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Medical Policy

Regence Medicare Advantage Medical Policy Updates

Last Updated: May 1, 2022

Changes to Regence Medicare Advantage Medical Policies Announced

Regence Medicare Advantage and its affiliated Plans use medical policies as guidelines for coverage decisions within the member’s written benefits. Below are summaries of recent changes to the Medicare Advantage medical policy manual. We have included the section and policy number for your convenience.

The complete Medicare Medical Policy Manual with detailed policies are available online at http://blue.regence.com/medicare/index.html.

     
Policy Name
Summary of Policy or Change
Medicare Manual Section and Policy #

Power Wheelchairs – Group 2 and Group 3

Title changing from Power Wheelchairs (PWCs) with this update.

Revising medical policy to add Medicare criteria and preauthorization requirements for Group 2 power wheelchairs to our existing Group 3 power wheelchair policy.

Updating the Required Documentation field to confirm a trial of less costly equipment was performed, based on Medicare requirements.

Effective Date: May 1, 2022

Durable Medical Equipment, Policy No. M-37
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

New Medicare guidance provided for non-coverage for all Platelet Rich Plasma (PRP) Injections and/or applications as a means of managing musculoskeletal injuries and/or joint conditions. These new guidelines are in addition to the existing Medicare guidance found in NCD 270.3. For PRP indications, not addressed by Medicare, the health plan’s medical policy is applicable.

Revised policy in accordance with Medicare guidelines outlined in NCD 270.3. Criteria used to require the member be enrolled in a clinical trial that addresses reliable methods of evaluation. This guideline now states CMS covers Platelet-rich plasma (PRP) for patients with chronic non-healing diabetic wounds for a duration of 20 weeks when prepared by FDA approved devices. For treatment beyond 20 weeks, or indications not addressed in NCD 270.3 and LCD L39060, the health plan’s medical policy is applicable.

Effective Date: May1, 2022

Medicine, Policy No. M-77
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate

This Medicare policy was revised with references to Medicare guidelines for policy criteria. Codes 0421T and C2596 have been added to the policy and require preauthorization.

Effective Date: April 15, 2022

Surgery, Policy No. M-210
Coverage with Evidence Development (CED) Studies and Registries

On 4/7/2022, CMS approved monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease (AD) (CAG-00460N) when furnished in accordance with CMS approved clinical studies. Our Medicare policy was revised to support this new Medicare National Coverage Determination.

Effective Date: April 7, 2022

Medicine, Policy No. M-156
Negative Pressure Wound Therapy Pumps

New Medicare Advantage medical policy will require an initial pre-authorization for a one-month therapeutic trial; subsequent pre-authorization requests will be required for up to three additional months for a total of four months

Effective Date: April 1, 2022

Durable Medical Equipment, Policy No. M-42
Electrical Stimulation and Electromagnetic Therapy Devices

Added new Q2 2022 HCPCS code K1029 to policy for neuromuscular electrical stimulation. There is no Medicare guidance for this service, therefore, the health plan's medical policy will be applied.

Effective Date: April 1, 2022

Durable Medical Equipment, Policy No. M-83
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Policy was updated to include new Medicare guidance for Minimal Residual Disease testing, Prolaris testing, and Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing.

Effective Date: April 1, 2022

Genetic Testing, Policy No. M-64
Varicose Vein Treatment

Medicare policy was revised to add criteria C for medical necessity review for various procedures/treatments, based on clarification of Medicare guidance.

Effective Date: March 1, 2022

Surgery, Policy No. M-104
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

Policy revised to state Medicare Advantage member contracts for 2022 may contain language for limited supplemental coverage for bathroom safety items. This EOC language will take precedence where applicable. If the EOC does not address an item, Medicare guidance will be followed as outlined in policy.

Effective Date: January 1, 2022

Durable Medical Equipment, Policy No. M-88
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Added and removed panel tests with their Medicare coverage determinations.

Effective Date: January 1, 2022

Genetic Testing, Policy No. M-64
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

Revised the guidance to reflect Medicare guidelines allow coverage for platelet-rich plasma for the treatment of chronic non-healing diabetic wounds for 20 weeks.

Effective Date: January 1, 2022

Medicine, Policy No. M-77
Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services

Updated the policy in alignment with the 2022 annual code update to address new investigational medical technologies and removed deleted codes.

Effective Date: January 1, 2022

Medicine, Policy No. M-149
Gender Affirming Interventions for Gender Dysphoria

Clarification was added to the policy regarding which criteria elements within the Commercial medical policy are to be used for Medicare Advantage.  According to the Medicare Managed Care Manual, Chapter 10 - MA Organization Compliance with State Law and Preemption by Federal Law, §30.1 – General, “unless they pertain to licensure and/or solvency, State laws and regulations that regulate health plans do not apply to MA plans offered by MA organizations.” Therefore, Medicare Advantage contracts are not subject to Washington’s Gender Affirming Treatment Act (SSB 5313) and the non-state specific criteria in the health plan’s policy is applicable to all Medicare Advantage members.

Effective Date: January 1, 2022

Medicine, Policy No. M-153
Periurethral Transperineal Adjustable Balloon Continence Device

New Medicare Advantage medical policy.

Effective Date: January 1, 2022

Medicine, Policy No. M-176
Laser Interstitial Thermal Therapy

New Medicare Advantage medical policy that will follow Commercial policy stating laser interstitial thermal therapy (LITT) may be considered medically necessary for the treatment of refractory epilepsy when criteria are met and is considered investigational for all other neurological indications, including but not limited to treatment of primary or metastatic brain tumors or radiation necrosis.

Effective Date: January 1, 2022

Medicine, Policy No. M-177
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

Update the required documentation.

Effective Date: January 1, 2022

Surgery, Policy No. M-166
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve

New Medicare Advantage medical policy.

Effective Date: January 1, 2022

Surgery, Policy No. M-225
Oxygen Concentrators

Updated our medical policy. Medicare has revised the NCD for home oxygen use to treat cluster headaches. Additionally, Medicare has determined oxygen therapy and oxygen equipment is covered in the home for acute or chronic conditions, short or long term, when the patient exhibits hypoxemia as defined in the Decision Summary.

Effective Date: December 1, 2021

Durable Medical Equipment, Policy No. M-22
Noninvasive Ventilators in the Home Setting

Updated the list of information needed for review to request inclusion of the specific device name with the documentation submitted for review.

Effective Date: December 1, 2021

Durable Medical Equipment, Policy No. M-87
Gradient Compression Garments (Excluding Burn Garments)

Updated the list of information needed for review to request inclusion of the specific manufacturer and product name/model with the documentation submitted for review.

Effective Date: December 1, 2021

Durable Medical Equipment, Policy No. M-92
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

Added CPT 38205, 38206, 38240 and 38241 to this policy; pre-authorization requirements for these codes remain in place.

Effective Date: December 1, 2021

Medicine, Policy No. M-100
Skin Lesion Imaging and Spectroscopy

New Medicare Advantage medical policy

Effective Date: December 1, 2021

Medicine, Policy No. M-174
Digital Health Products for Attention Deficit Hyperactivity Disorder

New medical policy.

Effective Date: December 1, 2021

Medicine, Policy No. M-175.01
Digital Health Products for Substance Use Disorders

New medical policy.

Effective Date: December 1, 2021

Medicine, Policy No. M-175.02
Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers)

New Medicare Advantage medical policy

Effective Date: December 1, 2021

Surgery, Policy No. M-155
Pressure Ulcer Treatment by Musculocutaneous or Free Flap

New Medicare Advantage medical policy

Effective Date: December 1, 2021

Surgery, Policy No. M-223
The following is a list of recently archived policies:
Policy Name
Summary of Policy or Change

Medicare Manual Section and
Policy #