Regence
Medical Policy Update, May 1, 2013 |
|
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. |
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|
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|
Policy Name |
Summary
of Policy or Change |
|
| Myoelectric Prosthetic Components for the Upper Limb |
Clarified that prosthesis with individually powered digits are considered investigational.
Effective Date: December 1, 2012 |
Durable Medical Equipment, Policy No. 80 |
| Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening |
New separate policy; investigational criteria formerly included in Regence Medical Policy Genetic Testing 20.
Effective Date: December 1, 2012 |
Genetic Testing, Policy No. 12 |
| Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer |
New separate policy; investigational criteria were formerly included in Regence Medical Policy Genetic Testing 20.
Effective Date: December 1, 2012 |
Genetic Testing, Policy No. 17 |
| Intensity Modulated Radiation Therapy (IMRT) of the Thorax (Breast, Esophageal, and Lung Cancer and Malignant Pleural Mesothelioma) |
Criteria liberalized to consider IMRT medically necessary for the treatment of esophageal cancer and malignant pleural mesothelioma.
Effective Date: December 1, 2012 |
Medicine, Policy No. 136 |
| Intensity Modulated Radiation Therapy (IMRT) of the Prostate |
For treatment of metastatic prostate cancer, Regence IMRT policy addressing the location of the metastasis now applies. In addition, language in criteria modified to further clarify policy intent.
Effective Date: December 1, 2012 |
Medicine, Policy No. 137 |
| Intensity Modulated Radiation Therapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer |
Criteria change to consider IMRT medically necessary for the treatment of thyroid cancer.
Effective Date: December 1, 2012 |
Medicine, Policy No. 138 |
| Intensity Modulated Radiation Therapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors |
New medical policy. IMRT may be considered medically necessary for the treatment of vertebral and CNS tumors.
Effective Date: December 1, 2012 |
Medicine, Policy No. 147 |
Dental and Orthodontic Treatment for Craniofacial Anomalies |
New policy to assist with interpreting Oregon House Bill 4128 which requires medical coverage of “dental and orthodontic services for the treatment of craniofacial anomalies if the services are medically necessary to restore function.”
Effective Date: January 1, 2013 |
Allied Health, Policy No. 33 |
Hyperbaric Oxygen Pressurization (HBO) |
Added acute ischemic stroke and radiation-induced injury in the head and neck to the investigational list of indications.
Effective Date: January 1, 2013 |
Medicine, Policy No. 14 |
Ingestible pH and Pressure Capsule |
Clarified that investigational status includes measurements of colonic transit time.
Effective Date: January 1, 2013 |
Medicine, Policy No. 117 |
Spinal Cord Stimulation for Treatment of Pain |
Policy change to consider spinal cord stimulation for treatment of angina investigational based upon poor quality evidence from studies reporting discrepant results.
Effective Date: January 1, 2013 |
Surgery, Policy No. 45 |
| Biofeedback |
Added orofacial and shoulder pain to list of investigational indications.
Effective Date: February 1, 2013 |
Allied Health, Policy No. 32 |
| Genetic Testing for Hereditary Breast and/or Ovarian Cancer |
Medical necessity criteria expanded to include breast cancer diagnosed at any age with at least two close blood relatives with pancreatic cancer at any age.
Effective Date: February 1, 2013 |
Genetic Testing, Policy No. 02 |
| Genetic Testing for Lynch Syndrome |
Added new indication for MMR gene mutation testing to medical necessity criteria: suspicion of Lynch syndrome in patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer.
Effective Date: February 1, 2013 |
Genetic Testing, Policy No. 06 |
| Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) |
Clarified that medically necessary indication is related to non-squamous cell-type NSCLC.
Effective Date: February 1, 2013 |
Genetic Testing, Policy No. 56 |
| Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer |
New investigational policy.
Effective Date: February 1, 2013 |
Laboratory, Policy No. 64 |
| Implantable Cardioverter Defibrillator |
Added subcutaneous ICDs to the policy criteria; these devices are considered investigational due to a lack of clinical trial data. Clarified that criteria for medically necessary indications are specific to transvenous ICDs.
Effective Date: February 1, 2013 |
Surgery, Policy No. 17 |
| Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease |
New investigational policy for apolipoprotein E as a marker to predict or manage cardiovascular disease.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 05 |
| Genetic Testing for Congenital Long QT Syndrome |
New separate policy; criteria formerly included in Regence Medical Policy Genetic Testing 20. This new policy provides medical necessity criteria and investigational indications for Long QT Syndrome mutation testing.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 07 |
| Genetic and Molecular Diagnostic Testing |
Reformatted to address only major review criteria for genetic testing services; specific indications are addressed individually in separate policies.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 20 |
| DNA-Based Testing for Adolescent Idiopathic Scoliosis |
New separate policy; investigational criteria formerly included in Regence Medical Policy Genetic Testing 20 regarding Adolescent Idiopathic Scoliosis mutation testing.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 45 |
| Gene Expression Testing to Predict Coronary Artery Disease |
New investigational policy for gene expression testing to predict coronary artery disease.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 46 |
| Genetic Testing for Hereditary Hemochromatosis |
New separate policy; criteria formerly included in Regence Medical Policy Genetic Testing 20. This new policy provides medical necessity criteria and investigational indications for Hereditary Hemochromatosis mutation testing.
Effective Date: March 1, 2013 |
Genetic Testing, Policy No. 48 |
| Proteomics-based testing for the Evaluation of Ovarian (Adnexal) Masses |
New policy provides medical necessity criteria and investigational indications for proteomic-based testing for evaluation of adnexal masses (e.g., OVA1™).
Effective Date: March 1, 2013 |
Laboratory, Policy No. 60 |
| Ventricular Assist Devices and Total Artificial Hearts |
Criteria unchanged with minor reformatting.
Effective Date: March 1, 2013 |
Surgery, Policy No. 52 |
| Hip Resurfacing |
New medical policy provides medical necessity criteria for hip resurfacing.
Effective Date: March 1, 2013 |
Surgery, Policy No. 113 |
| Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction |
Criterion II.A.2 clarified as related to conservative (non-surgical) therapy only.
Effective Date: March 1, 2013 |
Surgery, Policy No. 134 |
Gastric Reflux Surgery |
New policy containing medical necessity criteria for gastric reflux surgery.
Effective Date: March 1, 2013 |
Surgery, Policy No. 186 |
| Laboratory Tests of Uncertain Efficacy |
Deleted codes 95076 and 95079. These codes were added in error to the policy.
Correction Posted: March 20, 2013 |
Laboratory, Policy No. 01 |
| Hippotherapy |
New separate investigational policy. Hippotherapy was previously included in the Physical Therapy policy (UM06). There is no change to the investigational status of this therapy.
Effective Date: April 1, 2013 |
Allied Health, Policy No. 34 |
| Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA |
New policy. Sequencing-based tests to determine trisomy 21 from maternal plasma DNA may be medically necessary in high-risk singleton pregnancies when criteria are met.
Effective Date: April 1, 2013 |
Genetic Testing, Policy No. 44 |
| Endometrial Ablation |
Clarified policy criterion related to hormone therapy trial.
Effective Date: April 1, 2013 |
Surgery, Policy No. 01 |
| Surgeries for Snoring, Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome In Adults |
Added auto-adjusting PAP and bilevel PAP pressure delivery systems as alternative for failed CPAP.
Effective Date: April 1, 2013 |
Surgery, Policy No. 166 |
| Bariatric Surgery |
Criteria change for 2-stage procedures which are now considered investigational rather than not medically necessary.
Effective Date: April 9, 2013 |
Surgery, Policy No. 58 |
| Genetic Testing for FMR1 mutations (including Fragile X Syndrome) |
New policy.
Effective Date: May 1, 2013 |
Genetic Testing, Policy No. 43 |
| Genetic Testing for Inherited Thrombophilia |
New policy.
Effective Date: May 1, 2013 |
Genetic Testing, Policy No. 47 |
| Varicose Vein Treatment |
Added mechanochemical ablation as investigational new technology.
Effective Date: May 1, 2013 |
Surgery, Policy No. 104 |
| Lumbar Spinal Fusion |
New policy.
Effective Date: July 1, 2013 |
Surgery, Policy No. 187 |
| Air Ambulance Transport |
New policy.
Effective Date: July 1, 2013 |
Utilization Management, Policy No. 13 |
| Interferential Stimulation for the Treatment of Pain |
Criteria change to consider interferential stimulation as a treatment of pain not medically necessary. Added gastrointestinal indications to the criteria as investigational.
Effective Date: September 1, 2013 |
Durable Medical Equipment, Policy No. 83.07 |
| Percutaneous Intradiscal Electrothermal Annuloplasty (IDET) and Percutaneous Intradiscal Radiofrequency Thermocoagulation |
Criteria change to consider IDET and percutaneous intradiscal radiofrequency thermocoagulation as a treatment of pain not medically necessary.
Effective Date: September 1, 2013 |
Surgery, Policy No. 118 |
| The following
is a list of recently archived policies: |
| Dynamic Spinal Visualization |
Archive Effective Date:
December 1, 2012 |
Radiology, Policy No. 53 |
| Keratoprosthesis |
Archive Effective Date:
December 1, 2012 |
Surgery, Policy No. 85 |
| Autologous Chondrocyte Implantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions |
Archive Effective Date:
March 1, 2013 |
Surgery, Policy No. 87 |
| Radiofrequency Lesioning for the Treatment of Plantar Fasciitis |
Archive Effective Date:
March 1, 2013 |
Surgery, Policy No. 152 |
