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Medical Policy
Regence Medical Policy Update, April 1, 2014
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 #

Intensity Modulated Radiation Therapy (IMRT) of the Thorax

Specific conditions removed from title. Thymomas and thymic carcinoma added as medically necessary indications.

Effective Date: November 1, 2013

Medicine, Policy No. 136
Intensity-Modulated Radiation Therapy (IMRT) of the Abdomen and Pelvis

Criteria clarified to state that IMRT may be considered medically necessary for all anal cancers (not limited to squamous cell carcinoma).

Effective Date: November 1, 2013

Medicine, Policy No. 139
Endometrial Ablation

Clarified:  definitions for premenopausal, acute/chronic bleeding, and progestins; contraindications to hormone therapy.  Added exceptions to pre-procedural endometrial sampling. Clarification of criteria regarding endometrial sampling.

Effective Date: November 1, 2013

Surgery, Policy No. 01
Hematopoietic Stem Cell Transplantation for Multiple Myeloma and POEMS Syndrome

Criteria regarding POEMS syndrome added to the policy.

Effective Date: November 1, 2013

Transplant, Policy No. 45.22
Genetic and Molecular Diagnostic Testing

Minor criteria clarifications related to inconclusive diagnoses and clinical utility.

Effective Date: December 1, 2013

Genetic Testing, Policy No. 20
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

Added clarification regarding definition of mastectomy.

Effective Date: December 1, 2013

Surgery, Policy No. 40
Percutaneous Angioplasty and Stenting of Veins

Changed stenting of compressed upper arm veins from investigational to medically necessary when criteria are met. Added idiopathic intracranial hypertension to list of investigational indications. Added clarification of nomenclature for May-Thurner syndrome.

Effective Date: December 1, 2013

Surgery, Policy No. 109
Multigene Expression Assays for Predicting Recurrence in Colon Cancer

Addition of 4 gene expression profile (GEP) tests.

Effective Date: January 1, 2014

Genetic Testing, Policy No. 22
Evaluating the Utility of Genetic Panels

New policy.

Effective Date: January 1, 2014

Genetic Testing, Policy No. 64
Hyperbaric Oxygen Pressurization (HBO) Added bisphosphonate-related osteonecrosis of the jaw, herpes zoster, depression, hepatitis, and stroke-related motor dysfunction to list of investigational indications.

Effective Date: January 1, 2014

Medicine, Policy No. 14
Orthopedic Applications of Stem Cell Therapy

Investigational criteria added regarding allograft bone products, such as demineralized bone matrix, for orthopedic application.

Effective Date: January 1, 2014

Medicine, Policy No. 142
New and Emerging Medical Technologies and Procedures

New investigational criteria added to the policy.

Effective Date: January 1, 2014

Medicine, Policy No. 149
Coverage of Treatments Provided in a Clinical Trial

New policy.

Effective Date:  January 1, 2014

Medicine, Policy No. 150
Femoroacetabular Impingement Surgery

Criteria changed from investigational to not medically necessary when criteria are not met.

Removed criterion requiring patients to be young enough to be considered inappropriate candidates for hip arthroplasty of other reconstruction.

Effective Date: January 1, 2014

Surgery, Policy No. 160

Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Changed allogeneic HSCT from investigational to medically necessary for relapsing ALL after a prior autologous SCT.

Effective Date: January 1, 2014

Transplant, Policy No. 45.36
Supplement to MCG™ Discharge Criteria for Residential Treatment

New policy supplements MCG™ discharge criteria for behavioral health residential treatment settings

Effective Date: January 1, 2014

Utilization Management, Policy No. 14

Administrative Guidelines to Determine Dental vs Medical Services

New administrative policy which has been moved from the Dental policy manual to the Medical policy manual.  No change to the criteria.

Effective Date: February 1, 2014

Allied Health, Policy No. 35
Functional Neuromuscular Electrical Stimulation

Clarification added to the investigational criteria regarding congenital disorders.

Effective Date: February 1, 2014

Durable Medical Equipment, Policy No. 83.04
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Modified medical necessity criteria based on NCCN guideline updates. Addition of BART testing to criteria for clarification purposes.

Effective Date: February 1, 2014

Genetic Testing, Policy No. 02
Genetic Testing for Inherited Susceptibility to Colon Cancer

Added new criterion for BRAF V600E or MLH1 promoter methylation and clarification to EPCAM testing criteria.

Effective Date: February 1, 2014

Genetic Testing, Policy No. 06
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)

Addition of drug afatinib (GILOTRIF™) to medical necessity criteria.

Effective Date: February 1, 2014

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

Addition of new panel test YouScript® personalized prescribing system.

Effective Date: February 1, 2014

Genetic Testing, Policy No. 64
New and Emerging Medical Technologies and Procedures

New investigational procedures added to the policy.

Effective Date: February 1, 2014

Medicine, Policy No. 149
Computed Tomography (CT) Perfusion Imaging of the Brain

Added clarification that policy criteria are specific to the brain.

Effective Date: February 1, 2014

Radiology, Policy No. 54
Microwave Tumor Ablation

New policy.

Effective Date: February 1, 2014

Surgery, Policy No. 189
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Failed joint fusion following arthrodesis changed from medically necessary to investigational.

Effective Date: March 1, 2014

Durable Medical Equipment, Policy No. 83.11
Genetic Testing for Inherited Susceptibility to Colon Cancer

Removed criteria regarding gene testing in patients with a diagnosis of classical FAP.

Effective Date: March 1, 2014

Genetic Testing, Policy No. 06
Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA

Revised criteria to address additional aneuploidies, fetal sex determination, and microdeletion syndromes.

Effective Date: March 1, 2014

Genetic Testing, Policy No. 44
Evaluating the Utility of Genetic Panels

Added new investigational panels.

Effective Date: March 1, 2014

Genetic Testing, Policy No. 64
Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture (AmniSure® and ROM Plus® Tests)

Clarified that investigational criterion applies to all placental rapid immunoassays.

Effective Date: March 1, 2014

Laboratory, Policy No. 57
Cochlear Implant

Added clarification regarding repeat hearing tests and trials of hearing aids.

Effective Date: March 1, 2014

Surgery, Policy No. 08
Ventricular Assist Devices and Total Artificial Hearts

Clarified that total artificial heart criteria include patients being evaluated for candidacy for heart transplant.

Effective Date: March 1, 2014

Surgery, Policy No. 52
Percutaneous Vertebroplasty and Kyphoplasty

Medical necessity status of vertebroplasty changed to investigational.

Effective Date: March 1, 2014

Surgery, Policy No. 107
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction

Reduced minimum test stimulation trial period 1 week. Added criteria clarifications.

Effective Date: March 1, 2014

Surgery, Policy No. 134
Orthognathic Surgery

For required documentation, added written report of radiographs when available.

Effective Date: March 1, 2014

Surgery, Policy No. 137
Aqueous Shunts and Stents for Glaucoma

Criteria changed to consider the iStent Micro-Bypass medically necessary when criteria are met.

Effective Date: March 1, 2014

Surgery, Policy No. 164
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

Clarified criteria regarding the number of biopsies which constitute saturation biopsy.

Effective Date: March 1, 2014

Surgery, Policy No. 170
Gastric Reflux Surgery

Added clarification that medical necessity criteria apply to initial and repeat fundoplasty. Added criteria regarding fundoplasty performed in conjunction with paraesophageal hiatal hernia repair or esophageal myotomy.

Effective Date: March 1, 2014

Surgery, Policy No. 186
Evaluating the Utility of Genetic Panels

Deleted Panorama prenatal panel (Natera).

Effective Date: April 1, 2014

Genetic Testing, Policy No. 64
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 65
Genetic Testing for Lactase Insufficiency

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 67
Genetic Testing for Rett Syndrome

New policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 68
Genetic Testing for Duchenne and Becker Muscular Dystrophy

New policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 69
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 70
Microarray-based Gene Expression Analysis for Prostate Cancer

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 71
Spinal Cord Stimulation for Treatment of Pain

Added cancer-related pain to list of investigational indications.

Effective Date: April 1, 2014

Surgery, Policy No. 45
Gastric Electrical Stimulation

Revised criteria related to nutritional status.

Effective Date: April 1, 2014

Surgery, Policy No. 111
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome in Adults

Added clarification that policy applies to adult patients.

Effective Date: April 1, 2014

Surgery, Policy No. 166
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

New investigational policy.

Effective Date: April 1, 2014

Surgery, Policy No. 190
Vitamin D Testing

Medical necessity criteria clarified and policy appendices updated to include additional covered indications.

Effective Date: May 1, 2014

Laboratory, Policy No. 52

Tumor-Treatment Fields Therapy for Glioblastoma

New investigational policy.

Effective Date: July 1, 2014

Durable Medical Equipment, Policy No. 85
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

New investigational policy.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 66
Bariatric Surgery

Criteria clarified regarding reoperation in cases of band migration or slippage.

Effective Date: July 1, 2014

Surgery, Policy No. 58

The following is a list of recently archived policies:
Research Urgent Treatments Archive Effective Date:
January 1, 2014
Medicine, Policy No. 74
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure Archive Effective Date:
January 1, 2014
Surgery, Policy No. 136
Knee Arthroscopy in Patients with Osteoarthritis Archive Effective Date:
January 1, 2014
Surgery, Policy No. 185
Occupational Therapy (OT)

Archive Effective Date:
January 1, 2014

Utilization Mangaement, Policy No. 04
Physical Therapy (PT) Archive Effective Date:
January 1, 2014
Utilization Mangaement, Policy No. 06
Speech Therapy (ST) Archive Effective Date:
January 1, 2014
Utilization Mangaement, Policy No. 09