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Medical Policy
Regence Medical Policy Update, September 1, 2018
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

Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Changed policy title. Added circulating tumor/cell-free DNA to the investigational statement.

Effective Date: December 1, 2018

Laboratory, Policy No. 46 N/A N/A
Lumbar Spinal Fusion

Updated policy criteria statements, specifically with regard to neurogenic claudication, and clinical tools as a measure of disability. Updated policy guidelines to clarify documentation required for submission to support policy criteria.

Effective Date: November 1, 2018

Surgery, Policy No. 187 N/A N/A
Myoelectric Prosthetic and Orthotic Components for the Upper Limb

Changing policy title.
Adding investigational criteria for upper-limb prosthetic components with both sensor and myoelectric control and for myoelectric controlled upper-limb orthoses.

Effective Date: October 1, 2018

Durable Medical Equipment, Policy No. 80 Adding code L6693 with preauth edit. Adding code L6693 with preauth edit. Changing the policy title on the preauth website.
Evaluating the Utility of Genetic Panels

Added 12 new investigational panels and removed 1 panel.

Effective Date: September 1, 2018

Genetic Testing, Policy No. 64 N/A Added code 81413 to preauth website for this medical policy.
Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancers and Thyroid Cancer

Expanding the scope of the policy to address other cancers including, but not limited to skin cancers in the region.

Effective Date: September 1, 2018

Medicine, Policy No. 138 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Revised criteria related to the Karnofsky performance score requirements.

Effective Date: September 1, 2018

Surgery, Policy No. 16 N/A N/A
Implantable Bone Conduction and Bone-Anchored Hearing Aids

Adding audiology criteria for bilateral implantation.

Effective Date: September 1, 2018

Surgery, Policy No. 121 N/A N/A
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

Updated policy criteria to state that Magnetic resonance (MR) guided focused ultrasound (MRgFUS) may be considered medically necessary for medicine-refractory essential tremors (clinical documentation must be submitted for review).

Effective Date: September 1, 2018

Surgery, Policy No. 139 Removed investigational edit on code 0398T and added preauthorization requirement. Added code 0398T to the preauth website for this medical policy.
Sepsis

New clinical position statement that defines sepsis based on professional organization guidelines and indicates the response and documentation expected.

Effective Date: August 1, 2018

Clinical Position Statement, No. 03 N/A N/A
BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy

Added resectable stage III melanoma to criteria.

Effective Date: August 1, 2018

Genetic Testing, Policy No. 41 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Slight modification to policy title.Updated criteria to allow testing in any individual with primary breast cancer, stage I, II, or III.

Effective Date: August 1, 2018

Genetic Testing, Policy No. 42 N/A Update title on the preauth website
Immunological Cellular Therapies and Gene Therapies

Updated policy title. Updated background information to clarify scope. Added note that LUXTURNA is not addressed by this policy; see Medication Policy Manual for therapies not addressed in this policy.

Effective Date: August 1, 2018

Medicine, Policy No. 42 N/A N/A
Cosmetic and Reconstructive Surgery Added new criteria for rhinoplasty.

Effective Date: August 1, 2018

Surgery, Policy No. 12 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Revised criteria regarding metastases to CNS.

Effective Date: July 18, 2018

Surgery, Policy No. 16 N/A N/A
Cooling Devices Used in the Home Setting

Clarified phrasing in criteria to include circulating and noncirculating to the active and passive descriptions, respectively.

Effective Date: July 1, 2018

Durable Medical Equipment, Policy No. 07 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Updated medical necessity statement to include ThyroSeq®, ThyGenX®, and ThyraMIR when criteria are met.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 49 Remove investigational edit on codes 0018U and 0026U, and add preauth edit. Add codes 0018U and 0026U to the preauth website.
Evaluating the Utility of Genetic Panels

Added two new investigational panels and removed 16 panels.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 64 Remove investigational denial from codes 81410 and 81411 with move to the new medical policy GT77. N/A
Genetic Testing for Heritable Disorders of Connective Tissue

New policy addresses genetic testing for heritable disorders of connective tissue. Criteria for symptomatic individuals, and relatives of those with a known disorder describes when testing may be considered medically necessary. Policy Guidelines specify clinical documentation requirements.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 77 New policy adds codes 81405 an 81408 with a preauth edit. Codes 81410 and 81411 are added to this policy with no edit. Add medical policy to the preauth website for codes 81405 and 81408.
Urine Drug Testing for Substance Use and Pain Management

Updated criteria to:

  • Allow specific codes for presumptive and definitive testing when up to 15 units are billed per type of testing, per year
  • Deny G0482 and G0483 as not medically necessary

Effective Date: July 1, 2018

Laboratory, Policy No. 68 Limiting both presumptive and definitive testing to specific codes (five for presumptive; three for definitive), one code per date of service by the same or different provider, and 15 codes for each type of testing, per year. N/A
Charged-Particle (Proton) Radiotherapy

Changed policy title.

Changed to consider charged particle therapy such as proton beam therapy medically necessary for central nervous system tumors which extend to 10mm or less from the optic chiasm, brain stem, or cervical spinal cord and for reirradiation of head and neck and central nervous system tumors.

Effective Date: July 1, 2018

Medicine, Policy No. 49 N/A Update policy title on the preauth website.
Implantable Cardioverter Defibrillator

Added several new indications for transvenous ICD placement. Removed requirement for specific contraindications for a transvenous ICD to the subcutaneous ICD criteria.

Effective Date: July 1, 2018

Surgery, Policy No. 17 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Change to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 45 N/A N/A
Sacral Nerve Neuromodulation/ Stimulation for Pelvic Floor Dysfunction

Change policy title.

Change criteria to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 134 N/A Change title of medical policy on preauth website.
Sacroiliac Joint Fusion

Use of minimally invasive titanium triangular implants to fuse or stabilize the sacroiliac joint may be considered medically necessary when criteria are met.

Effective Date: July 1, 2018

Surgery, Policy No. 193 Remove investigational denial on code 27279. N/A
Genetic Testing for CADASIL Syndrome

Removed requirement for other methods of testing prior to genetic testing.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 51 N/A N/A
Chromosomal Microarray Analysis (CMA) for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies

Changed medical policy title. Revised criteria to exclude next-generation sequencing panels from this policy, as they will be addressed in other genetic testing policies.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 58 Deleted codes 81470 and 81471 from this medical policy and moved to GT20 and GT64. Changed title of medical policy on the PreAuth website.
Evaluating the Utility of Genetic Panels

Added five new investigational panels and removed 15 panels.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 64 Added codes 81470 and 81471 to this medical policy and keep the preauth requirement. Added codes 81470 and 81471 to this medical policy and keep the preauth requirement.
Urinary Tumor Markers for Bladder Cancer

New investigational policy addressing urinary tumor markers for bladder cancer.

Effective Date: June 1, 2018

Laboratory, Policy No. 52 N/A N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Clarified medical necessity criterion, and added clarification of documentation required to review in the Policy Guidelines section.

Effective Date: June 1, 2018

Surgery, Policy No. 107 N/A N/A
Implantable Bone Conduction and Bone-Anchored Hearing Aids

Changed criteria for clarity and consistency between audiology policies. Updated referenced devices to current models.

Effective Date: June 1, 2018

Surgery, Policy No. 121 N/A N/A
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Removed requirements to specific epidermal growth factor receptor (EGFR) variants.

Effective Date: May 1, 2018

Genetic Testing, Policy No. 56 N/A N/A
Evaluating the Utility of Genetic Panels

Added 14 new investigational panels and removed one panel.

Effective Date: May 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Bariatric Surgery

Added clarification to several criteria and detailed Policy Guidelines. Guidelines will aid in transparency of expectations for required documentation to support clinical review.

Effective Date: May 1, 2018

Surgery, Policy No. 58 N/A N/A
Varicose Vein Treatment

Liberalized the criteria to allow sclerotherapy for the great saphenous vein below the knee and decreased stocking compression to a minimum 15-20mmHg. Revised long and short to great and small saphenous veins throughout. Clarified and streamlined additional criteria elements.

Effective Date: May 1, 2018

Surgery, Policy No. 104 N/A N/A
Gastroesophageal Reflux Surgery

Updated one criterion regarding proton pump inhibitor therapy. When a trial of proton pump inhibitor (PPI) therapy is ineffective, contraindicated, or not tolerated, the total trial must be at least 4-months. Clarified definitions of hiatal hernias in Policy Guidelines.

Effective Date: May 1, 2018

Surgery, Policy No. 186 N/A N/A
Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin

New policy for implantable peripheral nerve stimulation (PNS) for chronic pain of peripheral nerve origin (e.g. StimRouter).

Effective Date: May 1, 2018

Surgery, Policy No. 205 Continue preauth on 64555, 64575, and 64590 (this policy is new to the list of policies that address these codes and requires preauth). Continue to review codes 64999, L8680 and L8683 (this policy is new to the list of policies that address these codes and requires review) Add this policy to the preauth website for codes 64555, 64575, and 64590.
Genetic Testing for Alzheimer's Disease

Added genetic testing for autosomal dominant Alzheimer's disease for reproductive decision-making.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 01 N/A N/A
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer

Moved gene expression analysis to this policy; maintaining investigational position.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 17 N/A N/A
Adoptive Immunotherapy

Removed review of CAR-T therapies, as Pharmacy now reviews this category of therapies. See the Pharmacy Medication Manual.

Effective Date: April 1, 2018

Medicine, Policy No. 42 N/A N/A
Transgender Services

See Coding/Implementation Changes and PreAuthorization Changes listed on this row in the columns to follow.

Effective Date: April 1, 2018

Medicine, Policy No. 153 Adding bypass to the preauth requirement on these codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, C1813 unless a transgender dx (F640, F641, F642, F648, F649) is found anywhere on the claim Adding codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, and C1813 to the preauth list for this policy.
The following is a list of recently archived policies:
Breast Duct Endoscopy (Ductoscopy) Archive Effective Date: June 1, 2018 Medicine, Policy No. 112
Endovascular Angioplasty and/or Stenting for Intracranial Arterial Disease (Atherosclerotic and Aneurysms) Archive Effective Date: June 1, 2018 Surgery, Policy No. 141
Gene Expression Analysis for Prostate Cancer Management

Archive Effective Date: April 1, 2018

NOTE: Now addressed in Medical Policy GT17.

Genetic Testing, Policy No. 71