and trastuzumab biosimilars (trastuzumab-dkst, trastuzumab-pkrb, trastuzumab-dttb, trastuzumab-qyyp, trastuzumab-anns) may be considered medically necessary when the following criteria are met: If the request is for trastuzumab (Herceptin) or non-preferred trastuzumab biosimilars, then both of the following criteria are met: patient has a documented serious adverse event that required medical intervention to both preferred trastuzumab biosimilar products [trastuzumab-anns (Kanjinti), trastuzumab-dkst (Ogivri)] that is not anticipated with the requested product; AND prescriber has completed and submitted an FDA MedWatch Adverse Event Reporting Form." Medical Director review 10/2020. Policy notification given 10/27/2020 for effective date 1/1/2021.
Treatment of Hereditary Angioedema Minor edits made throughout policy for clarity. Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous References added. Description section updated. Regulatory Status updated. The tradename "Kiva" was removed from policy statements. Specialty Matched Consultant Advisory Panel review 5/20/2020. Code C1062 added to Billing/Coding section for effective date 1/1/2021.
Vestibular Function Testing Reference added. New codes 92517, 92518, and 92519 added to Billing/Coding section effective 1/1/2021.
White Blood Cell Growth Factors Updated "Description", "When Covered", and "When Not Covered" sections to reflect addition of Nyvepria (pegfilgrastim-apgf), a biosimilar to Neulasta (pegfilgrastim), with same indications and coverage criteria as Udenyca, Fulphila, and Ziextenzo, and with HCPCS codes C9399, J3490, J3590 and J9999 in Billing/Coding Section. Reference added. Policy notification given 10/1/2020 for effective date 1/1/2021. Added HCPCS code Q5122 to Billing/Coding section effective 1/1/2021.
Xolair® (Omalizumab) Added the following criteria within initial/continuation coverage sections: "The patient will not be receiving Xolair (omalizumab) in combination with another biologic immunomodulator agent used for the same indication (i.e., mepolizumab, benralizumab, reslizumab, dupilumab)." Minor typographical edits made throughout policy for clarity. Medical Director review 10/2020. Notification given 10/27/2020 for effective date 1/1/2021. Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.