Recent Updates to the Regence Group Medical Policy Manual

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Regence Medical Policy Update, November 1, 2009
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 #*
Biofeedback	Multiple individual biofeedback policies were consolidated into this single policy which addresses biofeedback for numerous conditions. Effective date: June 1, 2009	Allied Health, Policy No. 32
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy	Clarification of a previous policy change: SRS for essential tremors or Parkinson’s disease was changed from medically necessary to investigational. Effective Date: June 9, 2009	Surgery, Policy No. 16
Autologous Hematopoietic Stem Cell Transplant	Added language to the policy criteria section to state autologous stem cell transplant is investigational for any indications not listed in the criteria table. Effective Date: June 9, 2009	Transplant, Policy No. 42
Allogeneic Hematopoietic Stem Cell Transplant	Added new medical necessity criteria for reduced intensity (RIC) allogeneic SCT for Non Hodkgin’s Lymphoma, Myelodysplastic disorders/Myeloproliferative Neoplasms, and Acute Myeloid Leukemia Policy criteria table was revised to add information on reduced intensity conditioning allogeneic SCT under each disease category. Revised the medical necessity criteria for AML to allow for those relapsing after an autologous SCT(6 month requirement was removed) Expanded AML criterion for those in remission to those with poor to intermediate risk AML in remission (i.e. abnormal cytogenetics). Added language to the policy criteria section to state allogeneic stem cell transplant is investigational for any indications not listed in the criteria table. Effective Date: June 9, 2009	Transplant, Policy No. 43
Tandem Hematopoietic Stem Cell Transplant	Added language to the policy criteria section to state autologous stem cell transplant is investigational for any indications not listed in the criteria table. Effective Date: June 9, 2009	Transplant, Policy No. 44
Reduction Mammaplasty	Policy change. Liposuction as an additional procedure to breast reduction surgery is considered not medically necessary. Also, minor wording change to criterion 2D. Effective Date: July 1, 2009	Surgery, Policy No. 60
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome In Adults	Two individual OSA/UARS surgery policies were combined into one new policy. New policy consolidates information from conventional surgeries and minimally invasive surgeries. Individual policies on conventional surgeries (Surgery 49) and minimally invasive surgeries (Surgery 142) were archived. Effective Date:July 1, 2009	Surgery, Policy No. 166
Cosmetic and Reconstructive Surgery	Major policy revision. Updated policy now includes a flow chart for determining cosmetic versus reconstructive procedures as well as specific criteria for individual procedures. Criteria added for brow ptosis repair, pectus excavatum, dermabrasion and microdermabrasion. Please see updated policy. Effective Date: This change requires 90-day notification. Implementation Date = August 1, 2009	Surgery, Policy No. 12
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy	New medical necessity criteria for stage 1 non-small cell lung cancer showing no nodal or distant disease for those who are not candidates for surgical resection. Removed medical necessity criteria for Parkinson’s disease. Added prior radiation treatment criteria for spinal cord and vertebral body tumors (metastatic or primary). Added the clarification for intracranial arteriovenous malformations. Effective Date: This change requires 90-day notification. Implementation Date = August 1, 2009	Surgery, Policy No. 16
Occupational Therapy	Removed separate case management criteria related to head injured patients. Effective Date: This change requires 90-day notification. Implementation Date = August 1, 2009	Utilization Management, Policy No. 4
Speech Therapy	Removed case management criteria related to head injured patients. Effective Date: August 1, 2009	Utilization Management, Policy No. 9
Femoroacetabular Impingement Surgery	Policy changed. Open or arthroscopic surgery for femoroacetabular impingement (FAI) may be considered medically necessary when symptom and imaging criteria are met, for skeletally mature patients who are young enough to be considered inappropriate candidates for hip arthroplasty or reconstruction. Cautionary statement added stating that this surgery should be performed only by surgeons trained and experienced in FAI and other hip surgery, at facilities with appropriate staff and experience in treating this condition. Effective Date: August 11, 2009	Surgery, Policy No. 160
Varicose Vein Treatment	Clarifications of the following criteria were added: additional treatment sessions, activities of daily living and occupational tasks, clinical documentation requirement, and conservative therapy requirement. Effective Date: September 1, 2009	Surgery, Policy No. 104
Biofeedback	Policy revised. Biofeedback now considered medically necessary for headaches. Effective Date: October 1, 2009	Allied Health, Policy No. 32
Enhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive Heart Failure	EECP remains investigational for all indications. Treatment records will be requested for services reported with CPT code 92971. Effective Date: October 1, 2009	Medicine, Policy No. 66
Surgical Treatments for Hyperhidrosis	Additional examples of significant medical complications added to criteria. Added lumbar sympathectomy and subdermal laser-assisted axillary hyperhidrosis treatment to list of investigational procedures. Added tympanic neurectomy as a medically necessary procedure for gustatory hyperhidrosis. Effective Date:October 1, 2009	Surgery, Policy No. 165
Shoulder Resurfacing	New investigational policy. Shoulder resurfacing as an alternative to total shoulder arthroplasty or hemiarthroplasty is considered investigational. There are no specific CPT codes for shoulder resurfacing. CPT code 23929 (unlisted procedure, shoulder) should be used to report this procedure. CPT codes 23470 (arthroplasty, glenohumeral joint; hemiarthroplasty) and 23472 (arthroplasty, glenohumeral joint; total shoulder) should not be used to report this procedure. Effective Date: October 1, 2009	Surgery, Policy No. 169
Genetic Testing	Major policy revision. Updated policy includes general criteria for determining medical necessity for genetic testing as well as specific criteria for individual tests. Separate policies for individual tests archived. Please see updated policy. Effective Date: This change requires 90-day notification. Implementation Date = November 1, 2009	Laboratory, Policy No. 20
Genetic Testing	New investigational indication added: Apolipoprotein E (apo E) genotyping and phenotyping for the risk assessment and management of cardiovascular disease. Effective Date: November 1, 2009	Laboratory, Policy No.20
Magnetoencephalography/ Magnetic Source Imaging (MSI)	Policy changed. MEG/MSI is now considered medically necessary for localization of language function as a substitute for Wada testing in patients undergoing surgery for epilepsy, brain tumor or other indications requiring brain resection. MSI remains investigational for all other indications. Effective Date: November 1, 2009	Radiology, Policy No. 22
Manipulation Under Anesthesia for the Treatment of Chronic Pain	New investigational policy addressing manipulation of joints for the treatment of chronic pain. Policy does not address manipulation under anesthesia for fractures, completely doslocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacmenet. Effective Date: February 1, 2010	Medicine, Policy No. 130
The following is a list of recently archived policies:
Biofeedback as a Treatment of Urinary Incontinence	Archive Effective Date: June 1, 2009	Allied Health, Policy No. 26
Biofeedback as a Treatment of Headache	Archive Effective Date: June 1, 2009	Allied Health, Policy No. 27
Biofeedback as a Treatment of Chronic Pain	Archive Effective Date: June 1, 2009	Allied Health, Policy No. 28
Biofeedback as a Treatment of Miscellaneous Indications	Archive Effective Date: June 1, 2009	Allied Health, Policy No. 29
Biofeedback as a Treatment of Fecal Incontinence	Archive Effective Date: June 1, 2009	Allied Health, Policy No. 30
Diagnosis and Management of Idiopathic Environmental Intolerance	Archive Effective Date: June 1, 2009	Medicine, Policy No. 37
Ocular Photoscreening in the Primary Care Physician’s Office as a Screening Tool to Detect Amblyogenic Factors	Archive Effective Date: June 1, 2009	Medicine, Policy No. 115
Computed Tomography for Pulmonary Indications	Archive Effective Date: June 1, 2009	Radiology, Policy No. 32
Miscellaneous Applications of PET Scans	Archive Effective Date: June 1, 2009	Radiology, Policy No. 35
Functional MRI	Archive Effective Date: June 1, 2009	Radiology, Policy No. 52
Positive Airway Pressure Systems and Oral Appliances for Treatment of Sleep Disordered Breathing	Archive Effective Date: July 1, 2009	Durable Medical Equipment, Policy No. 8
Dermatologic Applications of Photodynamic Therapy	Archive Effective Date: July 1, 2009	Medicine, Policy No. 99
Ultrafiltration in Decompensated Heart Failure	Archive Effective Date: July 1, 2009	Medicine, Policy No. 127
Surgical Management of Obstructive Sleep Apnea	Archive Effective Date: July 1, 2009	Surgery, Policy No. 49
Minimally Invasive Surgery for Snoring, Obstructive Sleep Apnea Syndrome/Upper Airway Resistance Syndrome	Archive Effective Date: July 1, 2009	Surgery, Policy No. 142
Blepharoplasty and Brow Ptosis Repair	Archive Effective Date: August 1, 2009 Policy is replaced by new cosmetic and reconstructive surgery policy.	Surgery, Policy No. 5
Mastectomy for Gynecomastia	Archive Effective Date: August 1, 2009 Policy is replaced by new cosmetic and reconstructive surgery policy.	Surgery, Policy No. 6
Laswer Treatment for Port Wine Stain	Archive Effective Date: August 1, 2009 Policy is replaced by new cosmetic and reconstructive surgery policy.	Surgery, Policy No. 34
Chemical Peels	Archive Effective Date: August 1, 2009 Policy is replaced by new cosmetic and reconstructive surgery policy.	Surgery, Policy No. 88
Local or Whole Body Hyperthermia	Archive Effective Date: September 1, 2009	Medicine, Policy No. 15
Sensory Stimulation for Coma Patients	Archive Effective Date: September 1, 2009	Medicine, Policy No. 57
Intraepidermal Nerve Fiber Density Testing in the Diagnosis of Small Fiber Neuropathy	Archive Effective Date: October 1, 2009	Laboratory, Policy No. 54
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 10
Genetic Testing for Inherited Susceptibility to Colon Cancer, Including Microsatellite Instability	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 12
Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 14
Genetic Testing for Familial Alzheimer's Disease	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 21
Analysis of Human DNA in Stool Samples	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 37
Gene-Based Tests for Screening, Detection and/or Management of Prostate Cancer	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 40
Cytochrome p450 Genotyping	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 45
Genetic Testing for Mutations Associated with Malignant Melanoma Susceptibility	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 49
Genetic Testing for Preconception and Prenatal Carrier Screening for Cystic Fibrosis	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 50
Genetic Testing for Initial Warfarin Dose	Archive Effective Date: November 1, 2009 Policy is replaced by genetic testing policy.	Laboratory, Policy No. 53


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.