Regence Medicare Advantage Medical Policy Updates
Last Updated: April 1, 2024
|
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 #
|
| Micro-Invasive Glaucoma Surgery (MIGS) and Laser Trabeculectomy and Trabeculostomy |
Changed policy title from:
Laser Trabeculotomy and Trabeculostomy
Expanded scope to include additional micro invasive surgeries such as stents.
Effective Date: May 1, 2024 |
Surgery, Policy No. M-227 |
| Electrical Stimulation and Electromagnetic Therapy Devices |
Policy updated to include new Noridian LCD L39591 which provides limited coverage for external upper limb tremor stimulators for essential tremor.
Effective Date: April 7, 2024 |
Durable Medical Equipment, Policy No. M-83 |
| Chemical Dependency and Substance Abuse Services |
Updated to include intensive outpatient programs per Medicare Benefit Manual Chapter 6.
Effective Date: April 1, 2024 |
Behavioral Health, Policy No. M-20 |
| Definitive Lower Limb Prostheses |
Policy updated to include new HCPCS codes for a pneumatic prosthetic knee (L5841) and the RevoFit System for socket volume adjustment (L5783).
Effective Date: April 1, 2024 |
Durable Medical Equipment, Policy No. M-18 |
| Powered Exoskeleton for Ambulation and Rehabilitation |
Policy title changed from Powered Exoskeleton for Ambulation.
Expanded policy scope to include powered exoskeleton devices for robot-assisted physical therapy.
Effective Date: April 1, 2024 |
Durable Medical Equipment, Policy No. M-89 |
| Upper Extremity Rehabilitation System with Brain-Computer Interface |
New policy that follows Commercial medical policy guidance.
Effective Date: April 1, 2024 |
Durable Medical Equipment, Policy No. M-94 |
| Genetic and Molecular Diagnostics – Testing for Inherited Cancer Risk |
New policy addresses genetic testing for hereditary cancer risk, which was previously in M-GT64.
Effective Date: April 1, 2024 |
Genetic Testing, Policy No. M-02 |
| Genetic and Molecular Diagnostics – Next Generation Sequencing, Genetic Panels, and Biomarker Testing |
Removed tests related to cancer from policy, as these are not addressed in new policies M-GT02 (hereditary cancer risk testing) and M-GT83 (other cancer-related testing).
Updated Medicare guidance and links where appropriate.
Effective Date: April 1, 2024 |
Genetic Testing, Policy No. M-64 |
| Genetic and Molecular Diagnostics – Testing for Cancer Diagnosis, Prognosis, and Treatment Selection |
New policy specifically addressing genetic and molecular testing related to cancer diagnosis, prognosis, and treatment selection.
Effective Date: April 1, 2024 |
Genetic Testing, Policy No. M-83 |
| Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services |
Updated the policy to add a new code effective 4/1/2024.
Effective Date: April 1, 2024 |
Medicine, Policy No. M-149 |
| Cosmetic and Reconstructive Procedures |
Removed dermal filler codes from policy as this will be addressed through Pharmacy Policy.
Effective Date: April 1, 2024 |
Surgery, Policy No. M-12 |
| Coronary Intravascular Lithotripsy |
New Policy that points to Commercial policy SUR233 for coronary intravascular lithotripsy.
Effective Date: April 1, 2024 |
Surgery, Policy No. M-233 |
| Genetic and Molecular Diagnostics – Next Generation Sequencing, Genetic Panels, and Biomarker Testing |
Updated Medicare guidance and links where appropriate, including new guidance for the SelectMDx, Colvera, and DecisionDx DiffDx-Melanoma tests.
Effective Date: March 1, 2024 |
Genetic Testing, Policy No. M-64 |
| Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS) Head, Neck and Thyroid |
New IMRT policies replace previous Intensity Modulated Radiation Therapy (IMRT), M-MED136.
No change in intent or policy criteria.
Effective Date: March 1, 2024 |
Medicine, Policy No. M-164 |
| Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities |
New IMRT policies replace previous Intensity Modulated Radiation Therapy (IMRT), M-MED136.
No change in intent or policy criteria.
Effective Date: March 1, 2024 |
Medicine, Policy No. M-165 |
| Intensity Modulated Radiotherapy (IMRT) for Breast Cancer |
New IMRT policies replace previous Intensity Modulated Radiation Therapy (IMRT), M-MED136.
No change in intent or policy criteria.
Effective Date: March 1, 2024 |
Medicine, Policy No. M-166 |
| Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk |
New IMRT policies replace previous Intensity Modulated Radiation Therapy (IMRT), M-MED136.
No change in intent or policy criteria.
Effective Date: March 1, 2024 |
Medicine, Policy No. M-167 |
| Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate |
Added new Local Coverage Determination (LCD) and Article guidance.
Effective Date: March 1, 2024 |
Surgery, Policy No. M-210 |
| Behavioral Health (Psychiatric) Services |
Updated references for level of care place determination criteria.
Effective Date: February 1, 2024 |
Behavioral Health, Policy No. M-19 |
| Intraosseous Radiofrequency Ablation of the Basivertebral Nerve |
Updated to remove Commercial policy guidance and point to a new LCD effective 1/28/2024.
Effective Date: February 1, 2024 |
Surgery, Policy No. M-225 |
| Stem Cell and Bone Marrow Transplants |
Changing policy guidance from Commercial policy to new Local Coverage Determination (LCD) and Article regarding allo-HCT for relapsed/refractory lymphomas. Policy had been pointing to Commercial guidance for this indication. Commercial guidance allowed same coverage as new LCD and Article.
Effective Date: February 1, 2024 |
Transplant, Policy No. M-45 |
| Gradient Compression Garments (Excluding Burn Garments) |
Updated policy to include lymphedema compression garments in new Medicare benefit category.
Effective Date: January 1, 2024 |
Durable Medical Equipment, Policy No. M-92 |
| Genetic and Molecular Diagnostics – Single Gene or Variant Testing |
Added most recent guidance related to APOE and CFTR genetic testing.
Updated policy to reference the general LCD, MolDX: Molecular Diagnostic Tests (MDT), for genes that do not have more specific guidance available.
Effective Date: January 1, 2024 |
Genetic Testing, Policy No. M-20 |
| Genetic and Molecular Diagnostics – Next Generation Sequencing, Genetic Panels, and Biomarker Testing |
Added new CPT codes with Medicare guidance and links, where appropriate.
Effective Date: January 1, 2024 |
Genetic Testing, Policy No. M-64 |
| Chemoresistance and Chemosensitivity Assays (CSRAs) |
Added new CPT code for the ChemoID test, which is addressed in the policy.
Clarified the language regarding what tests are addressed in the NCD, Human Tumor Stem Cell Drug Sensitivity Assays (190.7).
Effective Date: January 1, 2024 |
Laboratory, Policy No. M-06 |
| Extracorporeal Shock Wave Therapy (ESWT) |
Changed policy title from: Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Expanded scope to include Extracorporeal Shock Wave Treatment for all indications.
Effective Date: January 1, 2024 |
Medicine, Policy No. M-90 |
| Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services |
Updated the policy in alignment with the 2024 Q1 annual code update.
Effective Date: January 1, 2024 |
Medicine, Policy No. M-149 |
| Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products |
Added new Noridian LCD L39118 with noncoverage for amniotic produces used for musculoskeletal and non-wound indications.
Effective Date: January 1, 2024 |
Medicine, Policy No. M-170 |
| Subcutaneous Tibial Nerve Stimulation (STNS) |
New policy addressing implantable subcutaneous tibial nerve stimulation.
Effective Date: January 1, 2024 |
Surgery, Policy No. M-154 |
| Ablation for the Treatment of Chronic Rhinitis |
New policy addressing ablation for the treatment of chronic rhinitis.
Effective Date: January 1, 2024 |
Surgery, Policy No. M-224 |
| Vertebral Body Tethering and Stapling |
New policy addressing vertebral body tethering and stapling for scoliosis.
Effective Date: January 1, 2024 |
Surgery, Policy No. M-232 |
| Intensity Modulated Radiation Therapy (IMRT) |
Updating policy criteria, due to retired LCD L34080, to point to Commercial policies MED164, MED165, MED166, MED167.
Effective Date: December 1, 2023 |
Medicine, Policy No. M-136 |
| Digital Therapeutic Products for Chronic Low Back Pain |
Medicare coverage guidance is not available for virtual reality cognitive behavioral therapy devices that deliver multimodal pain self-management programs. Therefore, the health plan's Commercial medical policy, MED175.03 applies.
Effective Date: December 1, 2023 |
Medicine, Policy No. M-175.03 |
| Percutaneous Transluminal Angioplasty (PTA) and Stenting |
Added NCA Decision Memo guidance, effective 10/11/2023.
Effective Date: December 1, 2023 |
Surgery, Policy No. M-207 |
| The following
is a list of recently archived policies: |
Policy Name |
Summary
of Policy or Change |
Medicare Manual Section and
Policy #
|
| Genetic and Molecular Diagnostics – Single Gene or Variant Testing |
Archive Date: April 1, 2024 |
Genetic Testing, Policy No. M-20 |
| Intensity Modulated Radiation Therapy (IMRT) |
Archive Date: March 1, 2024
See new medical policies M-MED164, M-MED165, M-MED166, M-MED167 that replaced this medical policy |
Medicine, Policy No. M-136 |
| Inpatient Rehabilitation Facility (IRF) Services |
Archive Date: February 1, 2024 |
Utilization Management, Policy No. M-03 |
| Skilled Nursing Facility (SNF) Services |
Archive Date: February 1, 2024 |
Utilization Management, Policy No. M-08 |
| Home Health (HH) Services |
Archive Date: January 1, 2024 |
Utilization Management, Policy No. M-02 |
| Posterior Tibial Nerve Stimulation (PTNS) |
Archive Date: December 1, 2023 |
Surgery, Policy No. M-154 |
| Surgical Site of Service – Hospital Outpatient |
Archive Date: December 1, 2023 |
Utilization Management, Policy No. M-19 |
