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Medical Policy
Regence Medical Policy Update, July 1, 2018
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

Myoelectric Prosthetic and Orthotic Components for the Upper Limb

Changing policy title.
Adding investigational criteria for upper-limb prosthetic components with both sensor and myoelectric control and for myoelectric controlled upper-limb orthoses.

Effective Date: October 1, 2018

Durable Medical Equipment, Policy No. 80 Adding code L6693 with preauth edit. Adding code L6693 with preauth edit. Changing the policy title on the preauth website.
Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancers and Thyroid Cancer

Expanding the scope of the policy to address other cancers including, but not limited to skin cancers in the region.

Effective Date: September 1, 2018

Medicine, Policy No. 138 N/A N/A
Implantable Bone Conduction and Bone-Anchored Hearing Aids

Adding audiology criteria for bilateral implantation.

Effective Date: September 1, 2018

Surgery, Policy No. 121 N/A N/A
Sepsis

New clinical position statement that defines sepsis based on professional organization guidelines and indicates the response and documentation expected.

Effective Date: August 1, 2018

Clinical Position Statement, No. 03 N/A N/A
Cosmetic and Reconstructive Surgery Added new criteria for rhinoplasty.

Effective Date: August 1, 2018

Surgery, Policy No. 12 N/A N/A
Cooling Devices Used in the Home Setting

Clarified phrasing in criteria to include circulating and noncirculating to the active and passive descriptions, respectively.

Effective Date: July 1, 2018

Durable Medical Equipment, Policy No. 07 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Updated medical necessity statement to include ThyroSeq®, ThyGenX®, and ThyraMIR when criteria are met.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 49 Remove investigational edit on codes 0018U and 0026U, and add preauth edit. Add codes 0018U and 0026U to the preauth website.
Evaluating the Utility of Genetic Panels

Added two new investigational panels and removed 16 panels.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 64 Remove investigational denial from codes 81410 and 81411 with move to the new medical policy GT77. N/A
Genetic Testing for Heritable Disorders of Connective Tissue

New policy addresses genetic testing for heritable disorders of connective tissue. Criteria for symptomatic individuals, and relatives of those with a known disorder describes when testing may be considered medically necessary. Policy Guidelines specify clinical documentation requirements.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 77 New policy adds codes 81405 an 81408 with a preauth edit. Codes 81410 and 81411 are added to this policy with no edit. Add medical policy to the preauth website for codes 81405 and 81408.
Urine Drug Testing for Substance Use and Pain Management

Updated criteria to:

  • Allow specific codes for presumptive and definitive testing when up to 15 units are billed per type of testing, per year
  • Deny G0482 and G0483 as not medically necessary

Effective Date: July 1, 2018

Laboratory, Policy No. 68 Limiting both presumptive and definitive testing to specific codes (five for presumptive; three for definitive), one code per date of service by the same or different provider, and 15 codes for each type of testing, per year. N/A
Charged-Particle (Proton) Radiotherapy

Changed policy title.

Changed to consider charged particle therapy such as proton beam therapy medically necessary for central nervous system tumors which extend to 10mm or less from the optic chiasm, brain stem, or cervical spinal cord and for reirradiation of head and neck and central nervous system tumors.

Effective Date: July 1, 2018

Medicine, Policy No. 49 N/A Update policy title on the preauth website.
Implantable Cardioverter Defibrillator

Added several new indications for transvenous ICD placement. Removed requirement for specific contraindications for a transvenous ICD to the subcutaneous ICD criteria.

Effective Date: July 1, 2018

Surgery, Policy No. 17 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Change to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 45 N/A N/A
Sacral Nerve Neuromodulation/ Stimulation for Pelvic Floor Dysfunction

Change policy title.

Change criteria to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 134 N/A Change title of medical policy on preauth website.
Sacroiliac Joint Fusion

Use of minimally invasive titanium triangular implants to fuse or stabilize the sacroiliac joint may be considered medically necessary when criteria are met.

Effective Date: July 1, 2018

Surgery, Policy No. 193 Remove investigational denial on code 27279. N/A
Genetic Testing for CADASIL Syndrome

Removed requirement for other methods of testing prior to genetic testing.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 51 N/A N/A
Chromosomal Microarray Analysis (CMA) for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies

Changed medical policy title. Revised criteria to exclude next-generation sequencing panels from this policy, as they will be addressed in other genetic testing policies.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 58 Deleted codes 81470 and 81471 from this medical policy and moved to GT20 and GT64. Changed title of medical policy on the PreAuth website.
Evaluating the Utility of Genetic Panels

Added five new investigational panels and removed 15 panels.

Effective Date: June 1, 2018

Genetic Testing, Policy No. 64 Added codes 81470 and 81471 to this medical policy and keep the preauth requirement. Added codes 81470 and 81471 to this medical policy and keep the preauth requirement.
Urinary Tumor Markers for Bladder Cancer

New investigational policy addressing urinary tumor markers for bladder cancer.

Effective Date: June 1, 2018

Laboratory, Policy No. 52 N/A N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Clarified medical necessity criterion, and added clarification of documentation required to review in the Policy Guidelines section.

Effective Date: June 1, 2018

Surgery, Policy No. 107 N/A N/A
Implantable Bone Conduction and Bone-Anchored Hearing Aids

Changed criteria for clarity and consistency between audiology policies. Updated referenced devices to current models.

Effective Date: June 1, 2018

Surgery, Policy No. 121 N/A N/A
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Removed requirements to specific epidermal growth factor receptor (EGFR) variants.

Effective Date: May 1, 2018

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

Added 14 new investigational panels and removed one panel.

Effective Date: May 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Bariatric Surgery

Added clarification to several criteria and detailed Policy Guidelines. Guidelines will aid in transparency of expectations for required documentation to support clinical review.

Effective Date: May 1, 2018

Surgery, Policy No. 58 N/A N/A
Varicose Vein Treatment

Liberalized the criteria to allow sclerotherapy for the great saphenous vein below the knee and decreased stocking compression to a minimum 15-20mmHg. Revised long and short to great and small saphenous veins throughout. Clarified and streamlined additional criteria elements.

Effective Date: May 1, 2018

Surgery, Policy No. 104 N/A N/A
Gastroesophageal Reflux Surgery

Updated one criterion regarding proton pump inhibitor therapy. When a trial of proton pump inhibitor (PPI) therapy is ineffective, contraindicated, or not tolerated, the total trial must be at least 4-months. Clarified definitions of hiatal hernias in Policy Guidelines.

Effective Date: May 1, 2018

Surgery, Policy No. 186 N/A N/A
Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin

New policy for implantable peripheral nerve stimulation (PNS) for chronic pain of peripheral nerve origin (e.g. StimRouter).

Effective Date: May 1, 2018

Surgery, Policy No. 205 Continue preauth on 64555, 64575, and 64590 (this policy is new to the list of policies that address these codes and requires preauth). Continue to review codes 64999, L8680 and L8683 (this policy is new to the list of policies that address these codes and requires review) Add this policy to the preauth website for codes 64555, 64575, and 64590.
Genetic Testing for Alzheimer's Disease

Added genetic testing for autosomal dominant Alzheimer's disease for reproductive decision-making.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 01 N/A N/A
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer

Moved gene expression analysis to this policy; maintaining investigational position.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 17 N/A N/A
Adoptive Immunotherapy

Removed review of CAR-T therapies, as Pharmacy now reviews this category of therapies. See the Pharmacy Medication Manual.

Effective Date: April 1, 2018

Medicine, Policy No. 42 N/A N/A
Transgender Services

See Coding/Implementation Changes and PreAuthorization Changes listed on this row in the columns to follow.

Effective Date: April 1, 2018

Medicine, Policy No. 153 Adding bypass to the preauth requirement on these codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, C1813 unless a transgender dx (F640, F641, F642, F648, F649) is found anywhere on the claim Adding codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, and C1813 to the preauth list for this policy.
Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy

New policy for the RPE65 variant when Luxturna is being considered as a treatment option.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 21 N/A Add this new policy to the preauth website for CPT code 81406.
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Replaced “0.6-1 cm” in criteria with “greater than 0.5 to 1 cm” to more clearly align with NCCN’s recommendations.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 42 N/A N/A
Genetic Testing for Mental Health Conditions

New policy that considers genetic testing for mental health conditions, including medication selection, investigational.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 53 N/A N/A
Evaluating the Utility of Genetic Panels

Added 14 new investigational panels and removed four panels.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Laboratory and Genetic Testing for use of Thiopurines

Added NUDT15 genetic testing, which may be considered medically necessary when policy criteria are met.

Effective Date: March 1, 2018

Laboratory, Policy No. 70 Add code 0034U with preauth edit to this policy. Add code 0034U to the preauth website.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Liberalized the meningioma criteria. Removed the 6-month life expectancy criteria from the policy. Recategorized into intracranial and extracranial indications.

Effective Date: March 1, 2018

Surgery, Policy No. 16 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Updated medical necessity criteria for lung tumors. Removed the requirement for surgical resection for non-small cell lung cancer.

Effective Date: March 1, 2018

Surgery, Policy No. 132 N/A N/A
Wearable Cardioverter-Defibrillators

Revised “low ejection” in criteria I.B. to state “left ventricular ejection fraction (LVEF) less than or equal to 35 percent” and expanded criteria I.C. to state: “As a bridge to definitive therapy (e.g., cardiac transplant), when criteria I.B. is met.”

Effective Date: February 1, 2018

Durable Medical Equipment, Policy No. 61 N/A N/A
IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia

New policy addresses IDH1 and IDH2 testing for indications other than myeloid neoplasms or leukemia.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 19 Add preauth to new codes 81120 and 81121. Add preauth to new codes 81120 and 81121.
Genetic Testing for Statin-Induced Myopathy

New policy for genetic testing for statin-induced myopathy.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 50 Add edit for new code 81328 to deny as not medically necessary. N/A
Genetic Testing for α-Thalassemia

New policy on genetic testing for alpha-thalassemia.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 52 Continue preauth on 81257 and 81404 (this policy is new to the list of policies that address these codes and require preauth). Add preauth to new codes 81258, 81259, and 81269. Add this policy to the preauth website for codes 81257, 81404, 81258, 81259, and 81269.
Genetic Testing for Myeloid Neoplasms and Leukemia

Updated the policy to include IDH1 testing when criteria are met. Removed review of JAK2 and MPL which may be considered medically necessary.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 59

Add preauth to new codes 81120 and 81121. Remove preauth for codes 0017U, 0027U, and 81270.

Remove codes 0017U, 0027U, and 81270 from the preauth website.

NOTE: code 81270 is addressed in other medical policies still requiring preauth.

Laboratory and Genetic Testing for use of Thiopurines

New policy addressing genotypic and phenotypic analysis of the thiopurine methyltransferase (TPMT) enzyme and analysis of the metabolite markers azathioprine and mercaptopurine.

Effective Date: February 1, 2018

Laboratory, Policy No. 70 Continue preauth on 81401 (this policy is new to the list of policies that address this code and requires preauth). Add preauth to new code 81335. Add this policy to the preauth website for codes 81335, and 81401.
Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders

Removed fractional exhaled nitric oxide (FeNO) measurement (CPT 95012) as it may be considered medically necessary

Effective Date: February 1, 2018

Medicine, Policy No. 108 Removed investigational denial on CPT 95012. N/A
Ventricular Assist Devices and Total Artificial Hearts

Revised criteria as percutaneous ventricular assist devices (pVADs) may be considered medically necessary.

Effective Date: February 1, 2018

Surgery, Policy No. 52 Change edit on codes 33990, 33991, 33992, and 33993 from investigational to medically necessary. N/A
The following is a list of recently archived policies:
Breast Duct Endoscopy (Ductoscopy) Archive Effective Date: June 1, 2018 Medicine, Policy No. 112
Endovascular Angioplasty and/or Stenting for Intracranial Arterial Disease (Atherosclerotic and Aneurysms) Archive Effective Date: June 1, 2018 Surgery, Policy No. 141
Gene Expression Analysis for Prostate Cancer Management

Archive Effective Date: April 1, 2018

NOTE: Now addressed in Medical Policy GT17.

Genetic Testing, Policy No. 71
Outpatient Cardiac Telemetry Archive Effective Date: March 1, 2018 Medicine, Policy No. 135
Genetic Panel Testing (5-50 genes) for Hematolymphoid Neoplasms or Disorders Archive Effective Date: February 1, 2018 Genetic Testing, Policy No. 09
Fecal Microbiota Transplantation Archive Effective Date: February 1, 2018 Medicine, Policy No. 154