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 |
|
| 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 |
