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Medical Policy
Regence Medical Policy Update, June 1, 2017
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

Genetic Testing for Myeloid Neoplasms and Leukemia

Adding criteria for genetic testing associated with acute myeloid leukemia.

Effective Date: September 1, 2017

Genetic Testing, Policy No. 59 Adding preauth to code 81310 Adding codes 81218, 81245, 81246, 81272, 81273, and 81310 to the preauth website
Whole Exome and Whole Genome Sequencing

New policy which will consider chromosomal microarray analysis (CMA) testing as medically necessary in patients undergoing invasive diagnostic prenatal fetal testing.

Effective Date: August 1, 2017

Genetic Testing, Policy No. 76 N/A N/A
Implantable Cardioverter Defibrillator

Clarifying criteria regarding subcutaneous ICD placement when repeat transvenous ICD placement is contra-indicated.

Effective Date: August 1, 2017

Surgery, Policy No. 17 N/A N/A
Artificial Intervertebral Disc

Adding to the imaging criteria that if the request is for a second level disc replacement, then imaging must be within 6 months. Clarifying that hybrid construct is medically necessary when policy criteria are met.

Effective Date: August 1, 2017

Surgery, Policy No. 127 N/A N/A
Hematopoietic Cell Transplantation for Amyloid Light-Chain (AL) Amyloidosis or Waldenström Macroglobulinemia

Changing the policy title. Adding criteria stating that cell transplantation is considered not medically necessary to treat chemoresistant Waldenström macroglobulinemia and is considered investigational as a first-line treatment for the disease.

Effective Date: August 1, 2017

Transplant, Policy No. 45.40 N/A N/A
Cosmetic and Reconstructive Surgery

Effective Date: July 1, 2017

Surgery, Policy No. 12 Adding CPT codes 49654 and 49656 to this medical policy with PreAuth requirement. Adding CPT codes 49654 and 49656 to the PreAuth website for this medical policy.
Transgender Services

Clarified age requirement in surgical criteria regarding Female-to-Male breast surgery.

Effective Date: June 9, 2017

Medicine, Policy No. 153 N/A N/A
Gene Expression Profiling for Melanoma

Refocused policy to gene expression testing in melanoma.
Added criteria which finds testing for patients with uveal melanoma may be considered medically necessary when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 29 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Use of the Afirma GEC is considered investigational when medical necessity criteria are not met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 49 N/A N/A
Genetic Testing for CADASIL Syndrome

Added criteria on genetic testing for adults with relatives that have CADASIL syndrome, which may be considered medically necessary when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 51 N/A N/A
Genetic Testing for Myeloid Neoplasms and Leukemia

Expanded scope of policy.
Clarified title and description. Moved criteria for BCR-ABL kinase domain mutation testing into this policy.

Updated policy criteria to include CALR testing when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 59 Change edit on code 81219 to add preauth.

Change policy name on preauth list.

Add codes 81170, 81219, and 81401 to the preauth website.
Genetic Testing for Rett Syndrome Specify the genes that may be medically necessary for the testing of Rett syndrome and include guidance on panel testing.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 68 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Criteria added to define adverse pathologic findings and remove persistently detectable PSA levels. Added adaptive radiotherapy as investigational.

Effective Date: June 1, 2017

Medicine, Policy No. 137 N/A N/A
Radioembolization for Primary and Metastatic Tumors of the Liver

Clarified the criteria regarding systemic therapy for unresectable hepatic metastases from neuroendocrine tumors.

Effective Date: June 1, 2017

Medicine, Policy No. 140 N/A N/A
Endometrial Ablation Added requirement for contraindication to non-contraceptive progestins.

Effective Date: June 1, 2017

Surgery, Policy No. 01 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Changed policy criteria to consider high frequency spinal cord stimulation as medically necessary when criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 45 Remove investigational denial, and review code C1822. N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Symptomatic osteoporotic vertebral fractures that are less than six weeks in duration may be considered medically necessary when policy criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 107 N/A N/A
Percutaneous Axial Anterior Lumbar Fusion

Revised policy title and criteria terminology to Percutaneous Axial Lumbosacral Interbody Fusion.

Effective Date: June 1, 2017

Surgery, Policy No. 157 N/A N/A
Lumbar Spinal Fusion

Updated policy to consider in-situ instrumented spinal fusion surgery with bone grafting as medically necessary when policy criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 187 N/A N/A
Vagus Nerve Blocking Therapy for Obesity

Moved codes for vagus nerve blocking therapy into this new policy with no change to investigational criteria.

Effective Date: June 1, 2017

Surgery, Policy No. 200 Continue investigational denial on codes 0312T, 0313T, 0314T, 0315T, 0316T, 0317T N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Added two diagnostic codes (F84.5 Asperger’s syndrome and F84.9 Pervasive developmental disorder, unspecified) to the criteria.

Effective Date: May 5, 2017

Behavioral Health, Policy No. 18 Code H2020 will be mapped to the diagnosis codes added to the medical policy. Add CPT H2020 to the preauth list.
Genetic Testing for Hereditary Hearing Loss

Created criteria for nonsyndromic (NSHL) and syndromic hearing loss and clarified the use of single gene testing and multigene panel testing.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 36 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 Disorder or Congenital Anomalies

Changed the policy title. Updated criteria to state that CMA testing in adults is considered investigational. Removed CMA testing in the prenatal setting which is now addressed in a new policy.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 58 N/A N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed two panels.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 64 N/A N/A
Invasive Prenatal (Fetal) Diagnostic Testing Using Chromosomal Microarray Analysis (CMA)

New policy which considers chromosomal microarray analysis (CMA) testing as medically necessary in patients undergoing invasive diagnostic prenatal fetal testing.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 78 Add codes 81228, 81229, 81405, and 81470 to this new medical policy. No change to current edits on these codes. Add this medical policy and codes 81228, 81229, 81405, and 81470 to the pre-authorization website.
Chromosomal Microarray Analysis (CMA) for the Evaluation of Products of Conception and Pregnancy Loss

New policy which considers chromosomal microarray analysis (CMA) testing medically necessary for the evaluation of products of conception and pregnancy loss when policy criteria are met.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 79 Add codes 81228, 81229, 81479, 88299, and 88271 to this new medical policy. No change to current edits on these codes. Add this medical policy and codes 81228 and 81229 to the pre-authorization list
Orthopedic Applications of Stem-Cell Therapy

No medical policy criteria changes.

Effective Date: May 1, 2017

Medicine, Policy No. 142 Add this medical policy to the pre-authorization website.  Codes 38206, 38232, and 38241 will be reviewed using this policy. Add this medical policy and codes 38206, 38232, and 38241 to the pre-authorization list.
New and Emerging Medical Technologies and Procedures Effective Date: May 1, 2017 Medicine, Policy No. 149 N/A N/A
Single Photon Emission Computed Tomography (SPECT) of the Brain

Removed epilepsy and seizure disorders from the list of investigational indications.

Effective Date: May 1, 2017

Radiology, Policy No. 44 N/A N/A
Varicose Vein Treatment

Added language to the policy criteria for endovenous ablation stating "throughout the segment to be ablated" for vein measurement. Added guidance to the coding table for various procedures and relevant codes. Updated the list of information needed for review to specify venous study measurement locations.

Effective Date: May 1, 2017

Surgery, Policy No. 104 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

This is a correction to what was reported for a 4/1/2017 effective date. Corrections will be effective as identified in the following columns.

Surgery, Policy No. 110

Previously reported:
“Added code 43236 with investigational denial.”

Corrected to now report:
“Liberalized investigational denial on codes 43192 and 43201 to require Preauth effective 2/1/2017.

Added code 43236 with preauth required effective 5/1/2017.”

Preauth website updated with codes 43192 and 43201 effective 2/1/2017.

Code 43236 will be added to the Preauth website effective 5/1/2017.
Endobronchial and Intrabronchial Valves

Changed the policy title. Clarified that policy addresses intrabronchial valves in addition to endobronchial valves.

Effective Date: May 1, 2017

Surgery, Policy No. 184 N/A N/A
Tumor Treating Fields Therapy for Glioblastoma Policy title changed. Added criteria to address the software used to optimize tumor treating fields (TTF) therapy.

Effective Date: April 1, 2017

Durable Medical Equipment, Policy No. 85

Added CPT code 77299 to the policy with no change to the current edits.

Added CPT code 77261 to the policy with no clinical edits but a coding note added to the medical policy that this is not the correct code to use for the NovoTAL system software program.
Policy title updated to match the medical policy title change.
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Added PALB2 testing as medically necessary when policy criteria are met.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 02 N/A N/A
Cytochrome p450 Genotyping

Clarified that testing for mutations in more than one CYP450 gene is considered investigational.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 10 N/A N/A
Genetic Testing for FMR1 Mutations (including Fragile X Syndrome)

Clarified wording in criterion related to Fragile X ataxia/tremor.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 43 N/A N/A
Cosmetic and Reconstructive Surgery

Added treatment session criteria to blepharoplasty. Modified panniculectomy criteria.

Clarified blepharoplasty criterion II. C.  for the visual field assessment. Clarified criteria for the use of the component separation technique for ventral hernia repair. Added and clarified criteria for surgical repair of diastasis recti and abdominoplasty.

Effective Date: April 1, 2017

Surgery, Policy No. 12 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Added criteria for high frequency stimulation. Added language to the body of the policy to describe high frequency stimulation devices, including the Senza® system and corresponding HF10™ therapy.

Effective Date: April 1, 2017

Surgery, Policy No. 45 Change HCPCS code C1822 from reviewed to investigational denial. Change HCPCS code C1822 from reviewed to investigational denial.
Varicose Vein Treatment

Additional vein diameter measurement locations were added for ligation/stripping and endovenous ablation. For endovenous ablation, criterion added for clinical documentation that all incompetent segments of the same vein will be treated in the same session. Also, sclerotherapy for the upper extremities is considered investigational.

Effective Date: April 1, 2017

Surgery, Policy No. 104 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

Correction entered, see above entry for SUR110.

Added code with investigational denial.

Effective Date: April 1, 2017

Surgery, Policy No. 110 Added code 43236 with investigational denial. N/A
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Updated procedure names throughout policy including title and criteria usage.

Effective Date: April 1, 2017

Surgery, Policy No. 118 N/A N/A
Femoroacetabular Impingement Surgery

Removed imaging requirement for radiologist review. Added physical therapy and intra-articular injections, unless contraindicated, to the conservative treatment requirements. Added additional language that requested procedures must be consistent with the documented anatomical abnormalities. Added capsular plication, capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAI surgery, as components of and incidental to the FAI procedure.

Effective Date: April 1, 2017

Surgery, Policy No. 160 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Criteria restructured and reorganized. Clarified the medically necessary procedures in the policy and addressed partial glossectomy as one of these procedures. Revised CPAP trial requirements.

Effective Date: April 1, 2017

Surgery, Policy No. 166 Added CPT code 64568 with no change to the current edits Added CPT code 64568
Charged Particle (Proton or Helium Ion) Radiotherapy Change to consider pediatric malignant solid tumors medically necessary and clarified the criteria for ocular, cervical spinal cord, and skull base tumors.

Effective Date: March 1, 2017

Medicine, Policy No. 49 N/A N/A
In Vivo Analysis of Colorectal Polyps

Clarified criterion to indicate that policy applies to in vivo analysis of any colorectal lesions.

Effective Date: March 1, 2017

Medicine, Policy No. 104 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Change criteria to consider locally advanced prostate cancer, prior radiation to the planned target volume, and tumors close to organs at risk as medically necessary when policy criteria are met.

Effective Date: March 1, 2017

Medicine, Policy No. 137 N/A N/A
Endometrial Ablation Clarified several criteria required and concomitant procedures. Updated contraindications to contraceptives to align with Centers for Disease Control and Prevention.

Effective Date: March 1, 2017

Surgery, Policy No. 01 N/A N/A
Gastroesophageal Reflux Surgery Clarified hiatal hernia types in criteria for medically necessary and investigational indications.

Effective Date: March 1, 2017

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

Added additional investigational panels and updated the name of one panel.

Effective Date: February 1, 2017

Genetic Testing, Policy No. 64 N/A N/A
Analysis of Proteomic and Metabolomic Patterns for Early Detection of Cancer

Expanded the scope of the policy to address metabolomic tests which are considered investigational.

Effective Date: February 1, 2017

Laboratory, Policy No. 41 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 138 N/A N/A
Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Clarified the criteria language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 139 N/A N/A
Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 147 N/A N/A
Bariatric Surgery

Clarified reoperation criteria; added parietal cell separating gastrojejunostomy and AspireAssist device to investigational procedures; specified that sleeve gastrectomy and adjustable gastric banding are only medically necessary in the absence of GERD and takedown of fundoplication; separated out general criteria for reference throughout the policy.

Provided clarification for hiatal hernia repair, specifying the procedure includes either repair of sliding or paraesophageal hernia.

Effective Date: February 1, 2017

Surgery, Policy No. 58

Add preauth to code 43860.

HCPCS code S2083 does not require preauth, but coverage is available only for members with bariatric surgery benefits.

Add code 43860 to the preauth list for this policy.

Remove preauth on code S2083

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

Added EndoPredict and Breast Cancer Index tests to medical necessity criteria. Added additional language to clarify testing for patients with DCIS.

Effective Date: January 6, 2017

Genetic Testing, Policy No. 42 N/A N/A
Administrative Guidelines to Determine Dental vs Medical Services

Criteria updated to reflect new contract language allowing general anesthesia coverage by a medical provider under the medical benefit when criteria are met.

Effective Date: January 1, 2017

Allied Health, Policy No. 35 N/A N/A
Genetic Testing for Inherited Susceptibility to Colon Cancer

Added criterion that Lynch syndrome testing may be medically necessary in endometrial cancer patients below age 50 when policy criteria are met.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 06 N/A N/A
Genetic Testing for Familial Hypercholesterolemia

New policy for familial hypercholesterolemia genetic testing related to the PCSK9 inhibitor medications, which may require a definitive diagnosis of familial hypercholesterolemia.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 11 N/A Add new policy to PreAuth website.
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

Fecal DNA testing using Cologuard® is now considered medically necessary once every three years for patients aged 50 to 85 years who have no signs or symptoms of colorectal disease and are at average risk for colorectal cancer. Fecal DNA testing with tests other than Cologuard® remains investigational.

Effective Date: January 1, 2017

Genetic Testing, Policy No. 12 Termed investigational denial on CPT code 81528 and add preauth requirement. Add CPT code 81528 to PreAuth website.
Urine Drug Testing for Substance Abuse and Chronic Pain

Three presumptive testing codes have been deleted with the annual code update process, and three comparable codes have been added to replace.

Effective Date: January 1, 2017

Laboratory, Policy No. 68 Added new codes 80305, 80306, 80307, and G0659 with 15 unit per year limit. N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax Significant reformatting and clarifications made to the policy criteria. New requirements for histogram analysis and the term curative treatment was added to the criteria for specific indications. IMRT may be considered medically necessary for individuals with large breasts in order to avoid or minimize hot spots when policy criteria is met. A list of information needed for review was updated in the Policy Guidelines section.

Effective Date: January 1, 2017

Medicine, Policy No. 136 N/A N/A
New and Emerging Medical Technologies and Procedures

Update the policy in accordance with the annual code update. Moved code 0404T to Medical Policy, Radiofrequency Ablation for Tumors, No. SUR92.

Effective Date: January 1, 2017

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

Clarified the criteria and added a list of information needed for review.

Effective Date: January 1, 2017

Medicine, Policy No. 150 N/A N/A
Transgender Services

Revisions have been made to the not medically necessary services. Drugs for hair loss or growth have been removed from the policy. Breast augmentation, hair removal, hair transplantation, mastopexy, and nipple/areola reconstruction in the absence of concurrent or prior subcutaneous or simple/total mastectomy may be considered medically necessary when criteria are met.

Effective Date: January 1, 2017

Medicine, Policy No. 153 Changed Criteria B and C in that if the listed services are billed for gender identity disorders they will be denied as not medically necessary (provider write-off) and not billed for gender identity disorder the services will continue to be denied as cosmetic denials (member balance). Added 15775, 15776, and 17380 to PreAuth website.
Spinal Cord and Dorsal Root Ganglion Stimulation

Added criteria for dorsal root ganglion stimulation.

Effective Date: January 1, 2017

Surgery, Policy No. 45 Add HCPCS code C1820 for review. Name changed on PreAuth website.
Ventricular Assist Devices and Total Artificial Hearts

Clarified that aortic counterpulsation devices are included in investigational criteria, as they are not FDA-approved.

Effective Date: January 1, 2017

Surgery, Policy No. 52 N/A N/A
Deep Brain Stimulation

Policy criteria reorganized with no significant changes.

Effective Date: January 1, 2017

Surgery, Policy No. 84 N/A N/A
Radiofrequency Ablation of Tumors (RFA)

Clarified that RFA for treatment of uterine fibroids is investigational.

Effective Date: January 1, 2017

Surgery, Policy No. 92 N/A N/A
Varicose Vein Treatment

Policy reorganized and grouped together into general criteria, procedures, and treatment sessions. A list of information needed for review was updated in the Policy Guidelines section. Additional clarifications were added throughout the criteria.

Effective Date: January 1, 2017

Surgery, Policy No. 104 N/A N/A
Implantable Bone-Conduction and Bone-Anchored Hearing Aids

Consider partially-implantable bone-conduction (bone-anchored) hearing aid(s) to be medically necessary when criteria are met.

Effective Date: January 1, 2017

Surgery, Policy No. 121 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Clarified the policy scope to explicitly state pulmonary tumors are included.

Effective Date: January 1, 2017

Surgery, Policy No. 132 N/A Name changed on PreAuth website.
The following is a list of recently archived policies:
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia Archive Effective Date: June 1, 2017 Genetic Testing, Policy No. 27
Computed Tomography (CT) Perfusion Imaging of the Brain Archive Effective Date: March 1, 2017 Radiology, Policy No. 54
Thermal Capsulorrhaphy as a Treatment of Joint Instability Archive Effective Date: March 1, 2017 Surgery, Policy No. 100
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Archive Effective Date: February 1, 2017 Surgery, Policy No. 170
Transvaginal and Transuretheral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Archive Effective Date: Janaury 1, 2017 Surgery, Policy No. 130