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Medical Policy

Regence Medicare Advantage Medical Policy Updates

Last Updated: October 1, 2019

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

New Medicare Advantage medical policy.

Effective Date: November 1, 2019

Durable Medical Equipment (DME), Policy No. M-22
Power Wheelchairs (PWCs)

Added the remaining Group 3 power wheelchairs (PWCs) to the Medicare Advantage pre-authorization list.

Effective Date: November 1, 2019

DME, Policy No. M-37a
Continuous Glucose Monitors (CGMs) and External Insulin Infusion Pumps

Added external insulin infusion pumps to the Medicare Advantage pre-authorization list. Title revised to reflect the change in policy scope.

Effective Date: November 1, 2019

DME, Policy No. M-86a
Noninvasive Ventilators in the Home Setting

New Medicare Advantage medical policy.

Effective Date: November 1, 2019

DME, Policy No. M-87
Measurement of Serum Antibodies to Infliximab, Adalimumab, Ustekinumab, and Vedolizumab

Adding measurement of anti-drug antibodies to ustekinumab and vedolizumab to the scope of the policy. There are no Medicare criteria for the measurement of serum antibodies as related to any medication addressed by this policy, so this will continue to apply Commercial medical policy LAB65 criteria.

Effective Date: October 1, 2019

Laboratory, Policy No. M-65
Gender Affirming Interventions for Gender Dysphoria

No changes to policy criteria. Adding pre-authorization to CPT 57291, 57292, 57295, 57296 and 57426.

Effective Date: October 1, 2019

Medicine, Policy No. M-153a
Tumor Treatment Field Therapy (TTFT)

No change to policy criteria; Continued to use the Noridian local coverage determination (LCD) for TTFT; Removeding the non-coverage edits from the applicable HCPCS code, which and will now require pre-authorization because Noridian is revising the LCD to include coverage criteria.

Effective Date: September 1, 2019

DME, Policy No. M-85
Genetic and Molecular Diagnostics – Single Gene or Variant Testing

Removed the CPT code used to report for the 4KscoreTM test from this policy.

Effective Date: September 1, 2019

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

Added the applicable local coverage determination (LCD) and article (LCA) to be used for the ExoDx Prostate(IntelliScore) test (LCD L37733 and LCA A52986); Added the CPT code used to report for the 4KscoreTM test to this policy.

Effective Date: September 1, 2019

GT, Policy No. M-64
Allergy and Sensitivity Tests of Uncertain Efficacy

Added IgA testing to this Medicare Advantage medical policy, which does not include Medicare guidance; commercial criteria will be applied; Revised title to align with the commercial policy title.

Effective Date: September 1, 2019

Laboratory, Policy No. M-01
Cosmetic and Reconstructive Procedures

Adding pre-authorization to CPT 15734, which will be required only with diagnosis code K43.2 and K43.9 for the component separation technique (CST).

Effective Date: September 1, 2019

Surgery, Policy No. M-12
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)

Expanded scope of medical policy to include radioembolization, transarterial embolization (TAE), and transarterial chemoembolization (TACE) for all indications. TAE and TACE are considered medically necessary, and the policy no longer limits coverage of radioembolization to tumors of the liver; Policy will continue to use Medicare guidance when provided, but will also now use Commercial policy criteria for all other indications; Title revised to reflect the change in policy scope.

Effective Date: August 1, 2019

Medicine, Policy No. M-140
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

Removed hypoglossal nerve stimulation for obstructive sleep apnea (OSA) from the scope of this policy, and created a separate Medicare Advantage medical policy. No change to non-coverage status. Title revised to reflect the change in policy scope.

Effective Date: August 1, 2019

Surgery, Policy No. M-166
Transcatheter Aortic Valve Replacement (TAVR)

Adding the June 2019 Decision Memo to provide the revised Medicare criteria for transcatheter aortic valve replacement (TAVR). Once the national coverage determination (NCD) for TAVR is updated to reflect the new criteria, the Decision Memo will be removed.

Effective Date: August 1, 2019

Surgery, Policy No. M-201
Hypoglossal Nerve Stimulation

New Medicare Advantage medical policy for hypoglossal nerve stimulation. Note, this service was previously addressed within the existing Medicare Advantage medical policy for Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome. No change to non-coverage status.

Effective Date: August 1, 2019

Surgery, Policy No. M-215
Genetic and Molecular Diagnostics – Single Gene or Variant Testing

Clarified rows related to BCR-ABL testing, to provide details on how to use the reference.

Effective Date: July 1, 2019

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

Revised row for BDX-XL2, directing the reader to M-GT20; Revised wording for ColoNext test. Same LCD and criteria are used, just clarified how the LCD is to be applied; Revised wording for BCR-ABL testing. No changes to outcomes, or criteria, just clarified how it applies; Added new Q3 2019 Codes that are applicable to this policy

Effective Date: July 1, 2019

GT, Policy No. M-64
Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer

LCD L35000 was removed and local coverage article (LCA) A56199 was added to address CPT 81500; Added LCD L35396 to the row for ROMA testing performed in certain service areas.

Effective Date: July 1, 2019

Laboratory, Policy No. M-60
Investigational (Experimental) Services and New and Emerging Medical Technologies and Procedures

Removed existing Category III codes; Note: These codes remain non-covered under LCD L35008); Added new third quarter 2019 Category III and proprietary laboratory analyses (PLA) codes not addressed in other Medicare Advantage medical policies

Effective Date: July 1, 2019

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

Changed policy name; Updated description and format of criteria; Added new criteria for endometrial ablation, in line with commercial medical policy revisions.

Effective Date: July 1, 2019

Medicine, Policy No. M-153
Phrenic Nerve Stimulation for Central Sleep Apnea

New Medicare Advantage medical policy.

Effective Date: July 1, 2019

Surgery, Policy No. M-212
Pneumatic Compression Devices

Clarified that local coverage article (LCA) A52488 now addresses non-coverage for HCPCS E0676.

Effective Date: June 1, 2019

DME, Policy No. M-78
Powered Knee, Powered Ankle-Foot, Microprocessor-Controlled Ankle-Foot and Microprocessor-Controlled Knee Prostheses

Links and references to the Medicare Contractor for Pricing, Data Analysis and Coding (PDAC) were updated to reflect the new PDAC contractor (Palmetto GBA) as of January 15, 2019.

Effective Date: June 1, 2019

DME, Policy No. M-81
Genetic and Molecular Diagnostics – Next Generation Sequencing and Genetic Panel Testing

Added the following LCDs to the Medicare Advantage medical policy:
Noridian LCD for MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test (L37877);
Noridian LCDs L37859 and L37881 for the myPath test by Myriad Genetic Laboratories;
National Government Services (NGS) LCD L37810 for genomic sequence panels for solid tumors.

Effective Date: June 1, 2019

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

Medicare approved a Category B investigational device exemption (IDE) study, which involves the use of the CardioMEMS device; For members who are participating in this Medicare-approved IDE study, coverage may be approved based on Medicare requirements; For members who are not participating in this study or for which there is no documentation to support participation, the commercial medical policy criteria will continue to be applied and services will remain non-covered.

Effective Date: June 1, 2019

Medicine, Policy No. M-33
Clinical Trials and Investigational Device Exemption (IDE) Studies

Updated Medicare reference manual language regarding investigational device exemption (IDE) studies; No changes to policy use or what coverage of IDEs is expected of Medicare Advantage Organizations (MAOs).

Effective Date: June 1, 2019

Medicine, Policy No. M-150
Coverage with Evidence Development (CED) Studies and Registries

Removed references to archived Medicare Advantage medical policies.

Effective Date: June 1, 2019

Medicine, Policy No. M-156
Transcatheter Aortic Valve Replacement (TAVR)

Added a medically necessary statement to the policy to address a repeat TAVR when requested and when the national clinical trial (NCT) number is provided for the required registry information.

Effective Date: June 1, 2019

Surgery, Policy No. M-201
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

Reduced scope of policy to omit oscillating positive expiratory pressure (OPEP) devices.

Effective Date: May 1, 2019

DME, Policy No. M-45
Electrical Stimulation and Electromagnetic Therapy Devices

New Medicare Advantage medical policy, consolidating previous individual electrical stimulation device policies into a single policy (M-DME83.01, M-DME83.02, M-DME83.03, M-DME83.04, M-DME83.05, M-DME83.06, M-DME83.09, M-DME83.10).

Effective Date: May 1, 2019

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

Local coverage determination (LCD) L36314 was retired (effective 4/15/2019), and replaced with L37822; Updated row for comprehensive genomic profile testing for non-small cell lung cancer (NSCLC) to add previously retired LCDs to aid in lung cancer-related reviews due to the absence of current guidance by Noridian/MolDX; Updated information for tests that use NCD 90.2, as Transmittal 214 was replaced with Transmittal 215 earlier this month.

Effective Date: May 1, 2019

GT, Policy No. M-64
Auricular Electrostimulation

New Medicare Advantage medical policy.

Effective Date: May 1, 2019

Medicine, Policy No. M-146
Positional Magnetic Resonance Imaging (MRI)

Revised policy to consider lumbar positional MRIs to be medically necessary, but continue to use Commercial policy criteria for all other indications.

Effective Date: May 1, 2019

Radiology, Policy No. M-49
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 August 1, 2019
Policy Name

Medicare Manual Section and
Policy #

Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer Laboratory, Policy No. M-60
Intracardiac Ischemia Monitoring Surgery, Policy No. M-208
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 July 1, 2019
Policy Name

Medicare Manual Section and
Policy #

Intensity Modulated Radiation Therapy (IMRT) Medicine, Policy No. M-136
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, 2019
Policy Name

Medicare Manual Section and
Policy #

Vitamin D Testing Laboratory, Policy No. M-52
Hyperbaric Oxygen (HBO) Therapy Medicine, Policy No. M-14
Radiofrequency Ablation (RFA) of Tumors Surgery, Policy No. M-92
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Surgery, Policy No. M-190
The following is a list of recently archived policies:
Policy Name
Summary of Policy or Change

Medicare Manual Section and
Policy #

Galvanic Stimulation Archive Effective Date: May 1, 2019 DME, Policy No. M-83.01
H-Wave Stimulation Archive Effective Date: May 1, 2019 DME, Policy No. M-83.02
Microcurrent Stimulation (MENS) Archive Effective Date: May 1, 2019 DME, Policy No. M-83.03
Functional Neuromuscular Electrical Stimulation Archive Effective Date: May 1, 2019 DME, Policy No. M-83.04
Threshold Electrical Stimulation as a Treatment of Motor Disorders Archive Effective Date: May 1, 2019 DME, Policy No. M-83.05
Cranial Electrostimulation Therapy (CES) Archive Effective Date: May 1, 2019 DME, Policy No. M-83.06
Electrostimulation and Electromagnetic Therapy for the Treatment of Wounds Archive Effective Date: May 1, 2019 DME, Policy No. M-83.09
Electrical Stimulation and Electromagnetic Therapy for the Treatment of Arthritis Archive Effective Date: May 1, 2019 DME, Policy No. M-83.10