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Medical Policy
Regence Medical Policy Update, Juuly 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.
     
Policy Name
Summary of Policy or Change

Section and
Policy #

Surgical Treatment of Hyperhidrosis

Removed criteria for medical treatments; policy now addresses only surgical treatments.

Effective Date: January 1, 2009
Surgery, Policy No. 165
Nerve Graft in Association with Radical Prostatectomy

Criteria clarified to state that unilateral or bilateral nerve grafts in association with radical prostatectomy are considered investigational.

This is a long standing medical policy.  Regence will be placing an edit on the claims system so all claims for this procedure will be reviewed.  This will allow us to more consistently follow our set medical policy.

Effective Date:  This change requires 90-day notification.  Implementation Date = February 1, 2009

Surgery, Policy No. 117
Transplant; Autologous Hematopoietic Stem Cell Transplant

Multiple individual transplant policies were consolidated into three policies for autologous, allogeneic and tandem transplants. This policy addresses medically necessary and investigational indications for autologous stem cell transplant

Effective Date: March 1, 2009

Transplant, Policy No. 42
Transplant; Allogeneic Hematopoietic Stem Cell Transplant

Multiple individual transplant policies were consolidated into three policies for autologous, allogeneic and tandem transplants.  This policy addresses medically necessary and investigational indications for allogeneic stem cell transplant

Effective Date: March 1, 2009

Transplant, Policy No. 43
Transplant; Tandem Hematopoietic Stem Cell Transplant

Multiple individual transplant policies were consolidated into three policies for autologous, allogeneic and tandem transplants. This policy addresses medically necessary and investigational indications for tandem stem cell transplants.

Effective Date: March 1, 2009

Transplant, Policy No. 44
Radiofrequency Ablation of Tumors (RFA)

Criterion related to "metastatic liver tumors" changed for clarity to "metastases to the liver from other organ tumors”. 

Effective Date: March 10, 2009
Surgery, Policy No. 92
Extracorporeal Photopheresis as a Treatment of Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma

New medical necessity criteria added for cutaneous T-cell lymphoma stages III/IV, stages I/II progressive or refractory to other treatments.  New investigational criteria added for treatment of early stage (I/II) cutaneous T-cell lymphoma that is either previously untreated or is responding to established nonsystemic therapies.

Effective Date:  April 1, 2009
Medicine, Policy No. 84
Varicose Vein Treatment
  • Trial of compression stockings increased from six weeks to three months and failure of trial is required. Other non-operative treatments removed from criteria.
  • Accessory saphenous vein removed from list of medically necessary veins.
  • Added criteria allowing only one treatment session per extremity to be approved at a time; future sessions may only be considered when the clinical outcome of prior treatment is documented.
  • Phlebitis indication changed from "Significant recurrent attacks of superficial phlebitis" to "Documented recurrent significant episodes of superficial phlebitis unrelated to sclerotherapy"
  • Updated nomenclature for greater and lesser saphenous veins which are now called the long and short saphenous veins
  • Activities of daily living (ADLs) defined in criteria related to symptoms, instrumental ADLs added, clarified that symptoms must be documented and that they be “persistent severe lower extremity symptoms attributable to varicose veins”.
  • Criterion addressing treatment sessions clarified to state that “Regence considers requests for coverage for each single operative session for either one or both legs.  Additional treatment sessions may be considered for benefits only after the clinical outcome of the prior treatment has been established and documented.”
Effective Date: This change requires 90-day notification.  Implementation Date = May 1, 2009
Surgery, Policy No. 104

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

New medical necessity criteria for Oncotype DX™ include

  • For patients who will be treated with adjuvant endocrine therapy, e.g., tamoxifen or aromatase inhibitors; AND
  •  For use when the test result will aid the patient in making the decision regarding chemotherapy (i.e., when chemotherapy is a therapeutic option).

New not medically necessary language states the use of Oncotype DX™ to determine patient risk in those who have already made the decision to undergo chemotherapy is considered not medically necessary.
Two additional gene expression profile tests were added to the investigational criteria the Mammostrat™ and the Molecular Grade Index (Aviara MGISM).

Effective date:  May 1, 2009

Laboratory, Policy No. 42

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

Added injection into ligaments to list of investigational indications.

Effective Date:  May 1, 2009

Medicine, Policy No. 77

Autologous Chondrocyte Implantation

New medical necessity criteria for selected patients in lieu of total knee arthroplasty.  Please see medical policy for new criteria.
ACI remains investigational for all other indications.

Effective date:  May 1, 2009

Surgery, Policy No. 87

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

The following is a list of recently archived policies:

Adjustable Banding as a Treatment of Nonsynostotic Plagicephaly

Archive Effective Date: January 1, 2009

Durable Medical Equipment, Policy No. 17

Continuous Passive Motion Devices

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 39

Ultrasound Accelerated Fracture Healing

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 40

Home Prothrombin Time Monitoring

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 44

Thoracic-Lumbo-Sacral Orthosis with Pneumatics

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 60

Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement and Automatic External Defibrillators for Home Use

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 61

Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 64

Prosthesis; Microprocessor-Controlled Prosthetic Knees

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 68

Air Fluidized Beds

Archive Effective Date:January 1, 2009

Durable Medical Equipment, Policy No. 76

Cognitive Evoked Potential Testing

Archive Effective Date:January 1, 2009

Medicine, Policy No. 38

Photodynamic Therapy for Oncologic Applications including Barrett's Esophagus

Archive Effective Date:January 1, 2009

Medicine, Policy No. 43

Fully Implantable Infusion Pumps

Archive Effective Date:January 1, 2009

Surgery, Policy No. 18

Erectile Dysfunction

Archive Effective Date:January 1, 2009

Surgery, Policy No. 25

Refractive Surgery

Archive Effective Date:January 1, 2009

Surgery, Policy No. 39

Partial Left Ventriculectomy

Archive Effective Date:January 1, 2009

Surgery, Policy No. 86

Lymphedema Pumps Archive Effective Date: February 1, 2009 Durable Medical Equipment, Policy No. 19
Pneumatic Compression Devices Archive Effective Date:February 1, 2009 Durable Medical Equipment, Policy No. 50
Home Spirometry Archive Effective Date:February 1, 2009 Durable Medical Equipment, Policy No. 54
Airway Clearance Devices Archive Effective Date:February 1, 2009 Durable Medical Equipment, Policy No. 62
Tests of Sperm Maturity, Function and DNA Integrity Archive Effective Date:February 1, 2009 Laboratory, Policy No. 11
Adoptive Immunotherapy Archive Effective Date:February 1, 2009 Medicine, Policy No. 42
Evaluation of Hearing Impairment Archive Effective Date:February 1, 2009 Medicine, Policy No. 46
Assisted Reproductive Technologies Archive Effective Date:February 1, 2009 Medicine, Policy No. 52
Oncologic Applications of PET Scanning Archive Effective Date:February 1, 2009 Radiology, Policy No. 14
Video Flouroscopic Evaluation of the Velopharyngeal Closure Archive Effective Date:February 1, 2009 Radiology, Policy No. 21
Cardiac Applications of PET Scanning Archive Effective Date:February 1, 2009 Radiology, Policy No. 34
MRI of the Breast Archive Effective Date:February 1, 2009 Radiology, Policy No. 43
Durable Medical Equipment Upgrades, Replacements and Duplicates Archive Effective Date: March 1, 2009 Durable Medical Equipment, Policy No. 75
Paternal and Fetal Antigen Immunotherapy for Recurrent Fetal Loss Archive Effective Date: March 1, 2009 Medicine, Policy No. 20
Brachytherapy for Prostate Cancer Archive Effective Date: March 1, 2009 Medicine, Policy No. 58
Enzyme-Potentiated Desensitization Archive Effective Date: March 1, 2009 Medicine, Policy No. 72

Liver Dialysis

Archive Effective Date: March 1, 2009 Medicine, Policy No. 81
Ultrasound for the Evaluation of Paranasal Sinuses Archive Effective Date: March 1, 2009 Radiology, Policy No. 26
FDG Using Camera-Based Imaging (FDG-SPECT) Archive Effective Date: March 1, 2009 Radiology, Policy No. 33
Magnetic Resonance Cholangiopancreatography (MRCP) Archive Effective Date: March 1, 2009 Radiology, Policy No. 42
Three-Dimensional (3-D) Reconstruction of Routine Obstetric Ultrasound Images Archive Effective Date: March 1, 2009 Radiology, Policy No. 45
Breast Brachytherapy after Breast Conserving Surgery, as Boost with Whole Breast Irradiation, or Alone as Partial Breast Irradiation (APBI) Archive Effective Date: March 1, 2009 Surgery, Policy No. 70
Temporomandibular Joint Dysfunction Archive Effective Date: March 1, 2009 Surgery, Policy No. 122
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin Archive Effective Date: March 1, 2009 Surgery, Policy No. 146
Placental and Umbilical Cord Blood as a Source of Stem Cells Archive Effective Date: March 1, 2009 Transplant, Policy No. 16
High-Dose Chemotherapy with Hematopoietic Stem Cell Support in the Treatment of Multiple Myeloma

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 22
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Non-Hodgkin’s Lymphomas

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 23
High-Dose Chemotherapy and Allogeneic Stem Cell Support for Myelodysplastic Diseases

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 24
High-Dose Chemotherapy and Allogeneic Stem Cell Support for Genetic Diseases and Acquired Anemias

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 25
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Epithelial Ovarian Cancer

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 26
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Miscellaneous Solid Tumors in Adults

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 27
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Acute Myelogenous Leukemia

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 28
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Breast Cancer

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 29
High-Dose Chemotherapy and Hematopoietic Stem Cell Support for Hodgkin’s Disease

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 30
High-Dose Chemotherapy and Hematopoietic Stem Cell Support for the Treatment of Chronic Myelogenous Leukemia

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 31
High Dose Chemotherapy and Autologous Stem Cell Support for Autoimmune Diseases, Including Multiple Sclerosis

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 32
High Dose Chemotherapy and Hematopoietic Stem Cell Support for Primitive Neuroectodermal Tumors (PNET) and Ependymoma

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 33
High Dose Chemotherapy and Autologous Stem Cell Support for Malignant Astrocytomas and Gliomas

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 34
High Dose Chemotherapy with Hematopoietic Stem Cell Support for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 35
High Dose Chemotherapy with Hematopoietic Stem Cell Support for the Treatment of Acute Lymphocytic Leukemia

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 36
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Selected Solid Tumors of Childhood and Young Adults

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 37
High Dose Chemotherapy with Hematopoietic Stem Cell Support as a treatment of Germ Cell Tumors

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 38
Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem Cells for Treatment of Malignancy

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 39
High-Dose Chemotherapy plus Hematopoietic Stem-Cell Support to Treat Primary Amyloidosis or Waldenström's Macroglobulinemia

Archive Effective Date: March 1, 2009

Policy is replaced by new policies on auto, allo and tandem transplant.

Transplant, Policy No. 40
Chiropractic Maintenance Therapy Archive Effective Date: March 1, 2009 Utilization Management, Policy No. 11
Trigger Point Therapy Archive Effective Date: March 1, 2009 Medicine, Policy No. 39

High Frequency Chest Compression Systems for the Treatment of Cystic Fibrosis and Other Respiratory Disorders

Archive Effective Date:  April 1, 2009

Durable Medical Equipment, Policy No. 45

Extracorporeal Immunoadsorption Using Protein A Columns

Archive Effective Date:  April 1, 2009

Medicine, Policy No. 23

Targeted Phototherapy for Psoriasis

Archive Effective Date:  April 1, 2009

Medicine, Policy No. 98

Daily Hemodialysis in the Home

Archive Effective Date:  April 1, 2009

Medicine, Policy No. 126

Pre-Diabetes and Diabetes Care

Archive Effective Date:  April 1, 2009

Medicine, Policy No. 129

Occlusion of Uterine Arteries using Transcatheter Embolization or Laparoscopic Occlusion to Treat Uterine Fibroids

Archive Effective Date:  April 1, 2009

Surgery, Policy No. 97

Percutaneous Transluminal Angioplasty and Stenting (Excluding Carotid and Intracranial)

Archive Effective Date:  April 1, 2009

Surgery, Policy No. 119

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

Archive Effective Date:  May 1, 2009

Laboratory, Policy No. 35

Speculoscopy

Archive Effective Date:  May 1, 2009

Medicine, Policy No. 106

Allograft Use in Breast Reconstructive Surgery

Archive Effective Date:  May 1, 2009

Surgery, Policy No. 161

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