Blue Medicare Medical Policies

Medical Policy Update June 30, 2020

Medical Guidelines Reason for Update
Amniotic Membrane and Amniotic Fluid Injections Coding section updated with new codes effective 7/1/20. Added codes Q4227 – Q4242, Q4244 – Q4248.
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy Added HCPCS code J1429 to Billing/Coding section and deleted codes C9399, J3490, and J3590 effective 7/1/2020.
Axial Lumbosacral Interbody Fusion Medical Director review. Archive policy.
Balloon Dilation of the Eustachian Tube Specialty Matched Consultant Advisory Panel review 2/19/2020.
Bioengineered Skin and Tissue Coding section updated with new code effective 7/1/20. Added code C1849.
Cardiac (Heart) Transplantation References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Carotid Artery Angioplasty/Stenting (CAS) References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Computer Assisted Surgical Navigational Orthopedic Procedures Reference added. List of FDA approved devices added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Computerized Corneal Topography Specialty Matched Consultant Advisory Panel review 6/17/2020. Updated Policy Guidelines section. Reference added. No change to policy statement. Medical Director review 6/2020.
Congenital Heart Defect, Repair Devices Added code 0613T to Billing/Coding section with effective date of 7/1/2020. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Continuous Passive Motion in the Home Setting Reference added. Specialty Matched Consultant Advisory Panel review 7/17/2020. Medical Director review. Archive policy.
Corneal Collagen Cross-linking Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement. Medical Director review 6/2020.
Crizanlizumab-tmca (Adakveo®) Added HCPCS code J0791 to Billing/Coding section effective 7/1/2020 and deleted codes C9053, C9399, J3490, and J3590 termed 6/30/2020.
Daratumumab (Darzalex®) Under When Covered, added Darzalex Faspro (daratumumab and hyaluronidase-fihj) for the treatment of multiple myeloma with same policy statements as Darzalex. Updated Description and Policy Guidelines sections to reflect addition of Darzalex Faspro to policy. Added HCPCS codes C9399, J3490, J3590, J9999 to Billing/Coding section. References added. Medical Director review 6/2020.
Electrical Bone Growth Stimulation References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Enfortumab vedotin-ejfv (Padcev™) Added HCPCS code J9177 to Billing/Coding section effective 7/1/2020 and deleted codes C9399, J3490, J3590, J9999 termed 6/30/2020.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement. Medical Director review 6/2020.
Eptinezumab-jjmr (Vyepti™) Added HCPCS code C9063 to Billing/Coding section effective 7/1/2020.
Erectile Dysfunction AHS - G2132 Specialty Matched Consultant Advisory Panel review 11/20/2019.
Evaluation of Dry Eyes AHS - G2138 Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement. Medical Director review 6/2020.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Reference added. Description section updated. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement. Medical Director review 6/2020.
Fam-Trastuzumab Deruxtecan-nxki (Enhertu®) Added HCPCS code J9358 to Billing/Coding section effective 7/1/2020 and deleted code C9399, J3490, J3590, and J9999 termed 6/30/2020.
Fundus Photography Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement. Medical Director review 6/2020.
Gene Expression Profiling for Uveal Melanoma AHS - M2071 Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement. Medical Director review 6/2020.
Genetic Testing for Macular Degeneration AHS-M2083 Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement. Medical Director review 6/2020.
Givosiran (Givlaari™) Added HCPCS code J0223 to Billing/Coding section effective 7/1/2020 and deleted code C9056, C9399, J3490 termed 6/30/2020.
Guselkumab (Tremfya®) and Tildrakizumab-asmn (Ilumya®) New policy developed. Guselkumab (Tremfya) or tildrakizumab-asmn (Ilumya) may be considered medically necessary for the treatment of plaque psoriasis in adult patients (≥ 18 years of age) when specified medical criteria and guidelines are met. Added HCPCS codes J1628 and J3245 to Billing/Coding section. References added. Medical Director review 3/2020. Notification given 3/31/2020 for effective date 6/30/2020. Removed criteria from When Covered section for Ilumya requiring trial of preferred biologics. Medical Director review 6/2020.
Heart-Lung Transplantation References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome Added HCPCS code J9246 to Billing/Coding section effective 7/1/2020.
Immunoglobulin Therapy Added HCPCS code J1558 to Billing/Coding section for Xembify subcutaneous immunoglobulin therapy effective 7/1/2020.
Infliximab (Remicade®) and Infliximab Biosimilars Added HCPCS code Q5121 to Billing/Coding section effective 7/1/2020.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Added summary of 2019 American College of Rheumatology guidelines and updated AAOS guidelines within Policy Guidelines section. Added HCPCS code J7333 to Billing/Coding section effective 7/1/2020. Updated table in Billing/Coding section to separate Visco-3 as a separate code. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statements.
Keratoprosthesis Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. Removed related policy: Implantation of Intrastromal Corneal Ring Segments due to archival. No change to policy statement. Medical Director review 6/2020.
Luspatercept-aamt (Reblozyl®) Added HCPCS code J0896 to Billing/Coding section effective 7/1/2020 and deleted codes C9399, J3490, J3590 termed 6/30/2020.
Magnetic Resonance Spectroscopy Added codes 0609T, 0610T, 0611T, 0612T. No change to policy statement.
Meniscal Allografts and Other Meniscal Implants Specialty Matched Consultant Advisory Panel review 6/17/2020.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added HCPCS code Q5119 to Billing/Coding section effective 7/1/2020.
Myoelectric Prosthetic Components for the Upper Limb Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Onasemnogene abeparvovec (Zolgensma®) Added HCPCS code J3399 to Billing/Coding section effective 7/1/2020 and deleted codes C9399, J3490, J3590 termed 6/30/2020.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. Medical Director review 6/2020. Added CPT codes 0604T, 0605T, 0606T to Billing/Coding section effective 7/1/2020. Policy statement added remote optical coherence tomography (OCT) of the retina is considered investigational.
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Medical Director review. Policy archived.
Refractive Surgery Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. Removed note to reference CMP Implantation of Intrastromal Corneal Ring Segments due to archival. No change to policy statement. Medical Director review.
Retinal Prosthesis Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement. Medical Director review 6/2020.
Sacituzumab govitecan-hziy (Trodelvy™) New policy developed. Trodelvy is considered medically necessary for the treatment of adult patients with mTNBC 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 6/2020.
Surgery for Femoroacetabular Impingement Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Surgery for Groin Pain in Athletes Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Surgical Management of Transcatheter Heart Valves References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Surgical Treatment of Sinus Disease New code C9122 added to Billing/Coding section.
Surgical Ventricular Restoration References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Teprotumumab-trbw (Tepezza™) Added HCPCS code C9061 to Billing/Coding section effective 7/1/2020. Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statements.
Transcatheter Closure of Ventricular Septal Defects Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
Vertebral Axial Decompression (VAD-X) Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Vestibular Function Testing Specialty Matched Consultant Advisory Panel review 2/19/2020.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement. Medical Director review 6/2020.
White Blood Cell Growth Factors Added HCPCS code Q5120 to Billing/Coding section effective 7/1/2020 and deleted code C9058 termed 6/30/2020.