Recent Updates to the Regence Group Medical Policy Manual

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Regence Medical Policy Update, May 1, 2020
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*
Identification of Microorganisms Using Nucleic Acid Probes	Added Gardnerella vaginalis testing as investigational. Effective Date: August 1, 2020	Genetic Testing, Policy No. 85	Adding investigational denial to CPT codes 87510 and 87511	N/A
New and Emerging Medical Technologies and Procedures	Added CPT code 0465T as always investigational. Effective Date: August 1, 2020	Medicine, Policy No. 149	Adding investigational denial to CPT code 0465T	N/A
Intensity Modulated Radiotherapy (IMRT) of the THorax, Abdomen, Pelvis, and Extremities	Changing policy title. Adding criteria for review of soft tissue sarcomas. Effective Date: June 1, 2020	Medicine, Policy No. 165	N/A	Updating title on preauth website.
Evaluating the Utility of Genetic Panels	Removed four panels from policy. Effective Date: May 1, 2020	Genetic Testing, Policy No. 64	N/A	N/A
Identification of Microorganisms Using Nucleic Acid Probes	Removed Chlamydophila pneumonia from investigational criterion. Removed nucleic acid gastrointestinal pathogen panels from policy. Effective Date: May 1, 2020	Genetic Testing, Policy No. 85	Changed CPT codes 87485 and 87486 from investigational to medically necessary.	N/A
New and Emerging Medical Technologies and Procedures	Added suction-assisted protein lipectomy to existing CPT code 38999 for this policy. Effective Date: May 1, 2020	Medicine, Policy No. 149	N/A	N/A
Surgical Treatments for Hyperhidrosis	Clarified primary craniofacial hyperhidrosis from secondary gustatory hyperhidrosis and removed “secondary fungal or bacterial infection” from recurrent skin maceration as a medical complication supporting surgical treatment. Added a coding note that procedure codes 11450 and 11451 should not be reported for hyperhidrosis. Effective Date: May 1, 2020	Surgery, Policy No. 165	Updated systems to override the preauth requirement on code 32664 unless one of these hyperhidrosis diagnoses is found on the claim: L74.510, L74.511, L74.512, L74.513, L74.519, L74.52, and R61	Updated the preauth page to read: Code 32664 only requires preauthorization for hyperhidrosis diagnoses L74.510, L74.511, L74.512, L74.513, L74.519, L74.52, and R61
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	Changed criteria to consider autologous transplant investigational in pediatric patients. Effective Date: May 1, 2020	Transplant, Policy No. 45.36	N/A	N/A
Insulin Infusion Pumps, Automated Insulin Deliver and Artificial Pancreas Device Systems	Changed policy title. Clarified the device terminology. Removed the requirement for the member to experience at least two nocturnal hypoglycemic events prior to considering an artificial pancreas device system as medically necessary. Effective Date: April 1, 2020	Durable Medical Equipment, Policy No. 77	N/A	Updated the policy title on the Preauth website.
Evaluating the Utility of Genetic Panels	Added 17 new investigational panels. Removed 15 panels. Effective Date: April 1, 2020	Genetic Testing, Policy No. 64	Add new CPT codes 0170U and 0171U with investigational denial.	N/A
Whole Exome and Whole Genome Sequencing	Whole exome sequencing may now be considered medically necessary for pediatric patients when policy criteria are met. Effective Date: April 1, 2020	Genetic Testing, Policy No. 76	Add preauth requirement to CPT codes 81415 and 81416 for this policy.	Add codes 81415 and 81416 to the preauth site for this medical policy.
Myocardial Strain Imaging	New investigational policy. Effective Date: April 1, 2020	Medicine, Policy No. 168	Added new CPT code 93356 with investigational denial edit.	N/A
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction	Change a subset of indications from investigational to not medically necessary. Effective Date: April 1, 2020	Surgery, Policy No. 134	N/A	N/A
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome	Added criteria for testing to confirm BRCA variants found through direct-to-consumer testing and BRIP1, RAD51C, and RAD51D testing for hereditary ovarian cancer risk. Effective Date: March 1, 2020	Genetic Testing, Policy No. 02	N/A	Updating title on preauth website.
Femoroacetabular Impingement Surgery	Removed criteria requiring no evidence of severe chondral damage. Removed criteria requiring documentation of activity modification to avoid symptoms. Effective Date: March 1, 2020	Surgery, Policy No. 160	N/A	N/A
Microwave Tumor Ablation	Added medical necessity criteria for microwave tumor ablation for some lung tumors. Effective Date: March 1, 2020	Surgery, Policy No. 189	N/A	N/A
Ablation of Primary and Metastatic Liver Tumors	Removed criteria requiring goal of treatment to be curative. Effective Date: March 1, 2020	Surgery, Policy No. 204	N/A	N/A
Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies	Changed policy title. Added copy number variation testing to policy. Effective Date: January 1, 2020	Genetic Testing, Policy No. 58	New CPT code 0156U added to the policy with preauth required.	Changed policy title and added code 0156U on the preauth website for this policy.
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)	Removed reference to non-squamous cell-type cancer from EGFR testing. Effective Date: January 1, 2020	Genetic Testing, Policy No. 56	N/A	N/A
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR	Changed policy title. Added MTHFR testing for thrombophilia to policy. Effective Date: January 1, 2020	Genetic Testing, Policy No. 65	N/A	Changed policy title on the preauth website for this policy.
Identification of Microorganisms Using Nucleic Acid Probes	Added semi-quantitative testing to policy. Effective Date: January 1, 2020	Genetic Testing, Policy No. 85	New CPT code 0151U added to the policy with investigational denial.	N/A
Urine Drug Testing for Substance Use and Pain Management	Updated policy to reflect that the rolling calendar year limit is based on the first date that a claim for the service is received and not on the actual date of service. Effective Date: January 1, 2020	Laboratory, Policy No. 68	Added new CPT codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, and 0150U to the policy with a not medically necessary denial edit.	N/A
New and Emerging Medical Technologies and Procedures	In accordance with the 2020 1st quarter code updates: Added new investigational medical technologies Removed deleted codes Effective Date: January 1, 2020	Medicine, Policy No. 149	Added new CPT codes 0139U, 0563T, 0567T, 0568T, 0569T, 0570T, 0582T, C1824, and C2596 with investigational denial edits to this policy. Removed deleted CPT codes 0205T , 0249T, 0341T, 0377T from this policy. NOTE: see entry for new policy SUR219 that address the replacement code 46948 (replaces 0249T).	N/A
Gender Affirming Interventions for Gender Dysphoria	Removed the requirement for 12 months of continuous hormone therapy prior to breast augmentation. Updated criteria to remove psychotherapy and hormone therapy, which are either medically necessary or if the member’s coverage includes a pharmacy benefit, it may have a Pharmacy review requirement. Effective Date: January 1, 2020	Medicine, Policy No. 153	Added CPT 67950 to this policy and continue preauth requirement. Added unlisted CPT codes 19499, 31899, and 40799 to this policy and continue to review these unlisted codes. Removed deleted CPT code 19304 from the policy.	Added CPT 67950 on the preauth website for this policy.
Implantable Cardioverter Defibrillator	Added extravascular (substernal) ICDs to policy. Effective Date: January 1, 2020	Surgery, Policy No. 17	Added new CPT codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T with investigational denial edit to this policy.	N/A
Bariatric Surgery	Reorganized criteria with no change to criteria intent. Effective Date: January 1, 2020	Surgery, Policy No. 58	Added CPT code 43820 with preauth requirement to this policy.	Added CPT code 43820 to the preauth website for this policy.
Percutaneous Angioplasty and Stenting of Veins	Removed age requirement from pulmonary artery stenosis criterion. Added symptomatic venous occlusion due to electrical device lead or central line placement to medically necessary indications. Effective Date: January 1, 2020	Surgery, Policy No. 109	N/A	N/A
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial	Added criteria to consider the WATCHMAN device medically necessary for stroke prevention in patients who are at increased risk for stroke and have contraindications to long-term anticoagulation therapy. Effective Date: January 1, 2020	Surgery, Policy No. 195	Removed investigational denial on code 33340 and added preauth requirement.	Added CPT code 33340 to the preauth website for this policy.
Transanal Hemorrhoidal Dearterialization	New investigational policy. Effective Date: January 1, 2020	Surgery, Policy No. 219	Added new CPT code 46948 with investigational denial for this policy.	N/A
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes	Added risk of Lynch syndrome based on prediction models to policy criteria. Effective Date: December 1, 2019	Genetic Testing, Policy No. 06	N/A	N/A
Evaluating the Utility of Genetic Panels	Added twenty-one new investigational panels to the policy. Removed three panels from the policy. Effective Date: December 1, 2019	Genetic Testing, Policy No. 64	N/A	N/A
The following is a list of recently archived policies:
Suprachoroidal Delivery of Pharmacological Agents		Archive Effective Date: May 1, 2020		Medicine, Policy No. 132
Programmable Pneumatic Compression Pumps		Archive Effective Date: February 1, 2020		Durable Medical Equipment, Policy No. 78
Tumor Treating Fields Therapy		Archive Effective Date: February 1, 2020		Durable Medical Equipment, Policy No. 85
Genetic Testing for Cardiac Ion Channelopathies		Archive Effective Date: February 1, 2020		Genetic Testing, Policy No. 07
Genetic Testing for Inherited Thrombophilia		Archive Effective Date: February 1, 2020		Genetic Testing, Policy No. 47
Genetic Testing for Hereditary Hemochromatosis		Archive Effective Date: February 1, 2020		Genetic Testing, Policy No. 48
Single Photon Emission Computed Tomography (SPECT) of the Brain		Archive Effective Date: January 1, 2020		Radiology, Policy No. 44
Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT)		Archive Effective Date: January 1, 2020		Radiology, Policy No. 57


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.