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Medical Policy

Regence Medicare Advantage Medical Policy Updates

Last Updated: October 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 #

Transcatheter Heart Valve Procedures

New Medicare Advantage medical policy

Effective Date: December 1, 2020

Surgery, Policy No. M-221
Oxygen Concentrators

Added clarification to “Required Documentation” section of policy.

Effective Date: October 1, 2020

Durable Medical Equipment (DME), Policy No. M-22
Durable Medical Equipment, Prosthetic and Orthotic Upgrades, Replacements, Duplicates, and Repairs

New Medicare Advantage medical policy.

Effective Date: October 1, 2020

DME, Policy No. M-75
Powered Exoskeleton for Ambulation

New Medicare Advantage medical policy.

Effective Date: October 1, 2020

DME, Policy No. M-89
Genetic and Molecular Diagnostics – Single Gene or Variant Testing

Replaced the LCDs for "MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L36312 and L36310) with the LCDs for MolDX: Pharmacogenomics Testing (L38337 and L38335), due to L36312/L36310 being retired mid-August 2020. Until Noridian develops the corresponding billing/coding LCA for their LCDs, added the Palmetto GBA companion billing/coding LCA for the above pharmacogenomic testing references since they include useful information regarding coverage determinations; Updated relevant Q4 2020 CPT code changes.

Effective Date: October 1, 2020

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

Removed CFTR from Table 2; Updated language for some tests that used local coverage determination (LCD) L35396, due to LCD language revision; Consolidated various tests when they use the same Medicare reference; With the removal of CPT codes from LCDs, also updated criteria sources from LCDs to the companion LCAs, when decision-making is based on the LCA; Replaced the LCDs for "MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L36312 and L36310) with the LCDs for MolDX: Pharmacogenomics Testing (L38337 and L38335), due to L36312/L36310 being retired mid-August 2020. Until Noridian develops the corresponding billing/coding LCA for their LCDs, added the Palmetto GBA companion billing/coding LCA for the above pharmacogenomic testing references since they include useful information regarding coverage determinations; Added the LCD for MolDX: Pharmacogenomics Testing (L38394) for tests performed in Ohio (e.g., GeneSight) and also LCDs L38294 and L38435 for other service areas; Updated relevant Q4 2020 CPT code changes.

Effective Date: September 1, 2020

GT, Policy No. M-64
Biochemical and Cellular Markers of Alzheimer’s Disease

New Medicare Advantage medical policy.

Effective Date: October 1, 2020

Laboratory, Policy No. M-22
COVID-19 Testing

Revised physician order requirements for repeat COVID-19 and related influenza or respiratory syncytial virus (RSV) testing per updated Medicare regulation (Note: A physician order continues to not be required for initial COVID-19, influenza, or RSV testing).

Effective Date: October 1, 2020

Laboratory, Policy No. M-74
Whole Body Hyperthermia

New Medicare Advantage medical policy.

Effective Date: October 1, 2020

Medicine, Policy No. M-15
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

Added reference to the new Noridian local coverage article (LCA) related to coding for Category III code 0232T. While coverage criteria are not changing, this LCA was incorporated into the policy.

Effective Date: October 1, 2020

Medicine, Policy No. M-77
Bone Growth Stimulators (Osteogenic Stimulation)

New Medicare Advantage medical policy; some related codes continue to be reviewed by a vendor under our Physical Medicine program and will, therefore, not be included in the scope of this policy.

Effective Date: September 1, 2020

DME, Policy No. M-83.12
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Added the test ePlex® Respiratory Pathogen 2 (GenMark) (PLA code 0225U) to this Medicare Advantage medical policy.

Effective Date: September 1, 2020

GT, Policy No. M-64
Chemoresistance and Chemosensitivity Assays (CSRAs)

Removed Medicare references to local coverage determination (LCD) L36634 and article (LCA) A56710 because they were retired for the Pennsylvania service area; replaced L36634 and A56710 with our commercial medical policy criteria. Note: The non-coverage position remains unchanged.

Effective Date: September 1, 2020

Laboratory, Policy No. M-06
COVID-19 Testing

New Medicare Advantage medical policy, consolidating COVID-19 testing services, includes molecular and antigen testing for active infection with the SARS-CoV-2 virus, as well as antibody testing (also called serology testing), which measures antibodies that the immune system develops in response to the virus; Some tests in this policy were previously addressed in the Medicare Advantage medical policy for genetic testing panels (M-GT64), but will be transferred to this new COVID-19 testing policy.

Effective Date: August 26, 2020

Laboratory, Policy No. M-74
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: August 1, 2020

DME, Policy No. M-22
Measurement of Serum Antibodies to Selected Biologic Agents

Added tests to the scope of the Medicare Advantage medical policy due to a new portfolio of tests for additional medications (certolizumab [Cimzia®], etanercept [Enbrel®], and golimumab [Simpon®]). Policy title revised to reflect update.

Effective Date: August 1, 2020
Laboratory, Policy No. M-65
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Medicine, Policy No. M-90
Low-Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Medicine, Policy No. M-105
Intensity Modulated Radiation Therapy (IMRT)

Replaced the Noridian local coverage determination (LCD) L34080 with the local coverage article (LCA) A58245.  The LCD is being retired and the LCA is being implemented on August 1, 2020.

Effective Date: August 1, 2020
Medicine, Policy No. M-136
Cell Therapy for Peripheral Arterial Disease

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Medicine, Policy No. M-141
Ultrasonographic Measurement of Carotid Artery Intima-Media Thickness as an Assessment of Atherosclerosis

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Radiology, Policy No. M-37
Total Facet Arthroplasty

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Surgery, Policy No. M-171
Image-Guided Minimally Invasive Spinal Decompression (IG-MSD) for Spinal Stenosis

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Surgery, Policy No. M-176
Baroreflex Stimulation Devices

New Medicare Advantage medical policy due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681).

Effective Date: August 1, 2020
Surgery, Policy No. M-183
Surgical Treatments for Lymphedema and Lipedema

New Medicare Advantage medical policy.

Effective Date: August 1, 2020
Surgery, Policy No. M-220
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Adding final local coverage determination (LCD) for proprietary laboratory analysis (PLA) testing code 0098U for California (L38151), which is effective 6/7/2020; Adding/Deleting Q3 2020 Code Set Update changes.

Effective Date: July 1, 2020

GT, Policy No. M-64
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting

Title change to this Medicare Advantage medical policy as a result of the Quarterly (Q3) Code Set Update.

Effective Date: July 1, 2020
Medicine, Policy No. M-33
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 Q3 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
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Added the new local coverage determination (LCD) for Decipher prostate cancer for men with intermediate-risk disease, effective May 4, 2020 (L38147); Added the new Noridian jurisdiction F and E LCDs for next generation sequence (NGS) testing for solid tumors and myeloid malignancies, effective May 17, 2020 (L38121, L38125, L38119, L38123) to assist with requests for testing performed in California, Idaho, Oregon, Utah and Washington; Added the new MolDX LCD for MolDX: Repeat Germline Testing (L38274) and companion local coverage article (LCA) (A58017), effective May 31, 2020; Added "Manufacturer or" to the laboratory column; This will account for tests as a kit, which may be used by multiple laboratories; Removed non-coverage statements for PLA code 0005U. This code is used to report for the test ExosomeDx® Prostate, also referred to as ExoDx®, and may now be covered when criteria are met.

Effective Date: June 1, 2020

GT, Policy No. M-64
Vagus Nerve Stimulation (VNS)

The Decision Memo (DM) used to provide coverage criteria of VNS for treatment resistant depression (TRD) has been removed since the national coverage determination (NCD) has been updated and now provides this information.

Effective Date: June 1, 2020

Surgery, Policy No. M-74
Varicose Vein Treatment

Added the portion of the LCA used for varicose vein requests other than the lower extremity.

Effective Date: June 1, 2020

Surgery, Policy No. M-104
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

GT, Policy No. M-64
The following is a list of additional policies which required minor revisions, but the LCD/LCA retirement did not affect coverage criteria sources. All of these revised versions are also effective October 1, 2020.
Policy Name

Medicare Manual Section and
Policy #

External Insulin Infusion Pumps

DME, Policy No. M-86
The following is a list of additional policies which required minor revisions, but the LCD/LCA retirement did not affect coverage criteria sources. All of these revised versions are also effective September 1, 2020.
Policy Name

Medicare Manual Section and
Policy #

Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer Laboratory, Policy No. M-60
Laboratory and Genetic Testing for Use of 5-Fluorouracil (5-FU) in Patients with Cancer Laboratory, Policy No. M-64
The following is a list of policies which required revision due to the retirement of the Noridian LCD for Non-Covered Services (L35008) and its related articles (LCAs) (A57642 and A55681). Most of the affected services remain non-covered and only the source of non-coverage changed. In addition, while these services previously were automatically denied during claim adjudication with no pre-authorization requirements, because of this change in non-coverage criteria, pre-authorization will be added to these services in compliance with Centers for Medicare & Medicaid Services (CMS) rules and regulations. All revised versions are effective August 1, 2020.
Policy Name

Medicare Manual Section and
Policy #

Dental Services Allied Health (AH), Policy No. M-35

Behavioral Health (Psychiatric) Services

BH, Policy No. M-19
Electrical Stimulation and Electromagnetic Therapy Devices DME, Policy No. M-83

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. 01
Chemoresistance and Chemosensitivity Assays (CSRAs) Laboratory, Policy No. 06
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting Medicine, Policy No. 33
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions Medicine, Policy No. 77
Quantitative Sensory Testing Medicine, Policy No. 91
Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders Medicine, Policy No. 108
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy Medicine, Policy No. 121
Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow Medicine, Policy No. 142
Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services (Formerly: Investigational (Experimental) Services and New and Emerging Medical Technologies and Procedures) Medicine, Policy No. 149
Cosmetic and Reconstructive Procedures Surgery, Policy No. 12
Percutaneous Neuromodulation Therapy (PNT) Surgery, Policy No. 44

Ventricular Assist Devices and Total Artificial Hearts

Surgery, Policy No. 52
Vagus Nerve Stimulation (VNS) Surgery, Policy No. 74
Radiofrequency Ablation (RFA) of Tumors Surgery, Policy No. 92
Varicose Vein Treatment Surgery, Policy No. 104
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. 110
Transanal Radiofrequency Treatment of Fecal Incontinence Surgery, Policy No. 129
Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) Surgery, Policy No. 131
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation Surgery, Policy No. 139
Subtalar Arthroereisis Surgery, Policy No. 144
Automated Percutaneous and Percutaneous Endoscopic Discectomy Surgery, Policy No. 145
Posterior Tibial Nerve Stimulation (PTNS) Surgery, Policy No. 154
Pulmonary Embolectomy (Formerly: Pulmonary Embolectomy and Angiojet System Thrombectomy) Surgery, Policy No. 158
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome Surgery, Policy No. 166
Plugs for Enteric and Anorectal Fistula Repair Surgery, Policy No. 175
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. 190
Vagus Nerve Blocking Therapy for Obesity Surgery, Policy No. 200
Percutaneous Transluminal Angioplasty (PTA) and Stenting Surgery, Policy No. 207
Intracardiac Ischemia Monitoring Surgery, Policy No. 208
Phrenic Nerve Stimulation for Central Sleep Apnea Surgery, Policy No. 212
Islet Cell Transplantation Transplant, Policy No. 13
The following is a list of additional policies which required minor revisions, but the LCD/LCA retirement did not affect coverage criteria sources. All of these revised versions are also effective August 1, 2020.
Policy Name

Medicare Manual Section and
Policy #

Medicare Advantage Medical Policy Development and Review Introduction, Policy No. 01
Surface Electromyography (SEMG) Including Paraspinal SEMG Medicine, Policy No. 73
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders Medicine, Policy No. 148
Clinical Trials and Investigational Device Exemption (IDE) Studies Medicine, Policy No. 150
Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction Surgery, Policy No. 134
Surgical Ventricular Restoration Surgery, Policy No. 149
Occipital Nerve Stimulation (ONS) Surgery, Policy No. 174
Hypoglossal Nerve Stimulation Surgery, Policy No. 215
Leadless Pacemakers Surgery, Policy No. 217
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 June 1, 2020.
Policy Name

Medicare Manual Section and
Policy #

External Insulin Infusion Pumps DME, Policy No. M-86
Genetic and Molecular Diagnostics – Single Gene or Variant Testing GT, Policy No. M-20
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 recently archived policies:
Policy Name
Summary of Policy or Change

Medicare Manual Section and
Policy #