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Medical Policy
Regence Medical Policy Update, December 1, 2016
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

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.

Effective Date: February 1, 2017

Surgery, Policy No. 58 Add preauth to code 43860. Add code 43860 to the preauth list for this policy.
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
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
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Reorganized the criteria to combine noninvasive indications.

Effective Date: October 1, 2016

Durable Medical Equipment, Policy No. 83.11 N/A N/A
Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Clarified the criteria for abdomen and pelvis which states that IMRT may be considered medically necessary when the tumor is in close proximity to organs at risk and dose/volume histograms demonstrate a need for IMRT. The title was updated to reflect the newer terminology of radiotherapy. A list of information needed for review was updated to align with the revised policy criteria.

Effective Date: October 1, 2016

Medicine, Policy No. 139 N/A N/A
New and Emerging Medical Technologies and Procedures

Code 0402T [Collagen Crosslinking with Riboflavin (CXL, C3-R, CCR, CCL)] has been removed from the policy and will be addressed in a new medical policy, Medicine 159.

Effective Date: October 1, 2016

Medicine, Policy No. 149 Move code 0402T to medical policy MED159. N/A
Corneal Collagen Cross-Linking

New policy to address corneal collagen cross-linking (CXL) procedures as a treatment for various corneal conditions.

Effective Date: October 1, 2016

Medicine, Policy No. 159 Add preauth to code 0402T. Add policy to the preauth website for code 0402T.
MRI-Guided Focused Ultrasound (MRgFUS)

Clarified our investigational criterion on the use of MRgFUS for the treatment of movement disorders.

Effective Date: October 1, 2016

Surgery, Policy No. 139 N/A N/A
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis

Criteria clarified that stents to treat recurrent polyposis are investigational.

Effective Date: October 1, 2016

Surgery, Policy No. 198 N/A N/A
Prefabricated Oral Appliances for Obstructive Sleep Apnea

New policy that considers prefabricated oral appliances investigational for the treatment of obstructive sleep apnea.

Effective Date: September 1, 2016

Allied Health, Policy No. 36 Add investigational denial to HCPCS E0485 and remove from the AIM list of codes to review Remove code E0485 from AIM list of codes
Cooling Devices Used in the Home Setting

Modify criteria to clarify noncoverage for the indication of compression only.

Effective Date: September 1, 2016

Durable Medical Equipment, Policy No. 07 N/A N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed several panels.

Effective Date: September 1, 2016

Genetic Testing, Policy No. 64 N/A N/A
Radioembolization for Primary and Metastatic Tumors of the Liver

Added medical necessity criteria (I.C.2.) for the use of radioembolization for unresectable hepatic metastases from melanoma (cutaneous and ocular/uveal). Clarified language in policy criteria for unresectable hepatic metastases.

Effective Date: September 1, 2016

Medicine, Policy No. 140 N/A N/A
Cosmetic and Reconstructive Surgery

No significant policy criteria changes. However, the policy criteria was reorganized to clarify medical necessity by procedure.

Effective Date: September 1, 2016

Surgery, Policy No. 12 N/A N/A
Reduction Mammaplasty

Added new criterion that reduction mammaplasty as a preparatory first stage procedure preceding a nipple-sparing mastectomy may be considered medically necessary when policy criteria are met. Additional criterion added that reduction mammaplasty for gynecomastia is considered not medically necessary.

Effective Date: September 1, 2016

Surgery, Policy No. 60 N/A N/A
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Clarified criterion to consider third-generation ACI therapies are investigational.

Effective Date: September 1, 2016

Surgery, Policy No. 87 N/A N/A
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy

Policy scope clarified to include ablation and sclerotherapy as treatment of pelvic congestion syndrome and varicoceles.

Effective Date: September 1, 2016

Surgery, Policy No. 147 N/A Title change
Plasma Exchange (Plasmapheresis)

Criteria changes to consider additional indications medically necessary.

Effective Date: August 19, 2016

Medicine, Policy No. 05 N/A N/A
Sequencing-based Tests to Determine Fetal Aneuploidies and Microdeletions from Maternal Plasma DNA

Scope of the policy has changed. Fetal trisomy aneuploidy (T13, T18, and T21) screening criteria was removed from the policy. Criteria added to state that testing for fetal sex chromosome anueploidies is considered investigational.

Effective Date: August 1, 2016

Genetic Testing, Policy No. 44 Delete CPT codes 81420, 81507, and 0009M from policy and remove preauth edit Delete CPT codes 81420, 81507, and 0009M from policy and remove from the preauth website
Vitamin D Testing

Added osteopenia with specific ICD-10 codes, M85.80 and M85.88, to Appendix I.

Effective Date: August 1, 2016

Laboratory, Policy No. 52 Add ICD 10 dx codes M85.80 and M85.88 as covered dx for code 82306 N/A
Intensity Modulated Radiotherapy (IMRT of the Prostate

Existing policy criteria liberalized. The list of information needed for review was updated.

Effective Date: August 1, 2016

Medicine, Policy No. 137 N/A Policy name changed on the PreAuth website
Implantable Bone-Conduction and Bone-Anchored Hearing Aids

Adding criteria to address replacements and upgrades.

Effective Date: August 1, 2016

Surgery, Policy No. 121 N/A N/A
Myoelectric Prosthetic Components for the Upper Limb

Policy update that a prosthesis with individually powered digits may be considered medically necessary when criteria are met.

Effective Date: July 1, 2016

Durable Medical Equipment, Policy No. 80 Investigational denial on code L6880 termed and preauth added to this code effective 7/1/2016. Investigational denial on code L6880 termed and preauth added to this code effective 7/1/2016.
Molecular Markers in Fine Needle Aspirates of the Thyroid

Criteria clarified to state that when the criteria for Afirma are not met, Afirma is considered not medically necessary and that all other gene expression classifiers, including but not limited to ThyraMIR are considered investigational.

Effective Date: July 1, 2016

Genetic Testing, Policy No. 49 N/A N/A
New and Emerging Medical Technologies and Procedures Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T.

Effective Date: July 1, 2016

Medicine, Policy No. 149 Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T. Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T.
Single Photon Emission Computed Tomography (SPECT) of the Brain

Added additional investigational indications and expanded the scope of the policy to brain imaging for a variety of neurologic, psychiatric, psychological, and other nononcologic indications.

Effective Date: July 1, 2016

Radiology, Policy No. 44 N/A N/A
Endometrial Ablation

Criterion now requires pre-procedural sampling regardless of age or unopposed estrogen exposure for initial and repeat ablation.  Criterion now requires pre-procedural imaging report for initial and repeat ablation.

Effective Date: July 1, 2016

Surgery, Policy No. 01 N/A N/A
Cosmetic and Reconstructive Surgery

Clarified blepharoplasty criteria requirements for visual field examinations.

Effective Date: July 1, 2016

Surgery, Policy No. 12 N/A N/A
Varicose Vein Treatment

Clarified and updated the general criteria requirements including but not limited to the use of unna boot and compression wraps, documentation of conservative therapy and documentation requirements for imaging studies. Clarified and updated the criteria for additional treatment sessions and imaging. Clarified treatments that don’t meet medically necessity criteria are considered not medically necessary. Added criteria that considers sclerotherapy of vulvar varices as not medically necessary.

Effective Date: July 1, 2016

Surgery, Policy No. 104

 

N/A N/A
Artificial Intervertebral Disc

Allow simultaneous two level disc replacement in addition to the removal of the exclusion of prior fusion at the same or any adjacent level.

Effective Date: July 1, 2016

Surgery, Policy No. 127 N/A N/A
Lumbar Spinal Fusion

Added that multi-session fusions are medically necessary for severe spinal deformities. Clarified medication use to state trial of at least two prescription analgesics or non-steroidal antiinflammatories unless contraindicated. Removed requirement for comprehensive evaluation by other providers including behavioral health.

Effective Date: July 1, 2016

Surgery, Policy No. 187 N/A N/A
Supplement to MCG™ Discharge Criteria for Residential Treatment The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines.

Effective Date: June 1, 2016

Behavioral Health, Policy No. 21 N/A N/A
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines.

Effective Date: June 1, 2016

Behavioral Health, Policy No. 23 N/A N/A
Bariatric Surgery

Criteria changed to only require one comorbidity for patients with a BMI equal to or greater than 35.

Added investigational criteria for laparoscopic duodenal switch with single anastomosis.  Removed sleeve gastrectomy as a reoperation procedure for lap band conversion. Added gastric balloon as an example of an investigational endoscopic procedure.

Effective Date: June 1, 2016

Surgery, Policy No. 58 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Added pediatric patients to the investigational and not medically necessary criteria.

Effective Date: June 1, 2016

Surgery, Policy No. 166 N/A Change name of policy on preauth website
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia

Added language to allogeneic hematopoietic stem-cell transplantation criteria specifying chemotherapy is planned to achieve complete remission. Added additional clarification to criteria.

Effective Date: June 1, 2016

Transplant, Policy No. 45.28 N/A N/A
Genetic Testing for CADASIL Syndrome

Changed criteria to consider genetic testing medically necessary to confirm a diagnosis of CADASIL syndrome when criteria are met.

Effective Date: May 1, 2016

Genetic Testing, Policy No. 51 N/A N/A
Dopamine Transporter Single-Photon Emission Computed Tomography

New policy which considers the use of DAT-SPECT investigational for all indications.

Effective Date: May 1, 2016

Radiology, Policy No. 57 Continue preauth requirement on code 78607. Add investigational denial to code A9584. Add policy to preauth website.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Significant update to the policy to consider additional indications as medically necessary. In addition, existing criteria was updated with further criteria changes.

Effective Date: May 1, 2016

Surgery, Policy No. 16 N/A N/A
Liver Transplant

Clarified the investigational criteria for retransplantation.

Effective Date: May 1, 2016

Transplant, Policy No. 05 N/A N/A
The following is a list of recently archived policies:
Enhanced External counterpulsation (EECP) Archive Effective Date: October 1, 2016 Medicine, Policy No. 66
Acoustic Cardiography Archive Effective Date: October 1, 2016 Medicine, Policy No. 114
T-Wave Alternans Archive Effective Date: September 1, 2016 Medicine, Policy No. 88
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures) Archive Effective Date: September 1, 2016 Surgery, Policy No. 177
Systems Pathology in Prostate Cancer Archive Effective Date: July 1, 2016 Laboratory, Policy No. 61
Manipulation Under Anesthesia for the Treatment of Pain Archive Effective Date: July 1, 2016 Medicine, Policy No. 130