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Medical Policy
Regence Medical Policy Update, March 1, 2019
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

Eating Disorder Inpatient Treatment

Eating Disorder Inpatient Treatment.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 25 N/A Policy added to the Preauth website.
Eating Disorder Intensive Outpatient

Eating Disorder Intensive Outpatient.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 26 N/A Policy added to the Preauth website.
Eating Disorder Partial Hospitalization

Eating Disorder Partial Hospitalization.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 27 N/A Policy added to the Preauth website.
Eating Disorder Residential Treatment

Eating Disorder Residential Treatment.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 28 N/A Policy added to the Preauth website.
Inpatient Psychiatric Hospitalization

New policy for inpatient psychiatric hospitalization.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 29 N/A Policy added to the Preauth website.
Psychiatric Intensive Outpatient

New policy on psychiatric intensive outpatient treatment.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 30 N/A Policy added to the Preauth website.
Psychiatric Partial Hospitalization

New policy on psychiatric partial hospitalization.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 31 N/A Policy added to the Preauth website.
Psychiatric Residential Treatment

New policy on psychiatric residential treatment.

Effective Date: April 1, 2019

Behavioral Health, Policy No. 32 N/A Policy added to the Preauth website.
Transurethral Water Vapor Thermal Therapy of the Prostate New policy considering transurethral water vapor thermal therapy investigational.

Effective Date: April 1, 2019

Surgery, Policy No. 210 Add investigational denial to new code 53854. Continue review on unlisted code 53899. N/A
Gastroesophageal Reflux Surgery

Clarified that hiatal hernia repair is investigational without current or prior fundoplication.

Effective Date: March 1, 2019

Surgery, Policy No. 186 N/A N/A
Sacroiliac Joint Fusion

This entry is here to document a coding/implementation change and preauthorization change.

Effective Date: March 1, 2019

Surgery, Policy No. 193 Add preauthorization requirement to code 27279. Add code 27279 to the preauth website.
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

New policy considering the insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse investigational.

Effective Date: March 1, 2019

Surgery, Policy No. 209 Add investigational denial to code C9749. Continue review on unlisted code 30999. N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Policy updated to consider additional medically necessary indications when criteria are met. The additional indications include pharmacoresistent epilepsy, pancreatic adenocarcinoma, oligometastases, and inoperable primary renal cell carcinoma.

Effective Date: February 15, 2019

Surgery, Policy No. 16 N/A N/A
Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome Testing may now be medically necessary for any patients with a personal history of pancreatic cancer or metastatic prostate cancer.

Effective Date: February 1, 2019

Genetic Testing, Policy No. 02 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Added MammaPrint to potentially medically necessary tests and removed tumor histology requirements.

Effective Date: February 1, 2019

Genetic Testing, Policy No. 42 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Updated list of medically necessary procedures for select populations when policy criteria are met.

Effective Date: February 1, 2019

Surgery, Policy No. 166 Removed investigational edit on CPT codes 0467T and 0468T. N/A
Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes)

Updated policy title.

Added AFF2 (FMR2) testing for fragile XE syndrome which is investigational.

Effective Date: January 1, 2019

Genetic Testing, Policy No. 43 Add investigational denial to new codes 81171, 81172. Updated policy title on the Preauth website.
Evaluating the Utility of Genetic Panels

Added 12 new investigational panels and removed one panel.

Effective Date: January 1, 2019

Genetic Testing, Policy No. 64 N/A N/A
Urine Drug Testing for Substance Use and Pain Management

Reformatted and clarified criteria for readability, with no changes to intent. Added 0082U as always not medically necessary with the annual code update process.

Effective Date: January 1, 2019

Laboratory, Policy No. 68 N/A N/A
Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow

Added criterion addressing synthetic bone grafts that require autologous bone marrow.

Effective Date: January 1, 2019

Medicine, Policy No. 142 N/A Updated policy title on the Preauth website.
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies and removed several in accordance with the annual code updates.

Effective Date: January 1, 2019

Medicine, Policy No. 149

Added investigational denial to new codes 0512T, 0513T, 0515T, 0516T, 0517T, 0518T, 0519T, 0520T, 0521T, 0522T, 0533T, 0534T, 0535T, 0536T, 0541T, 0542T, 33274, 33275, C9752, C9753.

Deleted codes 0337T, 0387T, 0388T, 0389T, 0390T, 0391T.
N/A
Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT)

Policy changed to consider DAT-SPECT potentially medically necessary for certain indications when criteria are met.

Effective Date: January 1, 2019

Radiology, Policy No. 57 N/A N/A

Cosmetic and Reconstructive Surgery

Moved the two cosmetic services out of SUR12 and into the following new individual policies:

Note: The separation of these indications into individual policies did not result in a change to policy criteria intent.

Effective Date: January 1, 2019

Surgery, Policy No.s:

12
12.04 (new)
12.06 (new)
CPT codes will be removed from SUR12 and added to the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication. N/A
Varicose Vein Treatment

Updated the policy criteria.

Effective Date: January 1, 2019

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

Updated policy title.

Added newly available devices and addressed replacement supplies in alignment with the Oregon Hearing Mandate.

Effective Date: January 1, 2019

Surgery, Policy No. 121 N/A Updated policy title on the Preauth website.
Genetic Testing for Epilepsy

New policy addressing genetic testing for epilepsy.

Effective Date: December 1, 2018

Genetic Testing, Policy No. 80 Continue to review unlisted code 81479. Continue the preauth requirement on codes 81401, 81403, 81404, 81405, 81406, and 81407. Added new policy with codes 81401, 81403, 81404, 81405, 81406, and 81407 to the preauth website.
Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Changed policy title. Added circulating tumor/cell-free DNA to the investigational statement.

Effective Date: December 1, 2018

Laboratory, Policy No. 46 N/A N/A
Charged-Particle (Proton) Radiotherapy

Added an investigational statement for charged particle irradiation for stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT)/stereotactic ablative radiotherapy (SABR).
Clarified the location of central nervous system tumors that meet medical necessity criteria.

To ensure proper documentation is submitted regarding CNS tumors, clarified the policy guidelines regarding the documentation required.

Effective Date: December 1, 2018

Medicine, Policy No. 49 Continue preauth requirement on 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340. Added codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340, to the preauth website.
Transgender Services

Clarified the policy criteria.

Effective Date: December 1, 2018

Medicine, Policy No. 153 N/A N/A
Bariatric Surgery

Updated the medically necessary critieria in three sections of the policy: general criteria, procedures and reoperation with revision.

Effective Date: December 1, 2018

Surgery, Policy No. 58 N/A N/A
Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome

Changed policy title. Added review of TP53 genetic testing.

Effective Date: November 1, 2018

Genetic Testing, Policy No. 02 N/A Updated policy title on preauth website.
Reproductive Carrier Screening for Genetic Diseases

Changed policy title.

Effective Date: November 1, 2018

Genetic Testing, Policy No. 81 N/A Updated policy title on preauth website.
Hyperbaric Oxygen Pressurization (HBOT)

Added to the list of medically necessary indications.

Effective Date: November 1, 2018

Medicine, Policy No. 14 N/A N/A
Lumbar Spinal Fusion

Updated policy criteria statements, specifically with regard to neurogenic claudication, and clinical tools as a measure of disability. Updated policy guidelines to clarify documentation required for submission to support policy criteria.

Effective Date: November 1, 2018

Surgery, Policy No. 187 N/A N/A
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.
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer

Changed policy title. Added microRNA expression testing to policy.

Effective Date: October 1, 2018

Genetic Testing, Policy No. 13 Add new CPT code 0069U to this medical policy as part of the quarterly code updates. N/A
Genetic and Molecular Diagnostic Testing

Added criteria to address review of a genetic panel test when the always investigational position of Evaluating the Utility of Genetic Panels (#64) does not apply.

Effective Date: October 1, 2018

Genetic Testing, Policy No. 20 N/A N/A
Evaluating the Utility of Genetic Panels

Added 12 new genetic panel tests to policy.

Effective Date: October 1, 2018

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

Changed policy title. Added clarification that policy includes testing for cancer risk.

Effective Date: October 1, 2018

Laboratory, Policy No. 41 Add new CPT code 0067U to this medical policy as part of the quarterly code updates. Delete CPT codes 81500, 81503, and 0002U from this medical policy. N/A
Urine Drug Testing for Substance Use and Pain Management

Removed 0020U from presumptive testing criterion as part of annual code set update process. Clarified definitive testing codes in not medically necessary criterion.

Effective Date: October 1, 2018

Laboratory, Policy No. 68 Removed deleted CPT code 0020U as part of the quarterly code updates. N/A
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

Changed policy title. Added urinary testing for colonic polyps to policy.

Effective Date: October 1, 2018

Laboratory, Policy No. 72 Add code 0002U and continue the investigational edit on this code. N/A
Molecular Testing in the Management of Pulmonary Nodules

New policy addressing proteomic and gene expression testing for lung nodules.

Effective Date: October 1, 2018

Laboratory, Policy No. 73 Continue no edit on code 83520 (code not specific) and continue to review unlisted code 64999. N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax

Changed policy to address partial breast irradiation with the same criteria as whole breast irradiation.

Effective Date: October 1, 2018

Medicine, Policy No. 136 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate

Defined adverse pathological findings in criterion II.A. using widely accepted definition.

Effective Date: October 1, 2018

Medicine, Policy No. 137 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Central Nervous System (CNS)

Changed policy title. Removing vertebral tumors from this policy, as they are addressed in other relevant IMRT policies.

Effective Date: October 1, 2018

Medicine, Policy No. 147 N/A Policy title updated on the PreAuth list
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies in accordance with the 4th quarter code update.

Effective Date: October 1, 2018

Medicine, Policy No. 149 Added CPT codes 0062U, 0063U, 0068U to this medical policy as part of the quarterly code updates. N/A
Endometrial Ablation

Updated criteria regarding hormonal therapy. Clarified documentation requirements.

Effective Date: October 1, 2018

Surgery, Policy No. 01 N/A N/A
Cosmetic and Reconstructive Surgery

Maintained services that are always cosmetic in Cosmetic and Reconstructive Surgery, Surgery 12. Separated services that could be potentially medically necessary into the following new individual policies:

Note: The separation of these indications into individual policies did not result in a change to policy criteria intent.

Effective Date: October 1, 2018

Surgery, Policy No.s:

12
12.01 (new)
12.02 (new)
12.03 (new)
12.05 (new)
12.28 (new)
12.34 (new)
12.50 (new)


CPT codes will be removed from SUR12 and added to the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication. The preauth website will be updated to reflect the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication.
Percutaneous Angioplasty and Stenting of Veins

Added inferior vena cava syndrome to the medically necessary indications.

Effective Date: October 1, 2018

Surgery, Policy No. 109 N/A N/A
Intracardiac Ischemia Monitoring

New investigational policy addressing intracardiac ischemia monitoring.

Effective Date: October 1, 2018

Surgery, Policy No. 208 Add CPT codes 33999 and 93799, and HCPCS code C9750 to this investigational medical policy. N/A
Evaluating the Utility of Genetic Panels

Added 12 new investigational panels and removed 1 panel.

Effective Date: September 1, 2018

Genetic Testing, Policy No. 64 N/A Added code 81413 to preauth website for this medical policy.
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
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Revised criteria related to the Karnofsky performance score requirements.

Effective Date: September 1, 2018

Surgery, Policy No. 16 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
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

Updated policy criteria to state that Magnetic resonance (MR) guided focused ultrasound (MRgFUS) may be considered medically necessary for medicine-refractory essential tremors (clinical documentation must be submitted for review).

Effective Date: September 1, 2018

Surgery, Policy No. 139 Removed investigational edit on code 0398T and added preauthorization requirement. Added code 0398T to the preauth website for this medical policy.
The following is a list of recently archived policies:
Intraocular Radiation Thearpy for Age-Related Macular Degeneration Archive Effective Date: January 1, 2019 Medicine, Policy No. 134
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care Archive Effective Date: November 1, 2018 Behavioral Health, Policy No. 23
Genetic Testing for Li-Fraumeni Syndrome

Archive Effective Date: November 1, 2018

NOTE: Criteria that was previously reviewed using GT82 was moved to GT02.

Genetic Testing, Policy No. 82
Percutaneous Tibial Nerve Stimulation Archive Effective Date: October 1, 2018 Surgery, Policy No. 154