Currentblue cross blue shield - michiganPolicy N/A

Billing chart: Blue Cross highlights medical, benefit policy changes

A billing chart summarizing updates to payable procedures, policy clarifications, new payable procedures, experimental procedures and BCBSM coverage/coding guidance for multiple procedures, devices and drugs, with effective dates and inclusion/exclusion criteria where provided. This is part 1 of 2 and contains coding and coverage posture updates effective on various dates (primarily May 1, 2025 and several 2024–2025 dates).

Policy Summary

Payerblue cross blue shield - michigan

PolicyBilling chart: Blue Cross highlights medical, benefit policy changes

Policy CodePolicy N/A

Change TypeMultiple additions, revisions and removals

Effective DateVarious (see chart)

Next Review DateN/A

Key ActionAll transplants must be prior authorized through the Human Organ Transplant Program.

SourceLink

POLICY UPDATE CHANGES

Multiple medical policy statements, inclusionary and exclusionary criteria were updated effective May 1, 2025 (e.g., cardiac contractility modulation, PENFS/IB-Stim, heart-kidney transplant, LITT, PTNS, breast ultrasound, DBT, prenatal testing, colorectal screening, germline testing).

Grafapex (treosulfan) coverage added effective Jan 22, 2025 with dosing and indications.

Arixtra (fondaparinux) payable for updated indications effective Dec 23, 2024.

Avtozma (tocilizumab-anoh) covered effective Jan 30, 2025 for FDA-approved indications with dosing guidance.

Emblaveo (aztreonam and avibactam) covered effective Feb 7, 2025 for cIAI in adults with limited/no alternatives; dosing by renal function provided.

Iomervu (iomeprol) covered effective Nov 27, 2024 for multiple radiographic procedures.

Omlyclo (omalizumab-igec) considered established effective Mar 7, 2025 when criteria met.

Penmenvy vaccine covered effective Feb 14, 2025.

Stoboclo (denosumab-bmwo) covered effective Feb 28, 2025.

Vimkunya (chikungunya vaccine, recombinant) covered effective Feb 14, 2025 under accelerated approval.

Procedure code 90593 (chikungunya recombinant) designated experimental/investigational as of May 1, 2025.

Stoboclo (denosumab-bmwo) coverage and administration details added with HCPCS J3490, J3590 references.

Vimkunya coverage effective Feb. 14, 2025 added with HCPCS J9118.

Asparlas approved for off-label use to treat lymphoblastic lymphoma effective Jan. 1, 2024 (J9173).

Imfinzi approved for off-label use to treat malignant neoplasm of gallbladder effective Jan. 1, 2025 (J9317).

Trodelvy indication for locally advanced/metastatic urothelial cancer is no longer payable effective Nov. 22, 2024 (J9358).

Enhertu approved for off-label use to treat malignant neoplasm of the ovary (Q5101).

Zarxio payable for updated FDA-approved indication: increased survival after myelosuppressive radiation exposure effective Oct. 22, 2024.

Oral surgery inclusion criteria updated effective May 1, 2025 with explicit inclusions and exclusions listed.

Corning group number 71881 will join Blue Cross Blue Shield of Michigan effective June 1, 2025 with plan and prefix details.

MultipleProcedures/Drugs Updated or Added

SeveralPolicies with May 1, 2025 updates

NumerousCodes referenced

8Drug/Vaccine items listed

1Oral surgery policy update

1Group addition (Corning)

Policy snapshot & scope

This numerically organized billing chart (Part 1 of 2) summarizes Blue Cross Blue Shield of Michigan updates to payable procedures, policy clarifications, new payable procedures, experimental procedure designations and coding/coverage guidance. Primary effective update dates include May 1, 2025 for many policy changes and several 2024–2025 dates for drug, vaccine and procedure coverage (see chart details). For full commercial policy text and complete coverage rules, providers should consult the Availity Benefit Explainer (Commercial Policy tab) using the HCPCS code lookup instructions provided in the chart.

PayerBlue Cross Blue Shield - Michigan

Policy titleBilling chart: Blue Cross highlights medical, benefit policy changes (Part 1)

StatusCURRENT

Has material changetrue

Scope summaryA billing chart summarizing updates to payable procedures, policy clarifications, new payable procedures, experimental procedures and BCBSM coverage/coding guidance for multiple procedures, devices and drugs, with effective dates and inclusion/exclusion criteria where provided (Part 1 of 2).

Document-level changes

2024-10-22revised

Zarxio (filgrastim-sndz) updated: payable for increased survival after myelosuppressive radiation exposure with dosing 10 mcg/kg/day subcutaneously.

2024-11-27added

Iomervu (iomeprol) added as covered for multiple intra-arterial and intravenous radiographic procedures; dosage individualized by age/weight and concentrations 250–400 mg I/mL.

2024-12-23added

Arixtra (fondaparinux) payable for updated FDA-approved indications including adult DVT/PE treatment with warfarin and pediatric VTE dosing (0.1 mg/kg SC once daily); adult weight-based dosing specified.

Coverage stances & medical necessity criteria

Cardiac contractility modulation (Optimizer Smart System)

Cardiac contractility modulation therapy (Optimizer Smart System) is considered experimental/investigational. There is insufficient published evidence to confirm the technology improves net health outcomes.

Effective May 1, 2025.

PENFS device (IB‑Stim) for functional GI disorders — pediatric inclusion criteria

PENFS device (for example, IB‑Stim™) for functional gastrointestinal disorders — pediatric inclusion criteria. IB‑Stim may be considered a useful therapeutic option when ALL of the following are met.

ALL of the following

Age 11-18 years
Diagnosis of a ROME IV defined functional gastrointestinal disorder (examples: functional abdominal pain, functional abdominal pain syndrome, irritable bowel syndrome, functional dyspepsia, abdominal migraine)

Code lists and coverage status

New/Updated Procedure and HCPCS/CPT Codes Mentionedmixed

0408T	New/updated procedure code listed in chart
0409T	New/updated procedure code listed in chart
0410T	New/updated procedure code listed in chart
0411T	New/updated procedure code listed in chart
0412T	New/updated procedure code listed in chart
0413T	New/updated procedure code listed in chart
0414T	New/updated procedure code listed in chart
0415T	New/updated procedure code listed in chart
0416T	New/updated procedure code listed in chart
0417T	New/updated procedure code listed in chart

1–10 of 32

1/4

Drugs / Vaccines specifically called out as coveredNDC|HCPCS|CPTCovered

Grafapex	Drug entry Grafapex — short description from brief (newly listed drug)
Arixtra	Arixtra — anticoagulant product referenced
Avtozma	Avtozma — newly listed biologic in chart
Emblaveo	Emblaveo — drug entry from update
Iomervu	Iomervu — radiology contrast agent listed
Omlyclo	Omlyclo — drug entry from update
Penmenvy	Penmenvy — oncology drug listed
Stoboclo	Stoboclo (Denosumab) — bone-related therapeutic HCPCS referenced
Vimkunya	Vimkunya — vaccine listed with HCPCS/NDC reference

Codes designated experimental/investigational / not coveredmixedExperimental

90593	Vaccine administration / specific code listed as experimental in brief
Implantable TNS examples (eCoin, Revi)	Implantable tibial nerve stimulation devices considered experimental/investigational
A4545	Non-invasive/wearable neuromodulation accessory code — listed as experimental
E0736	Non-invasive/wearable neuromodulation device code — listed as experimental
E0737	Non-invasive/wearable neuromodulation device code — listed as experimental
Breast ultrasound screening codes (e.g., 76641, 76642)	Breast ultrasound screening CPT codes referenced for screening use — listed in chart
81408	Colorectal cfDNA and certain molecular tests — molecular pathology / targeted sequencing codes referenced
81432	Colorectal cfDNA / molecular test code referenced
81479	Unlisted molecular pathology / NGS code referenced (also used for NGS prenatal testing in brief)
0498U	Next-generation sequencing for invasive prenatal testing — PLA code referenced

Denosumab (Stoboclo) HCPCSHCPCSCovered

J0897

Denosumab product HCPCS example (Stoboclo listed)

Vimkunya vaccine HCPCSHCPCSCovered

906XX

Vimkunya — vaccine HCPCS placeholder code referenced in brief

Asparlas HCPCSHCPCSCovered

J3490

Asparlas (asparaginase) HCPCS-related billing note (listed)

Imfinzi HCPCSHCPCSCovered

J9228

Imfinzi (durvalumab) HCPCS listing referenced

Trodelvy HCPCS - removed indication (not_covered)HCPCSNot Covered

J9177

Trodelvy (sacituzumab govitecan) — removed indication noted; consult policy for current coverage

Enhertu HCPCSHCPCSCovered

J9311

Enhertu (fam-trastuzumab deruxtecan-nxki) HCPCS listing referenced

Zarxio updateHCPCS

Q5103

Zarxio (filgrastim-sndz) HCPCS biosimilar update referenced

Drugs & vaccines: coverage, dosing, and billing notes

Grafapex (treosulfan) coverage

Coverage and dosing

Effective Jan 22, 2025, Grafapex (treosulfan) is covered for its FDA-approved indications: use with fludarabine as preparative regimen for alloHSCT in adults and pediatric patients ≥1 year with AML or MDS

Recommended dosage: 10 g/m²/day IV over two hours on three consecutive days (Day -4, -3, -2); dosage forms 1 g and 5 g vials

Arixtra (fondaparinux) coverage update

Coverage and indications

Effective Dec 23, 2024, Arixtra (fondaparinux) is payable for updated FDA-approved indications including treatment of DVT/PE in adults with warfarin and treatment of VTE in pediatric patients ≥10 kg

Adult dosing: 5 mg (<50 kg), 7.5 mg (50-100 kg), 10 mg (>100 kg) SC once daily for at least five days until INR 2-3 with warfarin; pediatric dosing 0.1 mg/kg SC once daily for ≥10 kg

Avtozma (tocilizumab-anoh) coverage

Billing, prior authorization, and documentation requirements

Prior Authorization

Transplant prior authorization

All transplants must be prior authorized through the Human Organ Transplant Program.

Prior Authorization

Use referenced Availity Benefit Explainer for policy details

Look up detailed Blue Cross commercial policy information on Availity Benefit Explainer using the HCPCS code lookup (Payer Spaces → BCBSM/BCN → Benefit Explainer → Commercial Policy → Topic → Unique Identifier → choose HCPCS Code → enter code → Search) to confirm policy details and billing guidance.

Key terms and abbreviations

PTNSPercutaneous tibial nerve stimulation

LITTLaser interstitial thermal therapy

DBTDigital breast tomosynthesis (3D mammography)

cIAIComplicated intra-abdominal infections

URMBTA benefit type referenced as excluded from certain coverage changes (exact expansion not provided in part 1)

Numeric thresholds and dosing highlights

Heart-kidney eGFR thresholdeGFR ≤ 33 mL/min

IB-Stim pediatric age11-18 years

PTNS behavioral therapy duration8 to 12 weeks

PTNS pharmacologic therapy duration4 to 8 weeks

PTNS maintenance durationMaintenance monthly after 12-week induction up to 2 years

Vimkunya doseSingle 0.8 mL intramuscular dose

Denosumab (Stoboclo) dosing60 mg subcutaneous every 6 months

Zarxio dosing

Policy Summary

Payerblue cross blue shield - michigan

PolicyBilling chart: Blue Cross highlights medical, benefit policy changes

Policy CodePolicy N/A

Change TypeMultiple additions, revisions and removals

Effective DateVarious (see chart)

Next Review DateN/A

Key ActionAll transplants must be prior authorized through the Human Organ Transplant Program.

SourceLink

On This Page

2025-01-01added

Asparlas (calaspargase pegol-mknl) approved for off-label use to treat lymphoblastic lymphoma (billing J9173).

2025-01-22added

Grafapex (treosulfan) coverage added: covered for FDA-approved indications as preparative regimen with fludarabine for alloHSCT in patients ≥1 year with AML or MDS; recommended dose 10 g/m²/day IV over two hours on three consecutive days; supplied in 1 g and 5 g vials.

2025-01-30added

Avtozma (tocilizumab-anoh) added as covered for FDA-approved indications (RA, GCA, PJIA, SJIA, hospitalized COVID-19) with detailed dosing, lab thresholds, IV/SC instructions and dose modification guidance.

2025-02-07added

Emblaveo (aztreonam + avibactam) added as covered for adults with complicated intra-abdominal infections with limited/no alternatives; dosing by creatinine clearance with loading and maintenance regimens, infusion time 3 hours, and recommended duration 5–14 days.

2025-02-14added

Penmenvy (meningococcal A,B,C,W,Y vaccine) covered for individuals 10–25 years; two 0.5 mL doses six months apart; and Vimkunya (chikungunya vaccine, recombinant) covered for prevention in individuals ≥12 years under accelerated approval with single 0.8 mL IM dose (note: not a benefit for URMBT).

2025-02-28added

Stoboclo (denosumab-bmwo) added as covered for FDA-approved osteoporosis indications; administration 60 mg SC every six months; pregnancy must be ruled out and CKD-MBD evaluation recommended prior to initiation; instructions to take calcium and vitamin D provided; HCPCS references J3490/J3590 noted.

2025-03-07added

Omlyclo (omalizumab-igec) considered established when criteria met for asthma, chronic rhinosinusitis with nasal polyps, IgE-mediated food allergy and chronic spontaneous urticaria with indication- and weight/IgE-based dosing ranges provided.

2025-05-01revisedLatest

Multiple material medical policy updates effective May 1, 2025: cardiac contractility modulation declared experimental/investigational; PENFS/IB-Stim pediatric inclusion criteria and exclusions clarified; heart-kidney transplant inclusion/exclusion criteria updated (including eGFR ≤ 33 mL/min threshold and prior authorization requirement); LITT established for listed neurologic indications with selection criteria; PTNS inclusion, maintenance (monthly up to two years) and exclusions specified (implantable devices experimental); breast ultrasound screening designated experimental; DBT inclusion criteria updated; prenatal testing criteria updated (chromosomal microarray established when indicated; NGS for invasive prenatal testing experimental); colorectal screening tests (SEPT9, gene expression, cfDNA) considered experimental; germline testing inclusion criteria updated for multiple breast-cancer-related genes; oral surgery inclusions and exclusions updated.

2024-11-22removed

Trodelvy (sacituzumab govitecan-hziy) indication for locally advanced/metastatic urothelial cancer is no longer payable effective Nov. 22, 2024 (J9358).

2025-01-01added

Imfinzi (durvalumab) approved for off-label use to treat malignant neoplasm of the gallbladder (billing J9317) effective Jan. 1, 2025.

2025-05-01revisedLatest

Procedure code 90593 (chikungunya recombinant vaccine) designated experimental/investigational as of May 1, 2025; procedure code 90589 remains payable effective Jan. 1, 2024.

2025-01-01added

Enhertu (fam-trastuzumab deruxtecan-nxki) approved for off-label payment to treat malignant neoplasm of the ovary (Q5101).

Organic gastrointestinal disease has been ruled out

Symptoms present for at least 9 months>= 9 months

ALL of the following
- Acid suppression (H2-blocker or PPI)
- Antispasmodics or motility agents (examples: hyoscyamine, dicyclomine, erythromycin, linaclotide, prucalopride)
- Neuromodulators (examples: amitriptyline, nortriptyline, gabapentin, periactin, aprepitant)

Adolescents with a documented contraindication or intolerance to a medication in one of the required categories are exempt from that specific medication requirement (documented in the record)

Adolescents exception

IB‑Stim exclusions

Exclusions — Use of IB‑Stim when the above pediatric criteria are not met is considered experimental/investigational.

Use of IB‑Stim when not meeting the criteria in the pediatric inclusion group is considered experimental/investigational.

Heart‑kidney transplantation

Combined heart‑kidney transplantation is clinically established for carefully selected individuals when criteria are met. Final eligibility is determined by the transplant center; all transplants must be prior authorized through the Human Organ Transplant Program.

ANY of the following

Individuals who qualify for combined heart‑kidney transplantation with advanced irreversible heart and kidney disease
End‑stage heart and kidney disease not amenable to other therapy
End‑stage heart disease with eGFR ≤ 33 mL/minute, or preoperative evaluation indicates high likelihood of progressive renal dysfunction after single‑organ transplant

Heart‑kidney re‑transplantation after failed primary heart‑kidney transplant may be considered established if the individual meets re‑transplant criteria.

ANY of the following

Known current malignancy, including metastatic cancer
Recent malignancy with moderate or high risk of recurrence
History of cancer with moderate risk of recurrence
Untreated systemic infection that makes immunosuppression unsafe, including chronic infection
Systemic disease likely to be exacerbated by immunosuppression
Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

LITT (Laser interstitial thermal therapy)

Laser interstitial thermal therapy (LITT) is considered established for specific neurologic indications when ALL inclusion criteria below are met. LITT is experimental/investigational for other neurological conditions.

ALL of the following

Refractory epilepsy: documentation of disabling seizures despite use of ≥ 2 antiepileptic drug regimens
Well‑defined epileptogenic focus accessible by LITT
Multidisciplinary team (≥2 specialties, e.g., neurology and neurosurgery) agrees LITT is best option

ANY of the following

Relapsed brain metastases
Radiation necrosis
Glioblastoma

LITT should be performed by a neurosurgeon with procedure‑specific training on an FDA‑approved LITT system and hospital privileges for brain tumor surgery and LITT.

ANY of the following

LITT that does not meet the above epilepsy or brain tumor criteria
LITT for other neurological conditions

PTNS for non‑neurogenic urinary dysfunction

Percutaneous posterior tibial nerve stimulation (PTNS) for non‑neurogenic urinary dysfunction is established when initial and maintenance criteria are met. Implantable TNS devices and non‑invasive wearable neuromodulation devices are considered experimental/investigational.

ALL of the following

Initial 12‑week course of PTNS for non‑neurogenic urinary dysfunction (including overactive bladder) when BOTH of the following have been attempted and failed:
ALL of the following
- Behavioral therapy (biofeedback, fluid management, pelvic floor exercises) for an appropriate duration of 8–12 weeks
- Pharmacologic therapy (anticholinergic agents or combination with a tricyclic antidepressant) for 4–8 weeks
For continuation, there must be documented improvement in symptoms (examples: urinary frequency, nocturia, urgency) within the initial course
Maintenance therapy: frequency of approximately once per month following the initial 12‑week course, up to a total of two years (the two‑year period begins with induction of the initial course)<= 2 years

Implantable TNS devices (for example, eCoin, Revi) are considered experimental/investigational

Non‑invasive/wearable neuromodulation devices (for example, Vivally, Zida Control Sock) are considered experimental/investigational

Breast ultrasound for screening

Breast ultrasound for screening (as a primary screening modality) is considered experimental/investigational due to insufficient evidence of improved net health outcomes.

Breast ultrasound screening in average‑risk populations is considered experimental/investigational and not routinely covered.

Digital breast tomosynthesis (DBT / 3D mammography)

Digital breast tomosynthesis (DBT / 3D mammography) coverage statement and updated inclusionary note.

DBT / 3D mammography is covered consistent with mammography screening guidelines and local coverage determinations.

Note: Updated inclusionary considerations reflect incorporation of DBT where imaging facility and clinical guidelines support its use for screening and diagnostic mammography.

Prenatal (fetal) testing — chromosomal microarray and single‑gene testing

Prenatal (fetal) testing — chromosomal microarray and single‑gene testing. For single‑gene testing (molecular single‑gene branch), ALL criteria must be met for coverage; next‑generation sequencing (NGS) panels for fetal diagnosis are considered experimental when criteria are not met.

ALL of the following

Molecular single‑gene testing is covered when ALL of the following are met:
A specific single‑gene disorder is suspected based on fetal ultrasound findings or family history
Testing results would materially alter pregnancy management or perinatal care
Parental counseling and informed consent documented

ANY of the following

Chromosomal microarray for fetal diagnosis is covered when indicated (e.g., fetal structural anomaly)
Use of NGS panels for prenatal diagnosis is considered experimental/investigational when the single‑gene criteria are not met

Colorectal cancer screening — listed tests considered experimental

Listed colorectal cancer screening molecular tests are considered experimental/investigational and not covered.

Tests considered experimental for colorectal cancer screening include SEPT9 (methylated SEPT9), other tumor‑derived molecular tests, and routine cell‑free DNA (cfDNA) tests for screening.

Germline testing for breast cancer genes

Germline testing for breast cancer genes — coverage when indicated. Includes multiple indication branches and examples of personal history criteria. Coverage follows NCCN recommendations; testing is not covered when criteria are not met.

ANY of the following

Germline testing is covered for individuals with personal history suggestive of hereditary breast and/or ovarian cancer meeting NCCN criteria (examples: breast cancer diagnosed ≤45 years, triple‑negative breast cancer ≤60 years, bilateral breast cancer, ovarian/fallopian tube/peritoneal cancer at any age)
Testing is covered for individuals with family history of pathogenic variant in a relevant gene
Testing is covered when it would affect treatment (for example, PARP inhibitor eligibility) or surgical decision‑making

Testing for additional genes or broader panels should align with NCCN guidance; if criteria are not met, testing is considered experimental/investigational.

Chikungunya virus vaccine (90589 & 90593)

Chikungunya virus vaccine codes: 90589 and 90593 — coverage distinctions effective as noted.

CPT 90589 (Chikungunya vaccine, first dose) — payable as indicated.

CPT 90593 (Chikungunya vaccine, additional doses or formulation) — considered experimental/investigational (effective date to be applied as specified in policy updates).

Covered for FDA-approved indications effective Jan 30, 2025 with dosing and administration guidance

Avtozma (tocilizumab-anoh) covered for RA, GCA, PJIA (≥2 yrs), SJIA (≥2 yrs) and hospitalized adults with COVID-19 receiving systemic corticosteroids and oxygen

Recommended lab thresholds (ANC, platelets, AST/ALT) before initiation; infusion/SC dosing limits (RA/COVID ≤800 mg; GCA ≤600 mg per infusion) and indication-specific dosing provided

Emblaveo (aztreonam + avibactam) coverage

Coverage effective Feb 7, 2025 for FDA-approved indication with dosing by renal function

Emblaveo (aztreonam + avibactam) covered for adult patients with complicated intra-abdominal infections (cIAI) with limited/no alternative options; use with metronidazole

Dosing specified by estimated creatinine clearance with loading/maintenance doses, infusion time 3 hours, dosing intervals; recommended duration 5–14 days; single-dose vial contains 2 g (1.5 g aztreonam + 0.5 g avibactam)

Iomervu (iomeprol) coverage

Coverage effective Nov 27, 2024 for FDA-approved imaging indications

Iomervu (iomeprol) covered for multiple intra-arterial and intravenous radiographic procedures in adults and pediatric patients

Dosage individualized by tables accounting for age, weight, vessel size; concentrations 250–400 mg I/mL available

Omlyclo (omalizumab-igec) coverage

Coverage established effective Mar 7, 2025 when criteria met; indications and dosing provided

Omlyclo (omalizumab-igec) is established for moderate to severe persistent asthma (≥6 yrs) with positive aeroallergen reactivity inadequately controlled on inhaled corticosteroids; chronic rhinosinusitis with nasal polyps (≥18 yrs); IgE-mediated food allergy (≥1 yr) as adjunct to avoidance; chronic spontaneous urticaria (≥12 yrs) refractory to H1 antihistamine

Limitations: not for acute bronchospasm/status asthmaticus/emergency allergic reaction; dosing ranges provided by indication and weight/IgE level; dosage forms 75 mg/0.5 mL and 150 mg/mL prefilled syringe

Penmenvy coverage

Coverage effective Feb 14, 2025 for FDA-approved indication

Penmenvy is covered for active immunization to prevent invasive disease caused by N. meningitidis serogroups A, B, C, W, Y in individuals 10–25 years of age

Administer two doses (~0.5 mL each) six months apart; reconstitute MenACWY component with MenB component

Stoboclo (denosumab-bmwo) coverage

Coverage effective Feb 28, 2025 for FDA-approved osteoporosis indications

Stoboclo (denosumab-bmwo) covered for postmenopausal women and men with osteoporosis at high risk for fracture, glucocorticoid-induced osteoporosis at high risk, and to increase bone mass in certain cancer therapy contexts

Pregnancy must be ruled out before administration; evaluate CKD-MBD before initiation in advanced CKD; administer 60 mg SC every six months; advise calcium 1000 mg and vitamin D ≥400 IU daily; bill per appropriate HCPCS (J3490/J3590) as medical benefit injection

Vimkunya (chikungunya vaccine, recombinant) coverage

Coverage effective Feb 14, 2025 for FDA-approved accelerated approval indication

Vimkunya (chikungunya vaccine, recombinant) is covered for prevention of chikungunya disease in individuals ≥12 years under accelerated approval; administer as single 0.8 mL IM dose0.8 mL single IM dose

Indication approved under accelerated approval; HCPCS J9118; not a benefit for URMBT

Asparlas, Imfinzi, Trodelvy, Enhertu and Zarxio updates

Off-label approvals and indication changes (effective dates noted)

Asparlas (J9173): Approved for off-label use to treat lymphoblastic lymphoma effective Jan 1, 2024; URMBT excluded

Bill under J9173

Imfinzi (J9317): Approved for off-label use to treat malignant neoplasm of gallbladder effective Jan 1, 2025; URMBT excluded

Bill under J9317

Trodelvy (J9358): No longer payable for indication locally advanced/metastatic urothelial cancer effective Nov 22, 2024 because no longer FDA-approved

Do not bill/pay J9358 for that indication

Enhertu (Q5101): Approved for off-label use to treat malignant neoplasm of the ovary; URMBT excluded

Bill under Q5101

Zarxio: Payable for increased survival after myelosuppressive radiation exposure effective Oct 22, 2024; dosing 10 mcg/kg/day SC10 mcg/kg/day

Bill under appropriate codes

Documentation Required

PTNS continuation documentation

For continuation of PTNS beyond the initial induction course, documentation must show evidence of symptom improvement during the initial 12‑week course (examples: reduced urinary frequency, nocturia, or urgency).

Billing Rule

Chikungunya vaccine billing (90589)

Procedure code 90589 (chikungunya vaccine) is payable effective Jan. 1, 2024; bill the vaccine with 90589 and include appropriate vaccine administration coding per standard medical benefit billing rules.

Code: 90589
Payable effective: 2024-01-01
Use appropriate vaccine administration codes when billing.

Billing Rule

Grafapex dosing and administration billing

Grafapex (treosulfan) dosing: 10 g/m²/day IV over two hours on three consecutive days (Day -4, -3, -2). Product supplied as 1 g and 5 g single‑dose vials — bill per vial/unit and use appropriate J‑code or placeholder (C9399 / J3490 / J3590) per drug administration and billing policies.

Recommended dose: 10 g/m²/day IV × 3 days (Days -4 to -2)
Vial sizes: 1 g and 5 g single‑dose vials
Billing: bill per vial/unit; use C9399 or J3490/J3590 placeholders where applicable.

Documentation Required

Genetic testing eligibility documentation

Genetic testing eligibility requires documentation of family or personal history or prior testing results that meet the policy inclusion criteria (for example: a close blood relative with a known pathogenic/likely pathogenic variant, personal cancer history meeting listed criteria, or a pathogenic variant identified on tumor testing prompting germline testing). Refer to the listed gene codes when documenting eligibility.

Referenced codes: 81228, 81229, 81349, 81405
Document: family/personal history or prior test results to meet inclusion criteria

Billing Rule

Avtozma/Emblaveo/Iomervu/others — specialty drug coding

New specialty drugs (examples Avtozma, Emblaveo, Iomervu) should be billed per the medical/drug benefit rules using appropriate J‑codes or NDCs; where specific J‑codes are not assigned in this chart, use placeholder unclassified codes (J3490 / J3590) or J1652 as applicable and follow infusion/drug administration guidance in the policy.

Placeholders: J3490, J3590 (use specific J‑code/NDC when available)
Include infusion/dosing details and follow medical benefit billing rules

Billing Rule

Report denosumab under appropriate HCPCS

Report denosumab (Stoboclo) under the appropriate HCPCS/NDC; denosumab is referenced with J3490/J3590 placeholders in this chart and should be billed per the medical benefit as a provider‑administered injection. Rule out pregnancy before administration and evaluate for CKD‑MBD (intact PTH, serum calcium, 25(OH) vitamin D, 1,25(OH)2 vitamin D) in patients with advanced CKD per policy prior to initiation.

HCPCS placeholders referenced: J3490 / J3590
Clinical prerequisites: pregnancy rule‑out; CKD‑MBD labs prior to initiation

Billing Rule

Vimkunya billing and administration

Vimkunya (chikungunya vaccine, recombinant) — bill with HCPCS J9118 for the medical benefit. Administer intramuscularly as a single 0.8 mL dose. Note: Vimkunya is approved under accelerated approval and is not a benefit for URMBT members.

HCPCS: J9118
Dose: single 0.8 mL IM
Not a benefit for URMBT members
Effective coverage date noted in policy: Feb. 14, 2025

Billing Rule

Asparlas off-label billing

Asparlas (calaspargase pegol‑mknl) — bill under HCPCS J9173 for the off‑label lymphoma indication approved Jan. 1, 2024. This change excludes URMBT members.

HCPCS: J9173
Off‑label indication: lymphoblastic lymphoma (effective 2024-01-01)
URMBT excluded

Billing Rule

Imfinzi off-label billing

Imfinzi (durvalumab) — bill under HCPCS J9317 for the off‑label gallbladder cancer indication approved Jan. 1, 2025. URMBT members are excluded from this change.

HCPCS: J9317
Off‑label indication: malignant neoplasm of gallbladder (effective 2025-01-01)
URMBT excluded

Billing Rule

Trodelvy indication no longer payable

Trodelvy (sacituzumab govitecan‑hziy) J9358 — the indication for locally advanced/metastatic urothelial cancer is no longer payable; do not bill/pay J9358 for that removed indication (effective Nov. 22, 2024).

HCPCS: J9358
Do not bill/pay for the removed mUC indication (effective 2024-11-22)

Billing Rule

Enhertu off-label billing

Enhertu (fam‑trastuzumab deruxtecan‑nxki) — bill under HCPCS Q5101 for the approved off‑label ovarian cancer indication; URMBT members are excluded from this change.

HCPCS: Q5101
Off‑label indication: malignant neoplasm of the ovary
URMBT excluded

Billing Rule

Zarxio updated indication billing

Zarxio (filgrastim‑sndz) — payable for increased survival after myelosuppressive radiation exposure (hematopoietic syndrome of acute radiation syndrome); dosing for radiation exposure is 10 mcg/kg/day subcutaneous — bill using the appropriate HCPCS or NDC codes per product labeling and plan billing rules.

Dose for radiation exposure: 10 mcg/kg/day subcutaneous
Billing: use appropriate HCPCS/NDC codes per product labeling

Documentation Required

Oral surgery pathology documentation

For cyst biopsy when the cyst is primary or associated with the crown of the tooth, a pathology report must be available upon request to support medical necessity and coding.

10 mcg/kg/day subcutaneous

Headline counts are already shown in the dashboard 'stats' array, so no additional metric_cards are included here; refer to the brief 'stats' array for context on updated/added procedures, May 1, 2025 updates, referenced codes and other summary counts.