BCBS Michigan billing updates: Coverage & codes

Coverage Criteria

FIT-DNA / FIT-RNA colorectal cancer screening

Covered when ALL of the following are met:

Age and risk: Member is 45 through 75 years old and at average risk for colorectal cancer (asymptomatic, no signs or symptoms of colorectal disease)age 45-75

Decision for ages 76-85 individualized based on overall health and prior screening history

Health and screening appropriateness: Member is healthy enough to undergo treatment if colorectal cancer is detected and does not have comorbid conditions that would significantly limit life expectancy

Repeat testing appropriate every 3 years for those who remain average risk

Transcutaneous electrical nerve stimulation (TENS) for chronic intractable pain

Covered when ALL of the following are met:

Chronic intractable pain definition: Pain causes significant disruption of function and has not responded to at least three months of conservative medical therapy (e.g., NSAIDs, ice, rest, physical therapy)>=3 months conservative therapy

Conservative therapy must precede TENS trial

Trial requirement: A monitored therapeutic trial of TENS of at least 30 days duration is performed and monitored by a physician>=30 days

Trial must demonstrate efficacy and compliance

Continued therapy: Continued TENS is covered only if the initial trial demonstrates efficacy and documented compliance with regular device usedemonstrated efficacy and compliance

Clinical summary should document perceived pain improvement, medication requirements, other modalities, and actual daily device use (frequency and duration)

Drugs, vaccines and biologics payable/established for FDA-approved indications

Covered when used for FDA-approved indications and per dosing/administration guidance provided in the chart.

Examples listed: MenQuadfi, Datroway, Tocilizumab-aazg, Docivyx, Enflonsia, mNEXSPIKE, Xifyrm, Jivi, Opdivo, Rituximab biosimilars (Truxima, Riabni, Rituxan), Zynyz, Ruxience, Fylnetra are listed as payable/established when used for their FDA-approved indications and per dosing/administration guidanceuse per FDA indication and dosing guidance

Refer to individual chart entries for specific age, dosing, administration and contraindication details

FIT-DNA and FIT-RNA stool testing are intended for average-risk colorectal cancer screening and are not appropriate for symptomatic patients or for diagnostic evaluation. Exclusions include individuals with symptoms of colorectal disease (for example, lower gastrointestinal pain or blood in the stool), a personal history of adenomatous polyps or colorectal cancer, inflammatory bowel disease, a family history of colorectal cancer or adenomatous polyps in a first-degree relative (particularly if the relative’s cancer onset was at age 45 years), familial adenomatous polyposis, and Lynch syndrome. Repeat FIT-DNA testing is appropriate at three‑year intervals only for members aged 45 through 75 who remain asymptomatic and otherwise meet average‑risk screening criteria.

Transcutaneous afferent patterned stimulation (TAPS) devices, specifically the CALA Trio and CALA klQ, are considered experimental and investigational for treatment of essential tremor or action tremor of Parkinson disease due to insufficient evidence of improved net health outcomes and therefore are not covered.

By contrast, Transcutaneous Electrical Nerve Stimulation (TENS) has been updated to a covered service when documented criteria are met (procedure code E0721, effective July 1, 2025). TAPS exclusions stand independent of TENS coverage and should be applied when a provider proposes the CALA Trio or CALA klQ for tremor indications.

Coding and Procedure Codes

Payable colorectal screening molecular testsHCPCSCovered

0421U	FIT-DNA analysis (new payable procedure)
0464U	FIT-RNA analysis (new payable procedure)
81528	Referenced in updates (context: payable effective March 1, 2017)

Notesmixed

Payable once every three years with a routine/screening diagnosis; not payable in an office location; Modifiers 26 and TC do not apply.

TENS/TAPS procedure codesHCPCS

E0721	Transcutaneous electrical nerve stimulation (TENS) — updated to covered when criteria met
E0720	Related TENS/TAPS device code listed in experimental grouping
E0730	Related device code
E0731	Related device code

Experimental / Other device codes referencedHCPCSNot Covered

A4595	Durable medical equipment / infusion related HCPCS code listed in experimental group context
A4630	Durable medical equipment / infusion related HCPCS code listed
A4541	Experimental device code listed (context: experimental)
A4542	Experimental device code listed (context: experimental)
E0732	Experimental device code listed
E0733	Experimental device code listed
E0734	Experimental device code listed
0766T	Experimental/temporary code listed
0767T	Experimental/temporary code listed

Drug and biologic J-/Q-/C-/A-codes referencedmixedCovered

C9174	Datroway (datopotamab deruxtecan-dlnk)
J3490	Miscellaneous drug (used for multiple vaccines/therapeutics in chart)
J3590	Unclassified biologics/vaccines (used in chart)
J9228	Jivi (antihemophilic factor [recombinant], PEGylated-aucl)
J7208	Xifyrm (meloxicam injection)
J9299	Yervoy (ipilimumab) or related high-cost oncology code
J9312	Opdivo (nivolumab)
J9345	Rituximab / Rituxan (rituximab and biosimilars)
Q5119	Zynyz (retifanlimab-dlwr)
Q5115	Opdivo related Q-code in chart

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COVID-19 vaccine codingHCPCSCovered

J3490	mNEXSPIKE (COVID-19 vaccine, mRNA) payable for approved indications
J3590	mNEXSPIKE (COVID-19 vaccine, mRNA) payable for approved indications

inv-10: TENS trial duration

Minimum trial duration>= 30 days (monitored therapeutic trial)

Prior conservative therapy requirementMember must have pain unresponsive to at least 3 months of conservative medical therapy before trial

Monitoring requirementTENS trial must be monitored by a physician

Documentation for continuationClinical summary should document perceived pain change, medication use, other modalities, and daily device use

inv-11: FIT-DNA screening interval

Payable screening interval

Provider Actions and Billing Guidance

Prior Authorization

Verify benefits and prior authorization via Availity

Confirm member benefits and whether prior authorization is required for newly payable procedures (examples include 0421U, 0464U for FIT‑DNA/FIT‑RNA and E0721 for TENS) by checking the Benefit Explainer on Availity before scheduling or billing.

Examples of newly payable procedure codes: 0421U, 0464U, E0721

Step Therapy

Require ≥3 months conservative therapy prior to TENS trial

Before initiating a TENS trial, document that the member had at least three months of conservative medical therapy (e.g., NSAIDs, ice, rest, or physical therapy) with insufficient response.

Minimum duration of prior conservative therapy: at least 3 months
Conservative therapies include nonsteroidal anti-inflammatory medications, ice, rest, or physical therapy.

Initial Therapy Criteria

Xifyrm initial therapy

Initial use guidance and required conditions:

Indication and patient selection: Xifyrm (meloxicam injection) is used for management of moderate-to-severe pain in adults when billed for its FDA-approved indicationadult patients

Not recommended for situations requiring rapid onset of analgesia alone; use for the shortest duration consistent with patient goals

Initial dosing: Recommended dosage is 30 mg once daily administered by intravenous bolus injection over 15 seconds30 mg once daily

Ensure patient is well hydrated before administration; monitor analgesic response and consider short-acting non-NSAID if inadequate

Continuation Therapy Criteria

TENS continuation

Continuation requires demonstration of benefit from the initial therapeutic trial:

Demonstrated efficacy: Efficacy demonstrated in the initial TENS therapeutic trial (for example, a two-point or >=30% improvement in visual analog scale)clinical improvement (e.g., >=30% VAS or two-point change)

Clinical summary should include perceived pain intensity with and without TENS

Demonstrated compliance: Member demonstrates regular device use during the trial (daily or near-daily use) and adherence to prescribed regimenregular/near-daily use during trial

Documentation should include actual frequency and duration of application

Additional documentation:

Step Therapy Requirements

Step	Requirement	Notes
1	Trial of conservative therapy for at least three months must be completed prior to initiating a TENS therapeutic trial	Conservative therapy includes NSAIDs, ice, rest or physical therapy; pain must be unresponsive to these measures for ≥3 months
2	Monitored TENS therapeutic trial of at least 30 days duration	Trial must be monitored by a physician and demonstrate efficacy and compliance (see continuation criteria)

Site of Care Requirements

Billing Rule

Do not bill FIT‑DNA/FIT‑RNA to office place of service

These procedures (FIT‑DNA/FIT‑RNA) are expressly not payable when billed with an office place of service; do not submit claims with office location for these molecular screening tests.

Payment policy: Not payable in an office location
Payable once every three years with a routine/screening diagnosis (for eligible patients)

Note

Use appropriate facility (hospital outpatient/infusion center) for oncology infusions

Administer oncology infusions (for example Docivyx/docetaxel) in an appropriate facility (hospital outpatient or infusion center) equipped to manage infusion‑related complications rather than in office settings.

Docivyx is payable for FDA‑approved indications and is administered as intravenous infusion

Quantity Limits and Biosimilar Guidance

inv-22: Fylnetra (pegfilgrastim-pbbk)

Quantity limit2 doses per course for radiation-exposure indication

Dose strength6 mg per dose administered subcutaneously

Dosing intervalTwo doses administered one week apart; first dose as soon as possible after exposure

Note

Ensure indication‑specific documentation for rituximab/biosimilars

Rituximab products (including Rituxan and approved biosimilars Truxima and Riabni) are considered established when criteria are met for FDA‑approved indications (e.g., moderate to severe pemphigus vulgaris); ensure documentation meets indication‑specific criteria when requesting coverage.

Truxima, Riabni, and Rituxan are considered established effective June 9, 2025
Indications include moderate to severe pemphigus vulgaris in adults (follow dosing/administration guidance)

Background

This policy aligns coverage determinations with the populations and indications described in governing clinical guidance and regulatory approvals. For colorectal cancer screening, coverage is matched to the screening population defined for FIT‑DNA/FIT‑RNA—asymptomatic, average‑risk adults aged 45 through 75, with repeat testing at three‑year intervals when criteria continue to be met—and excludes populations identified by clinical or family history that increase risk. Similarly, device and therapeutic determinations reference evidence-based use: TENS is covered only when defined trial and continuation criteria (including a physician‑monitored trial of at least 30 days and prior failure of ≥3 months of conservative therapy) are documented, while TAPS devices lacking sufficient evidence for tremor indications are designated investigational. These alignments ensure coverage mirrors FDA‑cleared/approved indications and the clinical inclusion/exclusion criteria described in the source material.

Definitions

inv-17: Average risk for colorectal cancer screening

Definition (average risk)Adults 45 through 75 years old who are asymptomatic and without personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, or significant family history (first-degree relative with colorectal cancer/adenomatous polyps)

Screening appropriatenessPatient should be healthy enough to undergo treatment if cancer is detected and not have comorbid conditions that significantly limit life expectancy

Repeat testingRepeat FIT‑DNA/FIT‑RNA appropriate at 3‑year intervals for individuals who remain at average risk

inv-18: Chronic intractable pain

Definition (chronic intractable pain)Pain causing significant disruption of function that has not responded to at least 3 months of conservative therapy (e.g., NSAIDs, ice, rest, physical therapy)

Conservative therapy examples

Billing chart: Updates to payable procedures, policy clarifications and new payable procedures

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