Regence
Medical Policy Update, March 10, 2010 |
|
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 |
|
| 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 |
| Transanal
Endoscopic Microsurgery (TEMS) |
Policy criteria changed from
investigational to medically necessary for treatment
of rectal adenomas and T1 rectal adenocarcinomas
when criteria are met.
Effective Date: December 8, 2009 |
Surgery, Policy No. 162 |
| Virtual
Colonoscopy/ CT Colonography |
Policy criteria changed from
investigational to medically necessary for those
who are unable to undergo a conventional colonoscopy
for medical reasons (e.g. continuous anticoagulation
therapy or high anesthesia risk); or for those
unable to complete a conventional colonoscopy
because of colonic stenosis or obstruction. Virtual
colonoscopy is considered not medically necessary
except as noted in the criteria above.
Effective Date: January 1, 2010 |
Radiology, Policy No. 36 |
| Radiofrequency
Ablation of Tumors (RFA) |
Policy criteria changed:
- Now considered medically necessary for renal
tumors and colorectal metastases in the liver
when criteria are met.
- Criterion for osteoid osteomas expanded to
specify that medically necessary tumors are
those that cannot be managed with medical treatment
- Added to investigational indications:
- Initial treatment of osteoid osteomas
- Bridge to liver transplant
- Debulking of liver tumors when treatment
goal is less than complete resection/ablation.
Effective Date: January 1, 2010 |
Surgery, Policy No. 92 |
| Electrical Bone Growth Stimulators
(Osteogenic Stimulation) |
Policy criteria updated. Added
systemic steroid use as a risk factor for failed
fusion; added semi-invasive EBGS as investigational
for all indications.
Effective Date: January 12, 2010 |
Durable Medical Equipment, Policy
No. 10 |
| 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 |
| Percutaneous Angioplasty and Stenting
of Veins |
Criterion II clarified to include
angioplasty and/or endoprostheses as medically
necessary for creation of intrahepatic shunt
connections between the portal venous system
and the hepatic vein.
Effective Date: February 9, 2010 |
Surgery, Policy No. 109 |
| Total
Facet Arthroplasty |
New investigational policy.
Effective Date: March 1, 2010 |
Surgery, Policy No. 171 |
| Spinal Cord Stimulation for Treatment
of Pain |
Clarification of criterion I.B.4
related to multispecialty consultation. Added
vulvodynia, vulvar vestibulitis, chronic pelvic
pain, migraine headache, and occipital nerve
stimulation for headache to list of investigational
indications.
Effective Date: March 10, 2010 |
Surgery, Policy No. 45 |
| Autologous Hematopoietic Stem Cell
Transplant |
The subtitle for primitive neuroectodermal
tumors was changed to central nervous system
(CNS) embryonal tumors. New medical necessity
criteria have been added for previously untreated
CNS embryonal tumors. The investigational criteria
for Hodgkin Lymphoma have been clarified to state
that a second autologous stem cell transplant
for relapsed lymphoma after a prior autologous
stem cell transplant is investigational.
Effective Date: March 10, 2010 |
Transplant, Policy No. 42 |
| Allogeneic Hematopoietic Stem Cell
Transplant |
The subtitle for primitive neuroectodermal
tumors was changed to central nervous system
(CNS) embryonal tumors. New medical necessity
criteria for reduced intensity conditioning allogeneic
stem cell transplant have been added to the Hodgkin
lymphoma section.
Effective Date: March 10, 2010 |
Transplant, Policy No. 43 |
| Tandem Hematopoietic Stem Cell Transplant |
The subtitle for primitive neuroectodermal
tumors (PNETs) was changed to central nervous
system (CNS) embryonal tumors and criteria language
was simplified to state tandem stem cell transplant
is investigational for CNS embryonal tumors.
New medical necessity criteria have been added
for primary refractory and relapsed Hodgkin lymphoma
with poor risk features.
Effective Date: March 10, 2010 |
Transplant, Policy No. 44 |
| Multi-Chamber
Programmable Pneumatic Compression Pumps |
New policy focusing on Multi-Chamber
Programmable Pneumatic Compression Pumps (Code
E0652) which finds these pumps not medically
necessary compared to either single- or multi-chamber
non-programmable compression pumps.
Effective Date: May 1, 2010 |
Durable Medical Equipment, Policy
No. 78 |
Varicose
Vein Treatment |
Policy criteria revised:
- Photographs of varicose veins to be treated
required;
- Procedures done in conjunction with endoluminal
ablation in the same operative session, same
vein are included in the ablation reimbursement.
Effective Date: May 1, 2010 |
Surgery, Policy No. 104 |
| The following
is a list of recently archived policies: |
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 |
| Hyperbaric Oxygen Pressurization |
Archive Effective
Date: December
1, 2009 |
Medicine, Policy No. 14 |
Scintimammography and Breast
Specific Gamma Imaging (BSGI) |
Archive Effective Date:
January 1, 2010 |
Radiology, Policy No. 15 |
| Spinal Manipulation Under Anesthesia |
Archive Effective Date: February
1, 2010 |
Medicine, Policy No. 103 |
| Total Ankle Replacement |
Archive Effective Date: February
1, 2010 |
Surgery, Policy No. 115 |
| Total Hip Resurfacing |
Archive Effective Date:
March 1, 2010 |
Surgery, Policy No. 113 |
