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Medical Policy
Regence Medical Policy Update, June 1, 2016
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

Prefabricated Oral Appliances for Obstructive Sleep Apnea

New policy that considers prefabricated oral appliances investigational for the treatment of obstructive sleep apnea.

Effective Date: September 1, 2016

Allied Health, Policy No. 36 Add investigational denial to HCPCS E0485 and remove from the AIM list of codes to review Remove code E0485 from AIM list of codes
Reduction Mammaplasty

Added new criterion that reduction mammaplasty as a preparatory first stage procedure preceding a nipple-sparing mastectomy may be considered medically necessary when policy criteria are met. Additional criterion added that reduction mammaplasty for gynecomastia is considered not medically necessary.

Effective Date: September 1, 2016

Surgery, Policy No. 60 N/A N/A
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy

Policy scope clarified to include ablation and sclerotherapy as treatment of pelvic congestion syndrome and varicoceles.

Effective Date: September 1, 2016

Surgery, Policy No. 147 N/A Title change
Sequencing-based Tests to Determine Fetal Aneuploidies and Microdeletions from Maternal Plasma DNA

Scope of the policy has changed. Fetal trisomy aneuploidy (T13, T18, and T21) screening criteria was removed from the policy. Criteria added to state that testing for fetal sex chromosome anueploidies is considered investigational.

Effective Date: August 1, 2016

Genetic Testing, Policy No. 44 Delete CPT codes 81420, 81507, and 0009M from policy and remove preauth edit Delete CPT codes 81420, 81507, and 0009M from policy and remove from the preauth website
Implantable Bone-Conduction and Bone-Anchored Hearing Aids

Adding criteria to address replacements and upgrades.

Effective Date: August 1, 2016

Surgery, Policy No. 121 N/A N/A
Single Photon Emission Computed Tomography (SPECT) of the Brain

Added additional investigational indications and expanded the scope of the policy to brain imaging for a variety of neurologic, psychiatric, psychological, and other nononcologic indications.

Effective Date: July 1, 2016

Radiology, Policy No. 44 N/A N/A
Endometrial Ablation

Criterion now requires pre-procedural sampling regardless of age or unopposed estrogen exposure for initial and repeat ablation.  Criterion now requires pre-procedural imaging report for initial and repeat ablation.

Effective Date: July 1, 2016

Surgery, Policy No. 01 N/A N/A
Varicose Vein Treatment

Clarified and updated the general criteria requirements including but not limited to the use of unna boot and compression wraps, documentation of conservative therapy and documentation requirements for imaging studies. Clarified and updated the criteria for additional treatment sessions and imaging. Clarified treatments that don’t meet medically necessity criteria are considered not medically necessary. Added criteria that considers sclerotherapy of vulvar varices as not medically necessary.

Effective Date: July 1, 2016

Surgery, Policy No. 104

 

N/A N/A
Supplement to MCG™ Discharge Criteria for Residential Treatment The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines.

Effective Date: June 1, 2016

Behavioral Health, Policy No. 21 N/A N/A
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines.

Effective Date: June 1, 2016

Behavioral Health, Policy No. 23 N/A N/A
Bariatric Surgery

Criteria changed to only require one comorbidity for patients with a BMI equal to or greater than 35.

Added investigational criteria for laparoscopic duodenal switch with single anastomosis.  Removed sleeve gastrectomy as a reoperation procedure for lap band conversion. Added gastric balloon as an example of an investigational endoscopic procedure.

Effective Date: June 1, 2016

Surgery, Policy No. 58 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Added pediatric patients to the investigational and not medically necessary criteria.

Effective Date: June 1, 2016

Surgery, Policy No. 166 N/A Change name of policy on preauth website
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia

Added language to allogeneic hematopoietic stem-cell transplantation criteria specifying chemotherapy is planned to achieve complete remission. Added additional clarification to criteria.

Effective Date: June 1, 2016

Transplant, Policy No. 45.28 N/A N/A
Genetic Testing for CADASIL Syndrome

Changed criteria to consider genetic testing medically necessary to confirm a diagnosis of CADASIL syndrome when criteria are met.

Effective Date: May 1, 2016

Genetic Testing, Policy No. 51 N/A N/A
Dopamine Transporter Single-Photon Emission Computed Tomography

New policy which considers the use of DAT-SPECT investigational for all indications.

Effective Date: May 1, 2016

Radiology, Policy No. 57 Continue preauth requirement on code 78607. Add investigational denial to code A9584. Add policy to preauth website.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Significant update to the policy to consider additional indications as medically necessary. In addition, existing criteria was updated with further criteria changes.

Effective Date: May 1, 2016

Surgery, Policy No. 16 N/A N/A
Liver Transplant

Clarified the investigational criteria for retransplantation.

Effective Date: May 1, 2016

Transplant, Policy No. 05 N/A N/A
Cytochrome p450 Genotyping

Medical necessity criteria was added to determine drug metabolizer status for patients with Huntington disease who are being considered for treatment with tetrabenazine in a dosage greater than 50mg per day.

The criteria for clopidogrel (Plavix) was clarified to reflect the more specific genotype, CYP2C19.

The criteria for Gaucher disease type I was also clarified to reflect the more specific genotype, CYP2D6.

Effective Date: April 1, 2016

Genetic Testing, Policy No. 10 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Clarified criterion I.E. to indicate that nodes with micrometastases < 2mm in size are considered node negative.

Effective Date: April 1, 2016

Genetic Testing, Policy No. 42 N/A N/A
Urine Drug Testing for Substance Abuse and Chronic Pain

New medical policy which addresses the medical necessity of presumptive and definitive urine drug testing.  Criteria are based upon new CMS coding guidelines which limit presumptive and definitive testing to one code for each test, per day.  In addition the medical policy requires medical necessity review after the first 15 presumptive or definitive tests per year.  Lastly, the policy indicates urine drug testing is not covered at a substance abuse facility as it is an included service.

Effective Date: April 1, 2016

Laboratory, Policy 68 Add 1 unit of service for CPT codes G0477, G0478, G0479, G0480, G0481, G0482, G0483, with a 15 code limit per year. N/A
Contrast Enhanced Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation

Policy is being archived as AIM Specialty Health (AIM) will provide guideline oversight.

CPT 75574 will continue to require authorization, however, authorization will be through AIM.

Effective Date: April 1, 2016

Radiology, Policy No. 46 Authorization will be through AIM for CPT 75574 Authorization will be through AIM for CPT 75574
Mechanical Embolectomy for Treatment of Acute Stroke

Liberalized policy criteria to include coverage for ME in all arterial segments.  Removed "arterial disection" as an exclusion for ME.

Effective Date: April 1, 2016

Surgery, Policy No. 158 N/A N/A
Small Bowel/Liver and Multivisceral Transplant

Clarified crtieria to state that small bowel/liver transplantation is condidered not medically necessary when criteria are not met.

Effective Date: April 1, 2016

Transplant, Policy No. 18 N/A N/A
Tumor-Treatment Fields Therapy for Glioblastoma

Liberalized policy to include medical necessity criteria for tumor-treatment fields in patients with primary glioblastoma when criteria are met.

Effective Date: March 1, 2016

Durable Medical Equipment, Policy No. 85

Remove investigational denial on codes A4555 and E0766.

Add preauth requirement to code E0766.
Add preauth requirement to code E0766.
Genetic Testing for Alzheimer’s Disease

Criteria clarified to include that genetic testing for risk assessment or in the evaluation of dementia or Alzheimer's disease, not just in familial Alzheimer's disease, is considered investigational.

Effective Date: March 1, 2016

Genetic Testing, Policy No. 01 Delete HCPCS S3855 Change name of policy on preauth website
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Added medical necessity criteria for the testing of genes PTEN, TP53, CDH1, and STK11 for the evaluation of hereditary breast cancer, when tested with or without BRCA1/2. Added investigational criteria for genetic panel testing that tests for other genes in combination with BRCA1, BRCA2, PTEN, TP53, CDH1, and STK11.

Effective Date: March 1, 2016

Genetic Testing, Policy No. 02 N/A Add codes 81321, 91322, 91323, 81404, 81405, and 81406 to preauth website for GT02
Evaluating the Utility of Genetic Panels

Combined the two investigational genetic panel testing policies into one policy addressing all investigational genetic panels. Added all of the investigational panels from GT73 into GT64.

Effective Date: March 1, 2016

Genetic Testing, Policy No. 64 N/A N/A
Genetic Testing for Rett Syndrome

Medically necessary criteria clarified, and preconception testing added to the list of investigational criteria.

Effective Date: March 1, 2016

Genetic Testing, Policy No. 68 N/A N/A
New and Emerging Medical Technologies and Procedures

Added new investigational codes to the policy criteria: 0205T, 0254T, 0255T, 0424T-0436T, 81538, C9743

Added unlisted code 38999 when it specifically addresses lymph node transfer, lymphaticovenous anastomosis (LVA), or lymphatic-venous-lymphatic plasty (LVLA) to the investigational policy.

Effective Date: March 1, 2016

Medicine, Policy No. 149 Add investigational denial to CPT 0205T, 0254T, 0255T, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 81538, C9743 N/A
Spinal Cord Stimulation

A note was added to the policy to clarify that the policy applies to the initial placement of the device, and does not apply to revision(s) or replacement(s) after the devices has been placed.

Effective Date: March 1, 2016

Surgery, Policy No. 45 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Added pediatric patients to the investigational and not medically necessary criteria.

Effective Date: March 1, 2016

Surgery, Policy No. 166 N/A N/A
Powered Knee Prosthesis, Powered Ankle-Foot Prosthesis, Microprocessor-Controlled Ankle-Foot Prosthesis, and Microprocessor-Controlled Knee Prosthesis

Added medical necessity criteria for microprocessors of the knee.

Effective Date: February 1, 2016

Durable Medical Equipment, Policy No. 81 Added preauth requirement to HCPCS codes L5856, L5857, and L5858. Added preauth requirement to HCPCS codes L5856, L5857, and L5858.
KRAS, NRAS, and BRAF Mutation Analysis in Colorectal Cancer

Added medical necessity criteria for NRAS and BRAF testing.

Effective Date: February 1, 2016

Genetic Testing, Policy No. 13 N/A N/A
New and Emerging Medical Technologies and Procedures

Removed code C9742 regarding laryngoscopy with injection into vocal cords.

Effective Date: February 1, 2016

Medicine, Policy No. 149 Remove investigational denial for code C9742 and review code for medical necessity. N/A
Fecal Microbiota Transplantation

Policy liberalized to include medical necessity criteria for the treatment of recurrent (second or subsequent episodes) of clostridium difficile infections.

Effective Date: February 1, 2016

Medicine, Policy No. 154 Remove investigational denial on codes 44705 and G0455. Will process via workflow indicating that criteria, if met, could make it medically necessary. N/A
Bariatric Surgery

Added new criteria to clarify that gastrectomy (other than sleeve gastrectomy) and hiatal hernia repair are considered investigational treatments of obesity. Added gastroparesis as an example of an investigational indication for bariatric surgery. Added endoscopic stomal revision as an example of an investigational endoscopic treatment of bariatric surgery.

Effective Date: February 1, 2016

Surgery, Policy No. 58 Added CPT codes 43631, 43632, 43633, 43634 to the policy and will allow or pend for review based on diagnosis. N/A
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Policy criteria liberalized to include medical necessity criteria for ACI on the patella and no requirement for a prior surgical procedure.

Effective Date: February 1, 2016

Surgery, Policy No. 87 N/A N/A
Ultrasound Guidance for Facet Joint Injection

New investigational policy to address ultrasound guidance for facet joint injection.

Effective Date: February 1, 2016

Surgery, Policy No. 135 Add investigational edit to CPT codes 0213T, 0214T, 0215T, 0216T, 0217T, 0218T. N/A
Gastroesophageal Reflux Surgery

Added new criterion to address the use of gastrectomy or hiatal hernia repair, performed without fundoplication, as investigational treatments for GERD. Clarified criteria regarding PPI trial. Clarified policy only applies to adults 18 years and older.

Effective Date: February 1, 2016

Surgery, Policy No. 186 Added CPT codes 43631, 43632, 43633, 43634 to the policy and will allow or pend for review based on diagnosis. N/A
Applied Behavior Analysis for the Treatment of Austism Spectrum Disorders

Added the Utah Services Amendment SB 57 (UCA 31A-22-642) language for diagnosis providing coverage for ABA effective 1/1/2016.

Effective Date: January 1, 2016

Behavioral Health, Policy No. 18 N/A N/A
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Criteria for pancreatic and prostate cancer modified to only require one additional affected close blood relative with breast cancer, ovarian cancer,  or pancreatic/prostate cancer. For individuals with pancreatic cancer and of Ashkenazi Jewish ancestry, no additional affected relative is needed.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 02 N/A N/A
Genetic Testing for Cardiac Ion Channelopathies

Added medical necessity criteria for two cardiac ion channelopathies previously considered investigational, Brugada syndrome and Short QT syndrome.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 07 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Added an indication to clarify that the tissue for Oncotype testing must come from the excised breast mass and not from an initial biopsy. This clarification is, in part, to reinforce that we require node-status to determine medical necessity.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 42 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Policy changed from investigational to medically necessary when criteria are met for the gene expression classifier (GEC) (i.e. Afirma). GEC testing is medically necessary for individuals who are 21 years or older, have thyroid nodules 1cm or greater, and have cytologically indeterminate fine needle aspirates samples.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 49 Add preauth to new CPT code 81545. Add preauth to new CPT code 81545.
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Added medical necessity criteria for the genetic testing of the T790M point mutation in the EGFR gene to direct the use of appropriate FDA-approved therapeutics for advanced NSCLC. Clarified investigational criteria for the use of EGFR testing in squamous cell-type NSCLC for any stage, and nonsquamous cell-type NSCLC for stages I and II.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 56 N/A N/A
Chromosomal Microarray Analysis (CMA) and Next-generation Sequencing Panels, for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum, or Congenital Disorders

Liberalized CMA testing criteria to include congenital anomalies and postnatal testing for patients with known or suspected ID/DD or ASD.  Liberalized criteria regarding prenatal CMA testing from investigational to medically necessary as an alternative to karyotyping.

Effective Date: January 1, 2016

Genetic Testing, Policy No. 58 N/A Change title on preauth website.
Evaluating the Utility of Genetic Panels

Removed FirstStepDx panel by Lineagen as it is now addressed in the updated GT43 and GT58 medical policies.

Effective Date: January 1, 2016

Seven new investigational panels were added to the policy.

Effective Date: December 1, 2015
Genetic Testing, Policy No. 64 N/A N/A
New and Emerging Medical Technologies and Procedures

New investigational codes were added to the policy: 0400T-0402T, 0404T, 0408T-0418T, 0421T, 0422T, 96931-96936.

Removed codes 0345T, 33418, and 33419 regarding transcatheter mitral valve repair as these codes will be addressed in the new SUR199 Medical Policy.

Effective Date: January 1, 2016

Medicine, Policy No. 149 New investigational CPT codes added to the policy 0400T-0402T, 0404T, 0408T-0418T, 0421T, 0422T, 96931-96936. Term investigational denial on CPT codes 33418, 33419, and 0345T. See SUR199 for future details on these codes. N/A

Transgender Services

Liberalized criterion regarding nipple/areola reconstruction after mastectomy.

Effective Date: January 1, 2016
Medicine, Policy No. 153 N/A N/A
Transcatheter Mitral Valve Repair

New policy which considers transcatheter mitral valve repair with an FDA approved device medically necessary in patients with symptomatic degenerative mitral regurgitation who are at prohibitive risk for open surgery.

Effective Date: January 1, 2016

Surgery, Policy No. 199 Term investigational denial on CPT codes 33418, 33419, and 0345T, and add preauth to these codes. Add this new medical policy to the preauth website for codes 33418, 33419, and 0345T.
The following is a list of recently archived policies:
Opioid Antagonists Under Heavy Sedation or General Anesthsia as a Technique of Opioid Detoxification Archive Effective Date: April 1, 2016 Behavioral Health, Policy No. 14
Fetal Surgery for Prenatally Diagnosed Malformations

Archive Effective Date: April 1, 2016

Note: This was the last policy in the Maternity section of the Manual. As a result, the Maternity section of the Manual was also archived.

Maternity, Policy No. 13
Contrast Enhanced Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation Archive Effective Date: April 1, 2016 Radiology, Policy No. 46
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

Not technically archived, but rather content from GT73 added to GT64 in the Manual

Archive Effective Date: March 1, 2016

Genetic Testing, Policy No. 73
Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Not technically archived, but rather moved from Medicine 144 to Surgery 195 in the Manual

Archive Effective Date: January 1, 2016

 
Supplement to MCG™ Discharge Criteria for Neonatal Levels of Care

 

The policy is effective through 12/31/2015 and after that MCG will be used for NICU stays.

Archive Effective Date: January 1, 2016