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Medical Policy
Regence Medical Policy Update, January 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

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.
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
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Added a note to policy specifying that the policy only applies to member contracts that are subject to preauthorization for Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder.

Effective Date: January 1, 2018

Behavioral Health, Policy No. 18

Retained existing edits on codes for the member contracts that are subject to preauthorization.

Termed edits for the member contracts that are no longer subject to preauthorization.

PreAuth lists updated as appropriate to align with the note in the policy that the policy only applies to member contracts that are subject to preauthorization for Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder.

Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Genetic testing for TP53 associated with Li-Fraumeni syndrome will now be addressed in a new policy, GT82.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 02 N/A N/A
Genetic Panel Testing (5-50 genes) for Hematolymphoid Neoplasms or Disorders

Added one genetic panel test that may be considered medically necessary and four that are considered investigational.

Effective Date: January 1, 2018

Genetic Testing; Policy No. 09 N/A Added codes 81170, 81218, 81219, 81245, 81246, 81270, 81272, 81275, 81276, 81273, 81310, 81311, to the preauth website for this policy.
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Added testing for BRAF V600E variant to criteria.

Effective Date: January 1, 2018

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

Added 18 new investigational panels and removed 61 panels. Added column to criteria to specify when a more specific medical policy applies.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Genetic Testing for Li-Fraumeni Syndrome

New policy which considers genetic testing for TP53 medically necessary when policy criteria are met.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 82 Continue preath on code 81405, and continue to review unlisted code 81479. Add this new medical policy with code 81405 on the preauth website.
Vitamin D Testing

Added HIV/AIDS and transplant recipients as conditions for which vitamin D testing may be considered medically necessary.

Effective Date: January 1, 2018

Laboratory, Policy No. 52 Added additional diagnosis codes for code 82306. The coding toolkit will be updated with these additional diagnoses for code 82306. N/A
Protein Biomarkers for Screening, Detection, and/or Management of Prostate Cancer

Removed Prostarix™ from criteria as the test is no longer available. Moved the Apifiny® test from MED149 to this policy and it continutes to be investigational.

Effective Date: January 1, 2018

Laboratory, Policy No. 69 N/A N/A
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies and removed several in accordance with the annual code updates. Moved code 0021U and evidence to medical policy LAB69.

Effective Date: January 1, 2018

Medicine, Policy No. 149 N/A N/A
Transgender Services

Added clarification to the Policy Guidelines regarding mastectomy.

Effective Date: January 1, 2018

Medicine, Policy No. 153 N/A N/A
Cosmetic and Reconstructive Surgery

Revised blepharoplasty criteria to include eyelid taping measurements.

Effective Date: January 1, 2018

Surgery, Policy No. 12 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Added medical necessity criteria for lung tumors.

Effective Date: January 1, 2018

Surgery, Policy No. 132 N/A N/A
Femoroacetabular Impingement Surgery

Removed requirement of intra-articular injection, and clarified language for conservative therapy.

Effective Date: January 1, 2018

Surgery, Policy No. 160 N/A N/A
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast

Changed policy title.

Changed policy to address only adipose-derived stem cell enrichment in autologous fat grafting to the breast.

Effective Date: January 1, 2018

Surgery, Policy No 182 N/A Added codes 11950, 11951, 11952, and11954, to the preauth website for this policy

Change applies to the following IMRT policies:

Intensity Modulated Radiotherapy (IMRT) of the Thorax

Intensity Modulated Radiotherapy (IMRT) of the Prostate

Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

An optional table has been added that can be filled out to aid the provider in demonstrating that only through IMRT planning can published dose/volume constraints be met for organs at risk. The table conveys the information needed for review and summary analysis.

Effective Date: December 1, 2017

 

 

Medicine, Policy No. 136


Medicine, Policy No. 137


Medicine, Policy No. 138

 


Medicine, Policy No. 139

 

Medicine, Policy No. 147

N/A N/A
Carrier Screening for Genetic Diseases

New policy with medically necessary and investigational criteria.

Effective Date: November 1, 2017

Genetic Testing, Policy No. 81 Continue the preauth requirement on CPT codes 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434 and HCPCS codes S3844, S3845, S3846, S3849, S3850, S3853, and continue to review unlisted code 81479. Add this new policy to the preauth list with CPT codes 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81479, and HCPCS codes S3844, S3845, S3846, S3849, S3850, S3853.
Charged Particle (Proton or Helium Ion) Radiotherapy Changed criteria II to specify that charged-particle irradiation has been shown to have comparable, but not superior, clinical outcomes compared to other irradiation approaches and to clar­ify when it will be considered medically necessary.

Effective Date: November 1, 2017

Medicine, Policy No. 49 N/A N/A
Extracranial Carotid Angioplasty/Stenting

Added carotid angioplasty without stenting to criteria.

Effective Date: November 1, 2017

Surgery, Policy No. 93 N/A N/A
Percutaneous Angioplasty and Stenting of Veins

Added several medically necessary indications.

Effective Date: November 1, 2017

Surgery, Policy No. 109 N/A N/A
Hematopoietic Cell Transplantation for Non-Hodgkin’s Lymphomas Clarified that myeloablative allogeneic HCT is considered investigational as an initial treatment for NHL.

Effective Date: November 1, 2017

Transplant, Policy No. 45.23 N/A N/A
BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy

Revised policy title. Added BRAF testing for glioma patients and treatment with MEK inhibitors.

Effective Date: October 1, 2017

Genetic Testing, Policy No. 41 N/A Update the medical policy title on the preauth website.
Genetic Testing for FMR1 Mutation (Including Fragile X Syndrome)

Change ovarian failure to ovarian insufficiency. Removed requirement for in vitro fertilization work-up.

Effective Date: October 1, 2017

Genetic Testing, Policy No. 43 N/A N/A
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Added companion diagnostic test for targeted treatment to policy.

Effective Date: October 1, 2017

Genetic Testing, Policy No. 56 Add new CPT code 0022U with preauth for this medical policy. Add new CPT code 0022U to the preauth website for this policy.
Evaluating the Utility of Genetic Panels

Added one new investigational panel.

Effective Date: October 1, 2017

Genetic Testing, Policy No. 64 Add new CPT code 0019U with investigational denial for this medical policy. N/A
Hyperbaric Oxygen Pressurization (HBOT)

Added idiopathic sudden sensironeural hearing loss which may be considered medically necessary when criteria are met.

Effective Date: October 1, 2017

Medicine, Policy No. 14 N/A N/A
New and Emerging Medical Technologies and Procedures

Added new CPT code 0021U.

Effective Date: October 1, 2017

Medicine, Policy No. 149 Add new CPT code 0021U with investigational denial for this medical policy. N/A
Sphenopalatine Ganglion Block for Headache and Pain

New medical policy that will consider sphenopalatine ganglion block investigational for all indications.

Effective Date: October 1, 2017
Medicine, Policy No. 160

Adding investigational denial on code 64505.

Continue to review unlisted code 64999.
N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Changed prostate cancer from investigational to medically necessary when policy criteria are met. Removed the requirement for no high-grade compression. Added SRS for spinal tumors as medically necessary.

Effective Date: October 1, 2017

Surgery, Policy No. 16 N/A N/A
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Liberalized to include Matrix-induced Autologous Chondrocyte Implantation therapies with FDA approved devices following published criteria.

Effective Date: October 1, 2017

Surgery, Policy No. 87 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Moved liver tumors into new policy, Ablation of Primary and Metastatic Liver Tumors, Surgery, Policy No. 204.

Effective Date: October 1, 2017

Surgery, Policy No. 132 Moving codes 47371, 47381, and 47383 to new medical policy SUR204. N/A
Ablation of Primary and Metastatic Liver Tumors

Adding percutaneous ethanol injection and cryoablation to ablative techniques.

Effective Date: October 1, 2017

Surgery, Policy No. 204 Adding preauth to codes 47371, 47381, and 47383. Adding codes 47371, 47381, and 47383 to the preauth website.
Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Added metastatic retinoblastoma to potentially medically necessary criterion. Clarified nonmetastatic retinoblastoma is considered investigational.

Effective Date: October 1, 2017

Transplant, Policy No. 45.37 N/A N/A
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

Removed Cologuard® test from policy.

Effective Date: September 1, 2017

Genetic Testing, Policy No. 12 Removed preauthorization from code 81528 Removed code 81528 from preauth website
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
Evaluating the Utility of Genetic Panels

Added additional investigational panels. Removed one panel.

Effective Date: September 1, 2017

Genetic Testing, Policy No. 64 Removed preauthorization from code 81301 for this policy Removed code 81301 from preauth website for this policy
Reduction Mammaplasty

Clarified criteria regarding documented pain from macromastia.

Effective Date: September 1, 2017

Surgery, Policy No. 60 N/A N/A
Deep Brain Stimulation Clarified criteria for dystonia and tremor.

Effective Date: September 1, 2017

Surgery, Policy No. 84 N/A N/A
Varicose Vein Treatment

Revised contract note at the top of the policy criteria box to clarify when there is a contract denial for treatment of varicose veins, the denial not only includes treatment but also the associated duplex scans (i.e. CPT 93970 or 93971) for treatment planning. Clarified the long saphenous vein diameter measurement via ultrasound to include knee or above the knee.

Effective Date: September 1, 2017

Surgery, Policy No. 104 N/A N/A
Genetic Testing for Rett Syndrome

Removed gender-specific diagnostic testing criteria, and added additional targeted carrier testing criteria in related females.

Effective Date: August 1, 2017

Genetic Testing, Policy No. 68 N/A N/A
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
Urine Drug Testing for Substance Abuse and Chronic Pain

Added new code 0007U to policy criteria.

Effective Date: August 1, 2017

Laboratory, Policy No. 68 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
Automated Percutaneous and Percutaneous Endoscopic Discectomy

Updated the policy title and corresponding criteria terminology.

Effective Date: August 1, 2017

Surgery, Policy No. 145 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
The following is a list of recently archived policies:
Microwave Thermotherapy for Primary Breast Cancer Archive Effective Date: January 1, 2018 Medicine, Policy No. 111
Noninvasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease Archive Effective Date: December 1, 2017 Radiology, Policy No. 56
Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease Archive Effective Date: November 1, 2017 Medicine, Policy No. 145
Mechanical Embolectomy for Treatment of Acute Stroke Archive Effective Date: November 1, 2017 Surgery, Policy No. 158
Genetic Testing for Hereditary Hearing Loss Archive Effective Date: October 1, 2017 Genetic Testing, Policy No. 36
Plasma Exchange Archive Effective Date: October 1, 2017 Medicine, Policy No. 05
Magnetoencephalography/Magnetic Source Imaging (MEG/MSI) Archive Effective Date: October 1, 2017 Radiology, Policy No. 22
Virtual Colonoscopy/CT Colonography Archive Effective Date: October 1, 2017 Radiology, Policy No. 36
Transanal Endoscopic Microsurgery (TEMS) Archive Effective Date: October 1, 2017 Surgery, Policy No. 162
Transcatheter Mitral Valve Repair Archive Effective Date: October 1, 2017 Surgery, Policy No. 199
Epithelial Cell Cytology in Breast Cancer Risk Asessment and High Risk Patient Management (Ductal Lavage and Suction Collection Systems) Archive Effective Date: August 1, 2017 Medicine, Policy No. 93