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Medical Policy

Regence Medicare Advantage Medical Policy Updates

Last Updated: May 1, 2020

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 #

Oxygen Concentrators

Making minor revisions to accommodate the new pre-authorization requirements that will be implemented when oxygen concentrators are used for more than 90 days (3 months).

Effective Date: May 1, 2020 This has been delayed until August 1, 2020

Durable Medical Equipment (DME), Policy No. M-22
External Insulin Infusion Pumps

Re-adding local coverage determination (LCD) L33822 to this policy because Noridian says coverage for HCPCS E0787 requires criteria from two separate LCDs to be met.

Effective Date: May 1, 2020

DME, Policy No. M-86
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Updated information regarding the Caris Life Sciences MI Tumor Seek and MI Profile tests; Updated reference for proprietary laboratory analyses (PLA) 0130U (A54995), which considers this to be a non-covered test; Updated “GenomeDX” to “Decipher Biosciences" for the Decipher prostate test with no change to the LCD used; Added the TruGraf test and corresponding LCD (L38135).

Effective Date: May 1, 2020

Genetic Testing (GT), Policy No. M-64
Myocardial Strain Imaging

New Medicare Advantage medical policy.

Effective Date: April 1, 2020

Medicine, Policy No. M-168
Vagus Nerve Stimulation (VNS)

Revised to address code related to hypoglossal nerve stimulation for obstructive sleep apnea.

Effective Date: April 1, 2020

Surgery, Policy No. M-74
Deep Brain Stimulation (DBS)

New Medicare Advantage medical policy.

Effective Date: April 1, 2020

Surgery, Policy No. M-84
Occipital Nerve Stimulation (ONS)

Revised to address code related to hypoglossal nerve stimulation for obstructive sleep apnea.

Effective Date: April 1, 2020

Surgery, Policy No. M-174
Sacroiliac Joint Fusion

New Medicare Advantage medical policy.

Effective Date: April 1, 2020

Surgery, Policy No. M-193
Hypoglossal Nerve Stimulation

Revised to add new local coverage determination (LCD) and article (LCA) for hypoglossal nerve stimulation for obstructive sleep apnea.

Effective Date: April 1, 2020

Surgery, Policy No. M-215
Responsive Neurostimulation

New Medicare Advantage medical policy.

Effective Date: April 1, 2020

Surgery, Policy No. M-216
Leadless Pacemakers

New Medicare Advantage medical policy.

Effective Date: April 1, 2020

Surgery, Policy No. M-217
Genetic and Molecular Diagnostics – Single Gene or Variant Testing

Updated description section with benefits and precautions around genetic testing, as well as general Medicare coverage statements; Added to the “Medicare criteria” section to address targeted panels that have coverage criteria available; Added reproductive carrier screening and prenatal testing, as well as a row for SMN1 gene testing; Added row for PABPN1 gene testing; Added clarification regarding JAK2 testing.

Effective Date: March 1, 2020

GT, Policy No. M-20
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Updated description section with benefits and precautions around genetic testing, as well as general Medicare coverage statements; Added to the Medicare criteria section to address targeted panels that have coverage criteria is available in other Medicare genetic testing policies; Added additional tests to the policy (e.g., the Colaris® Plus and Prospera tests); Added rows for next generation sequencing (NGS) testing for solid tumors and myeloid malignancies that are not otherwise stated; Updated the Medicare reference for the Pigmented Lesion Assay (PLA) test with new LCD effective mid-February; Added clarification regarding JAK2 testing.

After the Molecular Diagnostics (MolDX) program contractor reviews a given test, they will determine coverage or non-coverage. Not all tests are included within a local coverage determination (LCD) or article (LCA) policy; however, coverage or non-coverage may be found in the Change Healthcare DEX Exchange Registry website. This policy was updated to reflect this information when available.Note: For tests within this policy that are noted as covered, medical necessity criteria still need to be met. Tests continue to undergo further review by MolDX, which means tests that are currently listed as covered may become non-covered in the future. As test coverage changes, revisions to this policy will be made on an ongoing basis.

Effective Date: March 1, 2020

GT, Policy No. M-64
Behavioral Health (Psychiatric) Services

Revised policy to align with current utilization review practices.

Effective Date: February 1, 2020

Behavioral Health (BH), Policy No. M-19
Chemical Dependency and Substance Abuse Services

Revised policy to align with current utilization review practices.

Effective Date: February 1, 2020

BH, Policy No. M-20
External Insulin Infusion Pumps

Reduced the scope of this policy to omit continuous glucose monitor (CGM) systems and focus the policy on external insulin infusion pumps.

Effective Date: February 1, 2020

DME, Policy No. M-86
Genetic and Molecular Diagnostics – Single Gene or Variant Testing

Updated LCD L35008 references to LCA A57642; Added companion articles related to LCDs used for various tests; Updated coverage information for the Caris Life Science MI Tumor Seek test; Added LCA A57355 for PLA codes 0131U-0138U; Updated coverage information for several respiratory pathogen panel tests based on a 2019 LCA update.

Effective Date: January 1, 2020

GT, Policy No. M-20
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Added LCA A57354 for 0136U (ATM add-on test code); Added companion articles related to LCDs used for various tests.

Effective Date: January 1, 2020

GT, Policy No. M-64
Investigational (Experimental) Services and New and Emerging Medical Technologies and Procedures

Removed existing Category III codes (Note: These codes remain non-covered under LCA A57642); Added new first quarter 2020 Category III and proprietary laboratory analyses (PLA) codes not addressed in other Medicare Advantage medical policies.

Effective Date: January 1, 2020

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

Removed psychotherapy and hormone therapy, which are either medically necessary or may be reviewed by Pharmacy.

Effective Date: January 1, 2020

Medicine, Policy No. M-153
Cosmetic and Reconstructive Procedures

Removed hernia repair services from scope of this Medicare Advantage medical policy and added applicable first-quarter 2020 codes.

Effective Date: January 1, 2020

Surgery, Policy No. M-12
The following is a list of policies which include an update to an LCD or an LCA found within each policy. The hyperlink to the LCD/LCA was updated, and all revised versions are effective May 1, 2020
Policy Name

Medicare Manual Section and
Policy #

Behavioral Health (Psychiatric) Services

BH, Policy No. M-19
Chemical Dependency and Substance Abuse Services BH, Policy No. M-20
Vitamin D Testing Laboratory, Policy No. M-52

Cosmetic and Reconstructive Procedures

Surgery, Policy No. M-12
Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants Surgery, Policy No. M-40
Reduction Mammaplasty (Mammoplasty) Surgery, Policy No. M-60
Orthognathic Surgery Surgery, Policy No. M-137
Occipital Nerve Stimulation (ONS) Surgery, Policy No. M-174
Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) Surgery, Policy No. M-205
Home Health (HH) Services Utilization Management (UM), Policy No. M-02
The following is a list of policies which include an update to an LCD or an LCA found within each policy. The hyperlink to the LCD/LCA was updated, and all revised versions are effective April 1, 2020
Policy Name

Medicare Manual Section and
Policy #

Commode Chairs With Seat Lift Mechanism

DME, Policy No. M-06
Multi-Positional Patient Transfer System DME, Policy No. M-23
Pneumatic Compression Devices DME, Policy No. M-78
Powered Knee, Powered Ankle-Foot, Microprocessor-Controlled Ankle-Foot and Microprocessor-Controlled Knee Prostheses DME, Policy No. M-81
External Insulin Infusion Pumps DME, Policy No. M-86
Noninvasive Ventilators in the Home Setting DME, Policy No. M-87
Genetic and Molecular Diagnostics – Single Gene or Variant Testing GT, Policy No. M-20
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing GT, Policy No. M-64
Signal-Averaged Electrocardiography (SAECG) Medicine, Policy No. M-21
Surface Electromyography (SEMG) Including Paraspinal SEMG Medicine, Policy No. M-73
Varicose Vein Treatment Surgery, Policy No. M-104
Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction Surgery, Policy No. M-134
The following is a list of policies which include an update to an LCD or an LCA found within each policy. The hyperlink to the LCD/LCA was updated, and all revised versions are effective February 1, 2020
Policy Name

Medicare Manual Section and
Policy #

Dental Services Allied Health (AH), Policy No. M-35
Allergy and Sensitivity Tests of Uncertain Efficacy Laboratory, Policy No. M-01
Multi-Positional Patient Transfer System DME, Policy No. M-23
Power Wheelchairs (PWCs) DME, Policy No. M-37
Electrical Stimulation and Electromagnetic Therapy Devices DME, Policy No. M-83
Allergy and Sensitivity Tests of Uncertain Efficacy Laboratory, Policy No. M-01
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting Medicine, Policy No. M-33
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions Medicine, Policy No. M-77
Quantitative Sensory Testing Medicine, Policy No. M-91
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Respiratory Disorders Medicine, Policy No. M-108
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy Medicine, Policy No. M-121
Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow Medicine, Policy No. M-142
Investigational (Experimental) Services and New and Emerging Medical Technologies and Procedures Medicine, Policy No. M-149
Cosmetic and Reconstructive Procedures Surgery, Policy No. M-12
Percutaneous Neuromodulation Therapy (PNT) Surgery, Policy No. M-44
Ventricular Assist Devices and Total Artificial Hearts Surgery, Policy No. M-52
Reduction Mammaplasty (Mammoplasty) Surgery, Policy No. M-60
Vagus Nerve Stimulation (VNS) Surgery, Policy No. M-74
Radiofrequency Ablation (RFA) of Tumors Other Than the Liver Surgery, Policy No. M-92
Varicose Vein Treatment Surgery, Policy No. M-104
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. M-110
Transanal Radiofrequency Treatment of Fecal Incontinence Surgery, Policy No. M-129
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™) Surgery, Policy No. M-131
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation Surgery, Policy No. M-139
Subtalar Arthroereisis Surgery, Policy No. M-144
Automated Percutaneous and Percutaneous Endoscopic Discectomy Surgery, Policy No. M-145
Posterior Tibial Nerve Stimulation (PTNS) Surgery, Policy No. M-154
Pulmonary Embolectomy and Angiojet System Thrombectomy Surgery, Policy No. M-158
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome Surgery, Policy No. M-166
Occipital Nerve Stimulation (ONS) Surgery, Policy No. M-174
Plugs for Enteric and Anorectal Fistula Repair Surgery, Policy No. M-175
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. M-190
Vagus Nerve Blocking Therapy for Obesity Surgery, Policy No. M-200
Percutaneous Transluminal Angioplasty (PTA) and Stenting Surgery, Policy No. M-207
Intracardiac Ischemia Monitoring Surgery, Policy No. M-208
Phrenic Nerve Stimulation for Central Sleep Apnea Surgery, Policy No. M-212
Hypoglossal Nerve Stimulation Surgery, Policy No. M-215
Islet Cell Transplantation Transplant, Policy No. M-13
The following is a list of policies which include an update to an LCD or an LCA found within each policy. The hyperlink to the LCD/LCA was updated, and all revised versions are effective January 1, 2020
Policy Name

Medicare Manual Section and
Policy #

Behavioral Health (Psychiatric) Services BH, Policy No. M-19
Continuous Glucose Monitors (CGMs) and External Insulin Infusion Pumps DME, Policy No. M-86
Genetic and Molecular Diagnostics – Single Gene or Variant Testing GT, Policy No. M-20
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing GT, Policy No. M-64
Allergy and Sensitivity Tests of Uncertain Efficacy Laboratory, Policy No. M-01
Chemoresistance and Chemosensitivity Assays (CSRAs) Laboratory, Policy No. M-06
Multianalyte Assays with Algorithmic Analyses for the Evaluation and Monitoring of Patients with Chronic Liver Disease Laboratory, Policy No. M-47
Vitamin D Testing Laboratory, Policy No. M-52
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting Medicine, Policy No. M-33
Surface Electromyography (SEMG) Including Paraspinal SEMG Medicine, Policy No. M-73
Quantitative Sensory Testing Medicine, Policy No. M-91
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Respiratory Disorders Medicine, Policy No. M-108
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy Medicine, Policy No. M-121
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders Medicine, Policy No. M-148
Percutaneous Neuromodulation Therapy (PNT) Surgery, Policy No. M-44
Ventricular Assist Devices and Total Artificial Hearts Surgery, Policy No. M-52
Vagus Nerve Stimulation (VNS) Surgery, Policy No. M-74
Radiofrequency Ablation (RFA) of Tumors Other Than the Liver Surgery, Policy No. M-92
Varicose Vein Treatment Surgery, Policy No. M-104
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. M-110
Transanal Radiofrequency Treatment of Fecal Incontinence Surgery, Policy No. M-129
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™) Surgery, Policy No. M-131
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation Surgery, Policy No. M-139
Subtalar Arthroereisis Surgery, Policy No. M-144
Automated Percutaneous and Percutaneous Endoscopic Discectomy Surgery, Policy No. M-145
Posterior Tibial Nerve Stimulation (PTNS) Surgery, Policy No. M-154
Pulmonary Embolectomy and Angiojet System Thrombectomy Surgery, Policy No. M-158
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome Surgery, Policy No. M-166
Occipital Nerve Stimulation (ONS) Surgery, Policy No. M-174
Plugs for Enteric and Anorectal Fistula Repair Surgery, Policy No. M-175
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. M-190
Vagus Nerve Blocking Therapy for Obesity Surgery, Policy No. M-200
Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) Surgery, Policy No. M-205
Percutaneous Transluminal Angioplasty (PTA) and Stenting Surgery, Policy No. M-207
Intracardiac Ischemia Monitoring Surgery, Policy No. M-208
Phrenic Nerve Stimulation for Central Sleep Apnea Surgery, Policy No. M-212
Hypoglossal Nerve Stimulation Surgery, Policy No. M-215
The following is a list of policies which include an update to an LCD or an LCA found within each policy. The hyperlink to the LCD/LCA was updated, and all revised versions are effective December 1, 2019
Policy Name

Medicare Manual Section and
Policy #

Genetic and Molecular Diagnostics – Single Gene or Variant Testing GT, Policy No. M-20
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing GT, Policy No. M-64
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation Surgery, Policy No. M-139
The following is a list of recently archived policies:
Policy Name
Summary of Policy or Change

Medicare Manual Section and
Policy #

Speech Generating Devices (SGD) Archive Effective Date: January 1, 2020 DME, Policy No. M-52
Hyperbaric Oxygen (HBO) Therapy Archive Effective Date: January 1, 2020 Medicine, Policy No. M-14
Single Photon Emission Computed Tomography (SPECT) of the Brain Archive Effective Date: January 1, 2020 Radiology, Policy No. M-44
Bone-Conduction and Bone-Anchored Hearing Aid (BAHA) Implantation, Replacement, and Upgrades Archive Effective Date: January 1, 2020 Surgery, Policy No. M-121
Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy Archive Effective Date: January 1, 2020 Surgery, Policy No. M-147
Surgical Treatments for Hyperhidrosis Archive Effective Date: January 1, 2020 Surgery, Policy No. M-165
Percutaneous Left Atrial Appendage Closure (LAAC) Archive Effective Date: January 1, 2020 Surgery, Policy No. M-195
Transcatheter Aortic Valve Replacement (TAVR) Archive Effective Date: January 1, 2020 Surgery, Policy No. M-201
Temporomandibular Joint (TMJ) Surgical Interventions Archive Effective Date: December 1, 2019 Surgery, Policy No. M-122