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Medical Policy
Regence Medical Policy Update, April 1, 2017
Changes to Regence Medical Policies Announced
The Regence Group 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 Regence Group’s medical policies. The detailed policies and complete Medical Policy Manual are available online at www.regence.com. We have included the section and policy number for your convenience.
         
Policy Name
Summary of Policy or Change

Section and
Policy #

Coding / Implementation Change

PreAuthorization Change

Cosmetic and Reconstructive Surgery

Effective Date: July 1, 2017

Surgery, Policy No. 12 Adding CPT codes 49654 and 49656 to this medical policy with PreAuth requirement. Adding CPT codes 49654 and 49656 to the PreAuth website for this medical policy.
Genetic Testing for Rett Syndrome Specify the genes that may be medically necessary for the testing of Rett syndrome and include guidance on panel testing.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 68 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Criteria added to define adverse pathologic findings and remove persistently detectable PSA levels. Added adaptive radiotherapy as investigational.

Effective Date: June 1, 2017

Medicine, Policy No. 137 N/A N/A
Endometrial Ablation Added requirement for contraindication to non-contraceptive progestins.

Effective Date: June 1, 2017

Surgery, Policy No. 01 N/A N/A
Genetic Testing for Hereditary Hearing Loss

Created criteria for nonsyndromic (NSHL) and syndromic hearing loss and clarified the use of single gene testing and multigene panel testing.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 36 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

This is a correction to what was reported for a 4/1/2017 effective date. Corrections will be effective as identified in the following columns.

Surgery, Policy No. 110

Previously reported:
“Added code 43236 with investigational denial.”

Corrected to now report:
“Liberalized investigational denial on codes 43192 and 43201 to require Preauth effective 2/1/2017.

Added code 43236 with preauth required effective 5/1/2017.”

Preauth website updated with codes 43192 and 43201 effective 2/1/2017.

Code 43236 will be added to the Preauth website effective 5/1/2017.
Tumor Treating Fields Therapy for Glioblastoma Policy title changed. Added criteria to address the software used to optimize tumor treating fields (TTF) therapy.

Effective Date: April 1, 2017

Durable Medical Equipment, Policy No. 85

Added CPT code 77299 to the policy with no change to the current edits.

Added CPT code 77261 to the policy with no clinical edits but a coding note added to the medical policy that this is not the correct code to use for the NovoTAL system software program.
Policy title updated to match the medical policy title change.
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Added PALB2 testing as medically necessary when policy criteria are met.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 02 N/A N/A
Cytochrome p450 Genotyping

Clarified that testing for mutations in more than one CYP450 gene is considered investigational.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 10 N/A N/A
Genetic Testing for FMR1 Mutations (including Fragile X Syndrome)

Clarified wording in criterion related to Fragile X ataxia/tremor.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 43 N/A N/A
Cosmetic and Reconstructive Surgery

Added treatment session criteria to blepharoplasty. Modified panniculectomy criteria.

Clarified blepharoplasty criterion II. C.  for the visual field assessment. Clarified criteria for the use of the component separation technique for ventral hernia repair. Added and clarified criteria for surgical repair of diastasis recti and abdominoplasty.

Effective Date: April 1, 2017

Surgery, Policy No. 12 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Added criteria for high frequency stimulation. Added language to the body of the policy to describe high frequency stimulation devices, including the Senza® system and corresponding HF10™ therapy.

Effective Date: April 1, 2017

Surgery, Policy No. 45 Change HCPCS code C1822 from reviewed to investigational denial. Change HCPCS code C1822 from reviewed to investigational denial.
Varicose Vein Treatment

Additional vein diameter measurement locations were added for ligation/stripping and endovenous ablation. For endovenous ablation, criterion added for clinical documentation that all incompetent segments of the same vein will be treated in the same session. Also, sclerotherapy for the upper extremities is considered investigational.

Effective Date: April 1, 2017

Surgery, Policy No. 104 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

Correction entered, see above entry for SUR110.

Added code with investigational denial.

Effective Date: April 1, 2017

Surgery, Policy No. 110 Added code 43236 with investigational denial. N/A
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Updated procedure names throughout policy including title and criteria usage.

Effective Date: April 1, 2017

Surgery, Policy No. 118 N/A N/A
Femoroacetabular Impingement Surgery

Removed imaging requirement for radiologist review. Added physical therapy and intra-articular injections, unless contraindicated, to the conservative treatment requirements. Added additional language that requested procedures must be consistent with the documented anatomical abnormalities. Added capsular plication, capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAI surgery, as components of and incidental to the FAI procedure.

Effective Date: April 1, 2017

Surgery, Policy No. 160 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Criteria restructured and reorganized. Clarified the medically necessary procedures in the policy and addressed partial glossectomy as one of these procedures. Revised CPAP trial requirements.

Effective Date: April 1, 2017

Surgery, Policy No. 166 Added CPT code 64568 with no change to the current edits Added CPT code 64568
Charged Particle (Proton or Helium Ion) Radiotherapy Change to consider pediatric malignant solid tumors medically necessary and clarified the criteria for ocular, cervical spinal cord, and skull base tumors.

Effective Date: March 1, 2017

Medicine, Policy No. 49 N/A N/A
In Vivo Analysis of Colorectal Polyps

Clarified criterion to indicate that policy applies to in vivo analysis of any colorectal lesions.

Effective Date: March 1, 2017

Medicine, Policy No. 104 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Change criteria to consider locally advanced prostate cancer, prior radiation to the planned target volume, and tumors close to organs at risk as medically necessary when policy criteria are met.

Effective Date: March 1, 2017

Medicine, Policy No. 137 N/A N/A
Endometrial Ablation Clarified several criteria required and concomitant procedures. Updated contraindications to contraceptives to align with Centers for Disease Control and Prevention.

Effective Date: March 1, 2017

Surgery, Policy No. 01 N/A N/A
Gastroesophageal Reflux Surgery Clarified hiatal hernia types in criteria for medically necessary and investigational indications.

Effective Date: March 1, 2017

Surgery, Policy No. 186 N/A N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and updated the name of one panel.

Effective Date: February 1, 2017

Genetic Testing, Policy No. 64 N/A N/A
Analysis of Proteomic and Metabolomic Patterns for Early Detection of Cancer

Expanded the scope of the policy to address metabolomic tests which are considered investigational.

Effective Date: February 1, 2017

Laboratory, Policy No. 41 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 138 N/A N/A
Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Clarified the criteria language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 139 N/A N/A
Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 147 N/A N/A
Bariatric Surgery

Clarified reoperation criteria; added parietal cell separating gastrojejunostomy and AspireAssist device to investigational procedures; specified that sleeve gastrectomy and adjustable gastric banding are only medically necessary in the absence of GERD and takedown of fundoplication; separated out general criteria for reference throughout the policy.

Provided clarification for hiatal hernia repair, specifying the procedure includes either repair of sliding or paraesophageal hernia.

Effective Date: February 1, 2017

Surgery, Policy No. 58

Add preauth to code 43860.

HCPCS code S2083 does not require preauth, but coverage is available only for members with bariatric surgery benefits.

Add code 43860 to the preauth list for this policy.

Remove preauth on code S2083

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Added EndoPredict and Breast Cancer Index tests to medical necessity criteria. Added additional language to clarify testing for patients with DCIS.

Effective Date: January 6, 2017

Genetic Testing, Policy No. 42 N/A N/A
Administrative Guidelines to Determine Dental vs Medical Services

Criteria updated to reflect new contract language allowing general anesthesia coverage by a medical provider under the medical benefit when criteria are met.

Effective Date: January 1, 2017

Allied Health, Policy No. 35 N/A N/A
Genetic Testing for Inherited Susceptibility to Colon Cancer

Added criterion that Lynch syndrome testing may be medically necessary in endometrial cancer patients below age 50 when policy criteria are met.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 06 N/A N/A
Genetic Testing for Familial Hypercholesterolemia

New policy for familial hypercholesterolemia genetic testing related to the PCSK9 inhibitor medications, which may require a definitive diagnosis of familial hypercholesterolemia.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 11 N/A Add new policy to PreAuth website.
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

Fecal DNA testing using Cologuard® is now considered medically necessary once every three years for patients aged 50 to 85 years who have no signs or symptoms of colorectal disease and are at average risk for colorectal cancer. Fecal DNA testing with tests other than Cologuard® remains investigational.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 12 Termed investigational denial on CPT code 81528 and add preauth requirement. Add CPT code 81528 to PreAuth website.
Urine Drug Testing for Substance Abuse and Chronic Pain

Three presumptive testing codes have been deleted with the annual code update process, and three comparable codes have been added to replace.

Effective Date: January 1, 2017

Laboratory, Policy No. 68 Added new codes 80305, 80306, 80307, and G0659 with 15 unit per year limit. N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax Significant reformatting and clarifications made to the policy criteria. New requirements for histogram analysis and the term curative treatment was added to the criteria for specific indications. IMRT may be considered medically necessary for individuals with large breasts in order to avoid or minimize hot spots when policy criteria is met. A list of information needed for review was updated in the Policy Guidelines section.

Effective Date: January 1, 2017

Medicine, Policy No. 136 N/A N/A
New and Emerging Medical Technologies and Procedures

Update the policy in accordance with the annual code update. Moved code 0404T to Medical Policy, Radiofrequency Ablation for Tumors, No. SUR92.

Effective Date: January 1, 2017

Medicine, Policy No. 149 N/A N/A
Coverage of Treatments Provided in a Clinical Trial

Clarified the criteria and added a list of information needed for review.

Effective Date: January 1, 2017

Medicine, Policy No. 150 N/A N/A
Transgender Services

Revisions have been made to the not medically necessary services. Drugs for hair loss or growth have been removed from the policy. Breast augmentation, hair removal, hair transplantation, mastopexy, and nipple/areola reconstruction in the absence of concurrent or prior subcutaneous or simple/total mastectomy may be considered medically necessary when criteria are met.

Effective Date: January 1, 2017

Medicine, Policy No. 153 Changed Criteria B and C in that if the listed services are billed for gender identity disorders they will be denied as not medically necessary (provider write-off) and not billed for gender identity disorder the services will continue to be denied as cosmetic denials (member balance). Added 15775, 15776, and 17380 to PreAuth website.
Spinal Cord and Dorsal Root Ganglion Stimulation

Added criteria for dorsal root ganglion stimulation.

Effective Date: January 1, 2017

Surgery, Policy No. 45 Add HCPCS code C1820 for review. Name changed on PreAuth website.
Ventricular Assist Devices and Total Artificial Hearts

Clarified that aortic counterpulsation devices are included in investigational criteria, as they are not FDA-approved.

Effective Date: January 1, 2017

Surgery, Policy No. 52 N/A N/A
Deep Brain Stimulation

Policy criteria reorganized with no significant changes.

Effective Date: January 1, 2017

Surgery, Policy No. 84 N/A N/A
Radiofrequency Ablation of Tumors (RFA)

Clarified that RFA for treatment of uterine fibroids is investigational.

Effective Date: January 1, 2017

Surgery, Policy No. 92 N/A N/A
Varicose Vein Treatment

Policy reorganized and grouped together into general criteria, procedures, and treatment sessions. A list of information needed for review was updated in the Policy Guidelines section. Additional clarifications were added throughout the criteria.

Effective Date: January 1, 2017

Surgery, Policy No. 104 N/A N/A
Implantable Bone-Conduction and Bone-Anchored Hearing Aids

Consider partially-implantable bone-conduction (bone-anchored) hearing aid(s) to be medically necessary when criteria are met.

Effective Date: January 1, 2017

Surgery, Policy No. 121 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Clarified the policy scope to explicitly state pulmonary tumors are included.

Effective Date: January 1, 2017

Surgery, Policy No. 132 N/A Name changed on PreAuth website.
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Expand intervals for evaluation from every ‘three to six months’ to every ‘three to twelve months’.

Effective Date: December 1, 2016

Behavioral Health, Policy No. 18 Removed codes H0031, H0032, H0046, H2012, H2014, H2019, and S5111 from the medical policy and term current edits. A workflow will be created to deny codes H0031, H0032, H0046, H2014, and S5111 for Autism diagnoses and allow other diagnoses to pay. The edit changes will be effective 1/1/2017. N/A
Genetic Panel Testing (5-50 genes) for Hematolymphoid Neoplasms or Disorders

New policy implementation for targeted multiplex genetic sequence analysis panels using DNA/RNA analysis for hematolymphoid neoplasms or disorders comprised of at least five and up to 50 genes. These panels may be used to confirm a diagnosis. This policy will list medically necessary panels related to hematolymphoid neoplasms or disorders, such as myeloid neoplasms and acute leukemias. At this time, the policy contains one panel.

Effective Date: December 1, 2016

Genetic Testing, Policy No. 09 Adding unlisted codes 81479 and 81599 to this new policy and keeping existing edits. Add code 81450 to the new policy and term the current investigational denial and add preauth. Add policy to the preauth website for code 81450.
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed several panels.

Effective Date: December 1, 2016

Genetic Testing, Policy No. 64 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

IMRT for anaplastic thyroid carcinoma and locoregional recurrence may be considered medically necessary. In addition, IMRT for treatment of other thyroid cancers may be considered medically necessary when the tumor is in close proximity to organs at risk and dose/volume histograms demonstrate the need for IMRT. The policy title was updated to reflect the newer terminology of radiotherapy.

Effective Date: December 1, 2016

Medicine, Policy No. 138 N/A N/A
Radioembolization for Primary and Metastatic Tumors of the Liver

Specified that hepatocellular carcinoma (criteria I.B.) and intrahepatic cholangiocarcinoma (criteria I.E.) must be primary.

Effective Date: December 1, 2016

Medicine, Policy No. 140 N/A N/A
Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

Change term in title from “Radiation Therapy” to “Radiotherapy". Change criteria to only allow IMRT when the tumor is in close proximity to organs at risk. Added a Policy Guidelines section with a list of information needed for review, definition of at-risk organs, and an IMRT dose constraint reference.

Effective Date: December 1, 2016

Medicine, Policy No. 147 N/A N/A
Percutaneous Angioplasty and Stenting of Veins

Expanded medically necessary criteria to include superior vena cava syndrome as a result of non-malignant causes or from intrinsic stenosis/occlusion.

Effective Date: December 1, 2016

Surgery, Policy No. 109 N/A N/A
Adoptive Immunotherapy

New policy to address the use of adoptive immunotherapy as a treatment for a number of indications. Adoptive immunotherapy, regardless of cell type, is considered investigational for all indications.

Effective Date: November 1, 2016

Medicine, Policy No. 42 Add investigational denial to code S2107 and review on code 36511 to help identify service billed when provider is not using S2107. N/A
Intensity Modulated Radiotherapy (IMRT of the Prostate

One addition to the policy requiring 90-day notification that states IMRT for treatment of prostate cancer, including palliative treatment, at radiation doses less than 60 Gy is considered not medically necessary.

Effective Date: November 1, 2016

Medicine, Policy No. 137 N/A Code is already on the PreAuth list
Cochlear Implant

Criteria changed to consider hybrid cochlear implant/hearing aid devices medically necessary when criteria are met. In addition, cochlear implants may be considered medically necessary in individuals with a diagnosis of enlarged vestibular aqueduct when criteria are met.

Effective Date: November 1, 2016

Surgery, Policy No. 08 N/A N/A
The following is a list of recently archived policies:
Computed Tomography (CT) Perfusion Imaging of the Brain Archive Effective Date: March 1, 2017 Radiology, Policy No. 54
Thermal Capsulorrhaphy as a Treatment of Joint Instability Archive Effective Date: March 1, 2017 Surgery, Policy No. 100
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Archive Effective Date: February 1, 2017 Surgery, Policy No. 170
Transvaginal and Transuretheral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Archive Effective Date: Janaury 1, 2017 Surgery, Policy No. 130