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Medical Policy
Regence Medical Policy Update, November 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

Power Wheelchairs: Group 3

New policy will address group 3 wheelchairs.

Effective Date:  November 1, 2019

Durable Medical Equipment, Policy No. 37 Adding preauthorization to HCPCS codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864 for this new medical policy. Adding policy and HCPCS codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864 to the preauth list.
Insulin Infusion Pumps and Artificial Pancreas Device Systems

Policy title changed.

Added medical necessity criteria for insulin infusion pumps.

Effective Date:  November 1, 2019
Durable Medical Equipment, Policy No. 77 Adding preauthorization to HCPCS code E0784. Adding policy and HCPCS code E0784 to the preauth list.
Noninvasive Ventilators in the Home Setting

New policy with medical necessity criteria for home use of noninvasive ventilators.

Effective Date:  November 1, 2019

Durable Medical Equipment, Policy No. 87 Adding preauthorization to HCPCS code E0466 for this new medical policy. Adding policy and HCPCS code E0466 to the preauth list.
Oxygen Concentrators

New Clinical Position Statement addressing oxygen concentrator use.

Effective Date:  November 1, 2019

Clinical Position Statement, No. 04 N/A N/A
Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA)

Added fetal tissue testing based on ultrasound-detected anomalies to policy.

Effective Date:  November 1, 2019

Genetic Testing, Policy No. 78 N/A N/A
Identification of Microorganisms Using Nucleic Acid Probes New policy addressing nucleic acid probe testing for microorganisms.

Effective Date:  November 1, 2019

Genetic Testing, Policy No. 85 Adding investigational denial to codes 0097U, 87472, 87482, 87483, 87485, 87486, 87487, 87505, 87506, 87507, 87512, 87525, 87526, 87527, 87530, 87542, 87552, 87557, 87562, 87582, 87592, 87652 N/A
Hyperbaric Oxygen Therapy

Changed policy title.

Added coverage criteria for compromised skin grafts and flaps.

Effective Date:  November 1, 2019

Medicine, Policy No. 14 N/A Updated policy title on preauth website.
New and Emerging Medical Technologies and Procedures

Moved codes related to leadless cardiac pacemakers to new medical policy Surgery, Policy No. 217.

Effective Date:  November 1, 2019

Medicine, Policy No. 149 Removed CPT codes 33274 and 33275 from this medical policy, and move to new medical policy SUR217. N/A
Sacroiliac Joint Fusion

Clarified criteria to allow for easier entry in the Auto Auth program.

Effective Date:  November 1, 2019

Surgery, Policy No. 193 N/A N/A
Hypoglossal Nerve Stimulation

Updated criteria for adults to match FDA indications.

Effective Date:  November 1, 2019

Surgery, Policy No. 215 N/A N/A
Responsive Neurostimulation

New policy addressing responsive neurostimulation.

Effective Date:  November 1, 2019

Surgery, Policy No. 216 Add CPT codes 61850, 61860, 61863, 61864, 61880, 61885, 61886, 61888, 95970, 95971 and HCPCS codes L8680, L8686 L8688 to this policy with no change to current edits. New medical policy added to the preauth website.
Leadless Cardiac Pacemakers

New policy addressing leadless pacemakers.

Effective Date:  November 1, 2019

Surgery, Policy No. 217 Moved codes 33274 and 33275 from MED149 and added to this new medical policy. Removed investigational denial edit on both codes. Liberalized requirement for code 33274 by adding preauth requirement. New medical policy added to the preauth website.
Evaluating the Utility of Genetic Panels

Added six  new investigational panels to policy.

Effective Date: October 1, 2019

Genetic Testing, Policy No. 64 Added investigational edit to the following new CPT codes which are effective 10/1/2019: 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U N/A
Genetic Testing for Neurofibromatosis Type 1 or 2

New policy addressing genetic testing for neurofibromatosis.

Effective Date: October 1, 2019

Genetic Testing, Policy No. 84 No change to preauth edit for CPT codes 81405, 81406, and 81408. Added this policy to the preauth website for CPT codes 81405, 81406, and 81408
Measurement of Serum Antibodies to Infliximab, Adalimumab, Ustekinumab, and Vedolizumab

Policy title changed.

Added measurement of anti-drug antibodies to ustekinumab and vedolizumab to policy.

Effective Date: October 1, 2019

Laboratory, Policy No. 65 N/A N/A
New and Emerging Medical Technologies and Procedures

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

Effective Date: October 1, 2019

Medicine, Policy No. 149 Added investigational edit to the following new CPT code which is effective 10/1/2019: 0117U N/A
Gender Affirming Interventions for Gender Dysphoria

No medical policy changes.

Effective Date: October 1, 2019

Medicine, Policy No. 153 Code change only to add preauth to codes 57291, 57292, 57295, 57296, 57426. Add codes 57291, 57292, 57295, 57296, 57426 to the preauth list.
Gastroesophageal Reflux Surgery

Reformatted criteria for readability. Clarified medication trial criteria.

Effective Date: October 1, 2019

Surgery, Policy No. 186 N/A N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Removed Idaho Department of Health and Welfare Habilitative Interventionist certifications requirements, as they are no longer issued.

Effective Date: September 1, 2019

Behavioral Health, Policy No. 18 N/A N/A
BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy

Clarified criteria to refer to BRAF testing as opposed to specific BRAF variant testing.

Effective Date: September 1, 2019

Genetic Testing, Policy No. 41 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Changed criteria to consider testing to be medically necessary for select patients with 1-3 positive lymph nodes.

Effective Date: September 1, 2019

Genetic Testing, Policy No. 42 N/A N/A
Evaluating the Utility of Genetic Panels

Added one new investigational panel and removed 13 panels.

Effective Date: September 1, 2019

Genetic Testing, Policy No. 64 Remove preauth on CPT code 81442. Remove CPT code 81442 from the preauth list.
Allergy and Sensitivity Tests of Uncertain Efficacy

Title changed.

Clarified the investigational statement for IgA food panel testing.

Effective Date: September 1, 2019

Laboratory, Policy No. 01 N/A N/A
Ventral Hernia Repair

Notification based on changes to coding/implementation and Preauth change. See the last two columns.

Effective Date: September 1, 2019

Surgery, Policy No. 12.03 Added preauth to code 15734 required only with diagnosis code K43.2 and K43.9 for Component Separation Technique (CST). Add preauth to code 49652 required only with diagnosis code K43.9 for ventral hernia. Added code 15734 with note for this code preauth required only with diagnosis code K43.2 and K43.9 for component Separation Technique (CST). Add code 49652 with note for this code preauth required only with diagnosis code K43.9 for ventral hernia.
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Removed preauthorization requirement for initial ABA assessments.

Effective Date: August 1, 2019

Behavioral Health, Policy No. 18 N/A N/A
Applied Behavior Analysis Initial Assessment for the Treatment of Autism Spectrum Disorder

New policy applies to FEP for initial ABA assessments.

Effective Date: August 1, 2019

Behavioral Health, Policy No. 33 N/A N/A
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)

Policy title changed.

Moved criteria note into the scope of policy to state that transarterial embolization (TAE), and transarterial chemoembolization (TACE) are considered medically necessary.

No change to radioembolization criteria.

Effective Date: August 1, 2019

Medicine, Policy No. 140 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid

One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.

Added new medically necessary indications for thyroid cancer and lymphomas.

Effective Date: August 1, 2019

Medicine, Policy No. 164 Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list.
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, and Pelvis

One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.

Added new medically necessary indications for gastroesophageal junction cancers, pancreatic cancer, and prostate cancer.

Clarified "significant pulmonary function impairment."

Effective Date: August 1, 2019

Medicine, Policy No. 165 Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list.
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer

One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.

Effective Date: August 1, 2019

Medicine, Policy No. 166 Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list.
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk

One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.

Effective Date: August 1, 2019

Medicine, Policy No. 167 Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list.
Rhinoplasty

Revised symptomatic nasal airway obstruction by including "bony" under that criterion element.

Effective Date: August 1, 2019

Surgery, Policy No. 12.28 N/A N/A
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

Added breast revision surgery following a cosmetic procedure.

Effective Date: August 1, 2019

Surgery, Policy No. 40 N/A N/A
Balloon Ostial Dilation for Treatment of Sinusitis

Added coverage for balloon sinuplasty for the treatment of acute and chronic sinusitis when policy criteria are met.

Effective Date: August 1, 2019

Surgery, Policy No. 153 Removed investigational denial and liberalize by adding preauthorization requirement to CPT codes 31295, 31296, 31297, and 31298. Continue to review unlisted code 31299. Added CPT codes 31295, 31296, 31297, and 31298 to the preauth list for this policy.
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

Policy title changed.

Reformatted the policy.

Removed hypoglossal nerve stimulation, which is now addressed in its own policy, Surgery, Policy No. 215.

Effective Date: August 1, 2019

Surgery, Policy No. 166 Removed CPT codes 0466T, 0467T, 0468T, 64568 from this medical policy and move to new medical policy SUR215. Removed CPT codes 0466T, 64568 from the preauth list for this policy and move to new medical policy SUR215.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

One of two new policies replacing Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, Surgery, Policy No. 16.

Added medical necessity criteria for essential tremor.

Effective Date: August 1, 2019

Surgery, Policy No. 213 Continued the preauthorization requirement on CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340. Added this policy and CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340 to the preauth list.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

One of two new policies replacing Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, Surgery, Policy No. 16.

Effective Date: August 1, 2019

Surgery, Policy No. 214 Continued the preauthorization requirement on CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340. Added this policy and CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340 to the preauth list.
Hypoglossal Nerve Stimulation

New policy developed for hypoglossal nerve stimulation. Using the current criteria (from SUR166) for adults. New criteria to allow pediatric use when criteria are met.

Effective Date: August 1, 2019

Surgery, Policy No. 215 Continue preauthorization requirement on CPT codes 0466T, 64568 for this new medical policy. Add this policy and CPT codes 0466T, 64568 to the preauth list.
Hematopoietic Cell Transplantation for Autoimmune Diseases

Added medically necessary criteria for autologous Hematopoietic Cell Transplantation for systemic sclerosis/scleroderma.

Effective Date: August 1, 2019

Transplant, Policy No. 45.32 N/A N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Policy updated. Please see the 4/1/2019 Provider Newsletter for the implementation plan around this update.

Effective Date: July 1, 2019

Behavioral Health, Policy No. 18 Add PreAuth for codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 Policy added to the Preauth website.
Chromosomal Microarray Analysis (CMA) for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies

Title changed.

Added testing of adults for the same indications as testing of pediatric patients to the medical necessity criteria.

Effective Date: July 1, 2019

Genetic Testing, Policy No. 58 N/A Policy title updated on the preauth list.
Evaluating the Utility of Genetic Panels

Added 13 new investigational panels and removed four panels.

Effective Date: July 1, 2019

Genetic Testing, Policy No. 64 N/A N/A
Laboratory Tests for Heart and Kidney Transplant Rejection

Title changed.

Added donor-derived cell-free DNA testing for kidney transplant to policy.

Effective Date: July 1, 2019

Laboratory, Policy No. 51 New codes that are effective 7/1/2019 added to the policy - 0087U and 0088U. N/A
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies in accordance with the 3rd quarter code update.

Moved codes related to phrenic nerve stimulation for central sleep apnea to new medical policy Surgery, Policy No. 212.

Effective Date: July 1, 2019

Medicine, Policy No. 149

New codes that are effective 7/1/2019 added to the policy - 0543T, 0544T, 0545T, 0547T, 0548T, 0549T, 0550T, 0551T, 0553T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T, 0560T, 0561T, 0562T.
Deleted code that was effective 7/1/2019 from the policy – C9746.

Moved codes to the new investigational policy Surgery 212 - 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T.
N/A
Gender Affirming Interventions for Gender Dysphoria

Updated title, description, and format of criteria.

Added new criteria for endometrial ablation.

Effective Date: July 1, 2019

Medicine, Policy No. 153 Add preauth to codes 17999, 19316, 19318, 19324, 19325, 19350, L8600, 58353, 58356, 58563 for this medical policy. Update preauth list in alignment with policy changes. Add codes 17999, 19316, 19318, 19324, 19325, 19350, L8600, 58353, 58356, 58563 to the preauth list for this medical policy.
Spinal Cord and Dorsal Root Ganglion Stimulation

Added coverage for dorsal root ganglion stimulation when criteria are met.

Effective Date: July 1, 2019

Surgery, Policy No. 45 N/A N/A
Varicose Vein Treatment

Added criteria for use of endovenous glue/adhesives for the treatment of varicose veins.

Effective Date: July 1, 2019

Surgery, Policy No. 104 N/A N/A
Phrenic Nerve Stimulation for Central Sleep Apnea

New investigational policy addressing phrenic nerve stimulation for central sleep apnea.

Effective Date: July 1, 2019

Surgery, Policy No. 212 Add CPT codes 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T and continue investigational denial, and add HCPCS code C1823 with preauth to this new medical policy. Add new policy to the preauth list for code C1823.
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Merged criteria for reduced intensity conditioning (RIC) and myeloablative regimens. Added a criterion that states a myeloablative transplant after RIC is considered investigational.

Effective Date: July 1, 2019

Transplant, Policy No. 45.24 N/A N/A
Hematopoietic Cell Transplantation for Hodgkin Lymphoma

Policy criteria statements updated, specifically with regard to reduced-intensity conditioning, a second allogeneic hematopoietic cell transplant (HCT), and tandem HCT.

Effective Date: July 1, 2019

Transplant, Policy No. 45.30 N/A N/A
Programmable Pneumatic Compression Pumps

Added criteria for coverage of single- or multi-chamber programmable pumps.

Effective Date: June 1, 2019

Durable Medical Equipment, Policy No. 78 Liberalized edit on code E0652 from always denying as not medically necessary to now requiring preauth Added code E0652 to the preauth list for this policy.
Genetic Testing for Alzheimer's Disease

Notification based on changes to coding/implementation and Preauth change. See the last two columns.

Effective Date: June 1, 2019

Genetic Testing, Policy No. 01 Remove preauth from code 88363. Remove code 88363 from the preauth list.
Genetic Testing for Inherited Susceptibility to Colon Cancer

Notification based on changes to coding/implementation and Preauth change. See the last two columns.

Effective Date: June 1, 2019

Genetic Testing, Policy No. 06 Remove preauth from code 88363. Remove code 88363 from the preauth list.
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer

Notification based on changes to coding/implementation and Preauth change. See the last two columns.

Effective Date: June 1, 2019

Genetic Testing, Policy No. 13 Remove preauth from code 88363. Remove code 88363 from the preauth list.
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)

Added KRAS and NTRK gene fusion testing to medical necessity criteria.

Effective Date: June 1, 2019

Genetic Testing, Policy No. 56 Remove preauth from code 88363. Remove code 88363 from the preauth list.
Vagus Nerve Stimulation

Changed number of required antiepileptic drugs in criteria from 4 to 2.

Effective Date: June 1, 2019

Surgery, Policy No. 74 N/A N/A
The following is a list of recently archived policies:
Hematopoietic Cell Transplantation Index Archive Effective Date: November 1, 2019 Transplant, Policy No. 45
Electromagnetic Navigation Bronchoscopy Archive Effective Date: October 1, 2019 Surgery, Policy No. 179
Electrical Stimulation Devices Index Archive Effective Date: September 1, 2019 Durable Medical Equipment, Policy No. 83

Intensity Modulated Radiotherapy (IMRT) of the Thorax

NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies.

Archive Effective Date: August 1, 2019 Medicine, Policy No. 136

Intensity Modulated Radiotherapy (IMRT) of the Prostate

NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies.

Archive Effective Date: August 1, 2019 Medicine, Policy No. 137

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

NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies.

Archive Effective Date: August 1, 2019 Medicine, Policy No. 138

Intensity Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies.

Archive Effective Date: August 1, 2019 Medicine, Policy No. 139

Intensity Modulated Radiotherapy (IMRT) for Central Nervous System (CNS) Tumors

NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies.

Archive Effective Date: August 1, 2019 Medicine, Policy No. 147

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

NOTE: Archived policy replaced by criteria in one of the two new Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy policies.

Archive Effective Date: August 1, 2019 Surgery, Policy No. 16