Regence
Medical Policy Update, July 1, 2014 |
|
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 |
|
| Administrative Guidelines to Determine Dental vs Medical Services |
New administrative policy which has been moved from the Dental policy manual to the Medical policy manual. No change to the criteria.
Effective Date: February 1, 2014 |
Allied Health, Policy No. 35 |
| Functional Neuromuscular Electrical Stimulation |
Clarification added to the investigational criteria regarding congenital disorders.
Effective Date: February 1, 2014 |
Durable Medical Equipment, Policy No. 83.04 |
| Genetic Testing for Hereditary Breast and/or Ovarian Cancer |
Modified medical necessity criteria based on NCCN guideline updates. Addition of BART testing to criteria for clarification purposes.
Effective Date: February 1, 2014 |
Genetic Testing, Policy No. 02 |
| Genetic Testing for Inherited Susceptibility to Colon Cancer |
Added new criterion for BRAF V600E or MLH1 promoter methylation and clarification to EPCAM testing criteria.
Effective Date: February 1, 2014 |
Genetic Testing, Policy No. 06 |
| Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) |
Addition of drug afatinib (GILOTRIF™) to medical necessity criteria.
Effective Date: February 1, 2014 |
Genetic Testing, Policy No. 56 |
| Evaluating the Utility of Genetic Panels |
Addition of new panel test YouScript® personalized prescribing system.
Effective Date: February 1, 2014 |
Genetic Testing, Policy No. 64 |
| New and Emerging Medical Technologies and Procedures |
New investigational procedures added to the policy.
Effective Date: February 1, 2014 |
Medicine, Policy No. 149 |
| Computed Tomography (CT) Perfusion Imaging of the Brain |
Added clarification that policy criteria are specific to the brain.
Effective Date: February 1, 2014 |
Radiology, Policy No. 54 |
| Microwave Tumor Ablation |
New policy.
Effective Date: February 1, 2014 |
Surgery, Policy No. 189 |
| Electrical Bone Growth Stimulators (Osteogenic Stimulation) |
Failed joint fusion following arthrodesis changed from medically necessary to investigational.
Effective Date: March 1, 2014 |
Durable Medical Equipment, Policy No. 83.11 |
| Genetic Testing for Inherited Susceptibility to Colon Cancer |
Removed criteria regarding gene testing in patients with a diagnosis of classical FAP.
Effective Date: March 1, 2014 |
Genetic Testing, Policy No. 06 |
| Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA |
Revised criteria to address additional aneuploidies, fetal sex determination, and microdeletion syndromes.
Effective Date: March 1, 2014 |
Genetic Testing, Policy No. 44 |
| Evaluating the Utility of Genetic Panels |
Added new investigational panels.
Effective Date: March 1, 2014 |
Genetic Testing, Policy No. 64 |
| Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture (AmniSure® and ROM Plus® Tests) |
Clarified that investigational criterion applies to all placental rapid immunoassays.
Effective Date: March 1, 2014 |
Laboratory, Policy No. 57 |
| Cochlear Implant |
Added clarification regarding repeat hearing tests and trials of hearing aids.
Effective Date: March 1, 2014 |
Surgery, Policy No. 08 |
| Ventricular Assist Devices and Total Artificial Hearts |
Clarified that total artificial heart criteria include patients being evaluated for candidacy for heart transplant.
Effective Date: March 1, 2014 |
Surgery, Policy No. 52 |
| Percutaneous Vertebroplasty and Kyphoplasty |
Medical necessity status of vertebroplasty changed to investigational.
Effective Date: March 1, 2014 |
Surgery, Policy No. 107 |
| Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction |
Reduced minimum test stimulation trial period 1 week. Added criteria clarifications.
Effective Date: March 1, 2014 |
Surgery, Policy No. 134 |
| Orthognathic Surgery |
For required documentation, added written report of radiographs when available.
Effective Date: March 1, 2014 |
Surgery, Policy No. 137 |
| Aqueous Shunts and Stents for Glaucoma |
Criteria changed to consider the iStent Micro-Bypass medically necessary when criteria are met.
Effective Date: March 1, 2014 |
Surgery, Policy No. 164 |
| Saturation Biopsy for Diagnosis and Staging of Prostate Cancer |
Clarified criteria regarding the number of biopsies which constitute saturation biopsy.
Effective Date: March 1, 2014 |
Surgery, Policy No. 170 |
| Gastric Reflux Surgery |
Added clarification that medical necessity criteria apply to initial and repeat fundoplasty. Added criteria regarding fundoplasty performed in conjunction with paraesophageal hiatal hernia repair or esophageal myotomy.
Effective Date: March 1, 2014 |
Surgery, Policy No. 186 |
| Evaluating the Utility of Genetic Panels |
Deleted Panorama prenatal panel (Natera).
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 64 |
| Genetic Testing for Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia |
New investigational policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 65 |
| Genetic Testing for Lactase Insufficiency |
New investigational policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 67 |
| Genetic Testing for Rett Syndrome |
New policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 68 |
| Genetic Testing for Duchenne and Becker Muscular Dystrophy |
New policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 69 |
| Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification |
New investigational policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 70 |
| Microarray-based Gene Expression Analysis for Prostate Cancer |
New investigational policy.
Effective Date: April 1, 2014 |
Genetic Testing, Policy No. 71 |
| New and Emerging Medical Technologies and Procedures |
New investigational procedures added to the policy.
Effective Date: April 1, 2014 |
Medicine, Policy No. 149 |
| Spinal Cord Stimulation for Treatment of Pain |
Added cancer-related pain to list of investigational indications.
Effective Date: April 1, 2014 |
Surgery, Policy No. 45 |
| Gastric Electrical Stimulation |
Revised criteria related to nutritional status.
Effective Date: April 1, 2014 |
Surgery, Policy No. 111 |
| Surgeries for Snoring and Obstructive Sleep Apnea Syndrome in Adults |
Added clarification that policy applies to adult patients.
Effective Date: April 1, 2014 |
Surgery, Policy No. 166 |
| Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) |
New investigational policy.
Effective Date: April 1, 2014 |
Surgery, Policy No. 190 |
| Genetic Testing for Familial Alzheimer's Disease |
Added TREM2 gene to investigational list.
Effective Date: May 1, 2014 |
Genetic Testing, Policy No. 01 |
| Evaluating the Utility of Genetic Panels |
Added new panel tests to policy.
Effective Date: May 1, 2014 |
Genetic Testing, Policy No. 64 |
| Vitamin D Testing |
Medical necessity criteria clarified and policy appendices updated to include additional covered indications.
Effective Date: May 1, 2014 |
Laboratory, Policy No. 52 |
| Gastric Reflux Surgery |
Criteria added regarding fundoplication in patients with pulmonary fibrosis.
Effective Date: May 1, 2014 |
Surgery, Policy No. 186 |
| Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer |
Added new investigational criteria to policy.
Effective Date: June 1, 2014 |
Genetic Testing, Policy No. 42 |
| Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Esophagus, Small Bowel, and Colon |
Criteria clarified regarding capsule endoscopy in patients with ulcerative colitis and acute upper GI bleeding.
Effective Date: June 1, 2014 |
Radiology, Policy No. 38 |
| Percutaneous Vertebroplasty and Kyphoplasty |
Added medical necessity criteria for vertebroplasty. Added vertebral body stenting to list of investigational techniques.
Effective Date: June 1, 2014 |
Surgery, Policy No. 107 |
| Surgical Treatments for Hyperhidrosis |
Added radiofrequency ablation for palmar hyperhidrosis as investigational.
Effective Date: June 1, 2014 |
Surgery, Policy No. 165 |
| Lumbar Spinal Fusion |
Added investigational criterion for staged fusion.
Effective Date: June 1, 2014 |
Surgery, Policy No. 187 |
| Heart Transplant |
Added medical necessity criterion on retransplantation.
Effective Date: June 1, 2014 |
Transplant, Policy No. 02 |
| Heart/Lung Transplant |
Added medical necessity criterion for retransplantation.
Effective Date: June 1, 2014 |
Transplant, Policy No. 03 |
| Lung and Lobar Lung Transplant |
Added medical necessity criterion on retransplantation.
Effective Date: June 1, 2014 |
Transplant, Policy No. 08 |
| Small Bowel/Liver and Multivisceral Transplant |
Added medical necessity criteria for retransplantation.
Effective Date: June 1, 2014 |
Transplant, Policy No. 18 |
| Biofeedback |
Removed reference to dyssynergia-type constipation in children.
Effective Date: July 1, 2014 |
Allied Health, Policy No. 32 |
| Tumor-Treatment Fields Therapy for Glioblastoma |
New investigational policy.
Effective Date: July 1, 2014 |
Durable Medical Equipment, Policy No. 85 |
| Cytochrome p450 Genotyping |
Added investigational criterion for dosing of anti-tuberculosis medications.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 10 |
| Preimplantation Genetic Testing |
Clarification of medically necessary criteria.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 18 |
| BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia |
Added policy criteria for acute lymphoblastic leukemia.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 27 |
| Genetic Testing, including Chromosomal Microarray Analysis (CMA) and Next Generation Sequencing Panels, for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum Disorders |
Added medical neccesity criteria, investigational criteria, and a not medically necessary criterion that addresses CMA testing in children and for prenatal indications.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 58 |
| Evaluating the Utility of Genetic Panels |
Added new investigational panels.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 64 |
| Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies |
New investigational policy.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 66 |
| Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy |
New genetic testing policy for hypertrophic cardiomyopathy.
Effective Date: July 1, 2014 |
Genetic Testing, Policy No. 72 |
| Measurement of Serum Antibodies to Infliximab and Adalimumab |
Added adalimumab antibody testing as investigational.
Effective Date: July 1, 2014 |
Laboratory, Policy No. 65 |
| Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting |
Added left atrial pressure monitoring as investigational.
Effective Date: July 1, 2014 |
Medicine, Policy No. 33 |
| New and Emerging Medical Technologies and Procedures |
Added new investigational procedures: (0347T-0354T, 0356T, 0358T)
Effective Date: July 1, 2014 |
Medicine, Policy No. 149 |
| Implantable Cardioverter Defibrillator |
Added criterion for patients with LMNA gene mutations. Added clarifications: 1) secondary prevention criterion applies after exclusion of reversible causes of patient's condition; 2) policy addresses only initial device implantation.
Effective Date: July 1, 2014 |
Surgery, Policy No. 17 |
| Bariatric Surgery |
Criteria clarified regarding reoperation in cases of band migration or slippage.
Effective Date: July 1, 2014 |
Surgery, Policy No. 58 |
| Liver Transplant |
Criteria clarified for patients with polcyctic disease of the liver.
Effective Date: July 1, 2014 |
Transplant, Policy No. 05 |
| New and Emerging Medical Technologies and Procedures |
New investigational procedures added to the policy.
Effective Date: September 1, 2014 |
Medicine, Policy No. 149 |
| The following
is a list of recently archived policies: |
| Occupational Therapy (OT) |
Archive Effective Date:
February 1, 2014 |
Utilization Mangaement, Policy No. 04 |
| Physical Therapy (PT) |
Archive Effective Date:
February 1, 2014 |
Utilization Mangaement, Policy No. 06 |
| Speech Therapy (ST) |
Archive Effective Date:
February 1, 2014 |
Utilization Mangaement, Policy No. 09 |
| Home Uterine Activity Monitoring (HUAM) |
Archive Effective Date:
May 1, 2014 |
Maternity, Policy No. 04 |
| Sublingual Immunotherapy as a Technique of Allergen Specific Thearpy |
Archive Effective Date:
May 6, 2014 |
Medicine, Policy No. 121 |
