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Medical Policy
Regence Medical Policy Update, October 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 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.
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
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
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.
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
Wearable Cardioverter-Defibrillators Added medically necessary criteria for wearable cardioverter-defibrillators in patients at risk of arrhythmic death and as a bridge to definitive therapy (e.g., cardiac transplant).

Effective Date: July 7, 2017

Durable Medical Equipment, Policy No. 61 N/A Name change on preauth website.
Noninvasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Policy liberalized for TE which may be considered medically necessary.

Effective Date: July 7, 2017

Radiology, Policy No. 56 Investigational denial removed from code 0346T N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed seven panels.

Effective Date: July 1, 2017

Genetic Testing, Policy No. 64 Adding quarterly code update new codes 0008U and 0010U effective 8/1/2017. 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.
Radiofrequency Ablation of Tumors (RFA)

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

Effective Date: July 1, 2017

Surgery, Policy No. 92 Moved codes 47370, 47380, and 47382 to new medical policy SUR204. Removed codes 47370, 47380, and 47382 from this medical policy on the preauth website.
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

Changed policy title. Clarified policy scope to include High Intensity Focused Ultrasound (HIFU).

Effective Date: July 1, 2017

Surgery, Policy No. 139 Added preauth to new 7/1/2017 code C9747. Added policy to the preauth website for new 7/1/2017 code C9747.
Microwave Tumor Ablation

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

Effective Date: July 1, 2017

Surgery, Policy No. 189 Moved codes 47382, and 47399 to new medical policy SUR204. Removed code 47382 from this medical policy on the preauth website.
Ablation of Primary and Metastatic Liver Tumors Effective Date: July 1, 2017 Surgery, Policy No. 204 Added codes 47370, 47380, 47382, and 47399 to this new medical policy and continue preauth on these codes. Continue to review unlisted code 47399. Added policy to preauth website with codes 47370, 47380, 47382.
Balloon Dilation of the Eustachian Tube

New investigational policy for balloon dilation of the eustachian tube.

Effective Date: July 1, 2017

Surgery, Policy No. 206 Added preauth to new 7/1/2017 code C9745. Review unlisted code 67999. Added new policy to the preauth website with code C9745.
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
The following is a list of recently archived policies:
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
Prostatic Urethral Lift

Archive Effective Date: July 1, 2017

NOTE: New Clinical Position Statement addressing prostatic urethral lift; see Prostatic Urethral Lift.

Surgery, Policy No. 197
Sympathetic Electrical Stimulation Therapy Archive Effective Date: July 1, 2017 Durable Medical Equipment, Policy No. 83.08
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia Archive Effective Date: June 1, 2017 Genetic Testing, Policy No. 27