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. |
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|
|
|
Policy Name |
Summary
of Policy or Change |
|
| 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 |