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Medical Policy
Regence Medical Policy Update, May 1, 2022
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

Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, and Twin Zygosity Using Cell-Free DNA

Policy title changed from Noninvasive Prenatal Testing to Determine Fetal Aneuploidies and Microdeletions Using Cell-Free DNA.

Twin zygosity testing using cell free DNA has been added to the policy as investigational.

Effective Date: August 1, 2022

Genetic Testing, Policy No. 44

Add CPT code 0060U with investigational denial

N/A
Occipital Nerve Stimulation

There was no change to the medical policy. The change being made is to the edits on the codes in the policy.

Effective Date: August 1, 2022

Surgery, Policy No. 174 Term preauthorization and add investigational denial on CPT codes 64555, 64575. Remove CPT codes 64555, 64575 from the preauth website for this policy.
Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation

There was no change to the medical policy. The change being made is to the edits on the codes in the policy.

Effective Date: August 1, 2022

Surgery, Policy No. 205 Term preauthorization and add investigational denial on CPT codes 64555, 64575. Remove CPT codes 64555, 64575 from the preauth website for this policy.
Eating Disorder Inpatient Treatment

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 25 N/A N/A
Eating Disorder Intensive Outpatient

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 26 N/A N/A
Eating Disorder Partial Hospitalization

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 27 N/A N/A
Eating Disorder Residential Treatment

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 28 N/A N/A
Psychiatric Inpatient Hospitalization

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 29 N/A N/A
Psychiatric Intensive Outpatient

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 30 N/A N/A
Psychiatric Partial Hospitalization

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 31 N/A N/A
Psychiatric Residential Treatment

Added intensity of service criteria.

Effective Date: July 1, 2022

Behavioral Health, Policy No. 32 N/A N/A
Investigational Gene Expression and Multianalyte Testing

Added the TissueCypher Barrett's esophagus test to the policy.

Effective Date: July 1, 2022

Laboratory, Policy No. 77 Adding CPT code 0108U with investigational denial. N/A
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

New medical policy. Wireless capsule endoscopy of the small bowel may be considered medically necessary when Policy Criteria are met. Wireless capsule endoscopy is considered investigational when Policy Criteria are not met. The patency capsule and magnetic capsule endoscopy are considered investigational for all indications.

Effective Date: June 1, 2022

Radiology, Policy No. 38 Add CPT codes 0651T, 91110, 91111, 91113 with preauth, and add CPT code 91299 with no change to unlisted code review for this policy. Add this policy to the preauth website for CPT codes 0651T, 91110, 91111, 91113.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

Added medical necessity criteria for genetic testing to diagnose peripheral neuropathies when a patient has signs/symptoms and a clinical diagnosis cannot be made, or when a genetic diagnosis is needed for reproductive decision-making.

Effective Date: May 1, 2022

Genetic Testing, Policy No. 66 Change edits on CPT codes 81324, 81325, 81326, 81448 to term investigational denial and add preauth with this update.

Add CPT codes 81324, 81325, 81326, 81448 to the preauth website for this policy.

NOTE: CPT codes 81324, 81325, 81326 are also part of GT20 and GT64 so these codes will be added to both of these policies on the preauth website effective 5/1/2022.
Maternal Serum Analysis for Risk of Adverse Obstetric Outcomes

Policy title changed from Maternal Serum Analysis for Risk of Preterm Birth.

Added maternal serum analysis for predicting risk of preeclampsia (no claims received to date) to the investigational criterion.

Effective Date: May 1, 2022

Laboratory, Policy No. 75 Added investigational denial edit to CPT code 0243U. N/A
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

Editing the criteria for autologous hematopoietic cell transplantation (HCT) to limit coverage to “minimal-residual disease-negative patients with no available donor or when haploidentical allogeneic HCT is not feasible.”

Effective Date: May 1, 2022

Transplant, Policy No. 45.36 N/A N/A
Dental and Orthodontic Treatment for Craniofacial Anomalies

Added the following coding note: In order for claims to be considered for the medical benefit, the medical procedure code 41899 (Unlisted procedure, dentoalveolar structures) may be used by dental providers.

Effective Date: April 1, 2022

Allied Health, Policy No. 33 N/A N/A
Negative Pressure Wound Therapy in the Outpatient Setting

New policy with criteria for negative pressure wound therapy. The policy will require an initial PA for a 1-month therapeutic trial and then after one month, another PA for continuation of three more months will be required demonstrating improvement in the wound.

Effective Date: April 1, 2022

Durable Medical Equipment, Policy No. 42

Adding CPT 97605, 97606,97607,97608, and HCPCS E2402 to this policy with preauth.

Adding HCPCS A6550, A7000, A7001, A9272, K0743, K0744, K0745, K0746 to this policy.
Adding CPT 97605, 97606,97607,97608, and HCPCS E2402 to the preauth website for this policy.
Evaluating the Utility of Genetic Panels

Added seven new investigational panels, removed 15 panels, and updated the name on four panels.

Effective Date: April 1, 2022

Genetic Testing, Policy No. 64

Delete CPT code 0271U and remove investigational denial.

Remove CPT codes 0006M and 0007M from this policy and move to LAB77 with no change to investigational denial.
N/A
Laboratory Tests for Organ Transplant Rejection

This policy now addresses gene expression testing using peripheral blood for risk of rejection for all organ transplants.

Effective Date: April 1, 2022

Laboratory, Policy No. 51 Add new Q2 CPT codes 0319U and 0320U with investigational denial. N/A
Investigational Gene Expression and Multianalyte Testing

Added eight investigational tests to the policy.

Effective Date: April 1, 2022

Laboratory, Policy No. 77

Add CPT codes 0063U and 0263U (previously in MED149) and 006M and 0007M (previously in GT64) to this policy with no change to investigational edits.

Add new Q2 CPT codes 0308U, 0309U, 0310U, 0312U, 0313U, 0315U, 0316U, 0322U, all with investigational denial.
N/A
New and Emerging Medical Technologies and Procedures

Removed 0063U and 0263U, which will be addressed by LAB77.

Updated the policy in alignment with the Q2 2022 quarterly code update to address new investigational medical technologies, represented by HCPCS codes C9781 and K1030.

Effective Date: April 1, 2022

Medicine, Policy No. 149

Remove CPT codes 0063U and 0263U from this policy and move to LAB77 with no change to investigational edit.

Add new Q2 HCPCS codes C9781, K1030 to this policy with investigational edit.
N/A
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Updated the policy criteria for visual field exams to clarify only points of vision not seen may be provided so long as they are clearly identified and include points on the central axis.

Effective Date: April 1, 2022

Surgery, Policy No. 12.05 N/A N/A
Ventricular Assist Devices and Total Artificial Hearts

The Criteria for destination therapy were updated to match the criteria for the MOMENTUM 3 clinical trial.

Effective Date: April 1, 2022

Surgery, Policy No. 52 N/A N/A
Bariatric Surgery

Adjustable gastric banding is now considered not medically necessary. Added specificity to the list of comorbidities in the policy.

Effective Date: April 1, 2022

Surgery, Policy No. 58 Removing preauth from CPT code 43770 and adding an investigational denial for this policy. Removing CPT code 43770 from the preauth website for this policy.
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

Clarified medical necessity criteria includes removal of an existing sacral nerve neuromodulation device.

Effective Date: April 1, 2022

Surgery, Policy No. 134 N/A N/A
New and Emerging Medical Technologies and Procedures

Removing CPT codes 0421T, 0468T and 0469T and HCPCS codes C2596. Added CPT codes 0691T, 0710T, 0711T, 0712T, 0713T.

Effective Date: March 13, 2022

Medicine, Policy No. 149 Add CPT codes 0691T, 0710T, 0711T, 0712T, 0713T with investigational edit.
Delete CPT codes 0648T, 0649T from this policy. Move CPT code 0421T and HCPCS code C2596 to SUR210 and keep the investigational edit.
N/A
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate

Medical policy had a title change: Previous title: Transurethral Water Vapor Thermal Therapy of the Prostate.

Added investigational criterion for transurethral waterjet ablation (aquablation) for the treatment of benign prostatic hyperplasia (previously addressed in Medical Policy MED149).

Effective Date: March 13, 2022

Surgery, Policy No. 210 Add CPT code 0421T and HPCPS code C2596 and keep the investigational edit on these codes for this policy. Update medical policy title on the preauth website.
Intensive In-Home Family Intervention

New policy for Intensive In-Home Family Intervention (IIFI), which only applies to IIFI services delivered by groups/practitioners the health plan has contracted specially to provide these services.

Effective Date: March 1, 2022

Behavioral Health, Policy No. 34 N/A – medical policy has no codes N/A
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

Clarified criteria regarding supplies and accessories.

Effective Date: March 1, 2022

Durable Medical Equipment, Policy No. 88 N/A N/A
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer

Removed references to specific drugs in medical necessity criteria for BRAF, KRAS, and NRAS testing.

Effective Date: March 1, 2022

Genetic Testing, Policy No. 13 N/A N/A
Genetic Testing for Primary Mitochondrial Disorders

New policy addressing genetic testing for primary mitochondrial disorders.

Effective Date: March 1, 2022

Genetic Testing, Policy No. 54 Add CPT codes 81401, 81403, 81404, 81405, 81406 and continue preauth requirement, and add CPT codes 81440, 81460, 81465 and term investigational denial and add preauth requirement for this policy. Add this new policy and CPT codes 81401, 81403, 81404, 81405, 81406, 81440, 81460, 81465 to the preauth website for this policy.
Evaluating the Utility of Genetic Panels

Added 15 new investigational panels and removed three panels.

Effective Date: March 1, 2022

Genetic Testing, Policy No. 64 N/A Adding codes 81440, 81460, 81465 to the preauth website for this policy for transparency, due to these codes remaining in this investigational policy while a preauth requirement is being added to these codes for new medical policy GT54.
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults

Revising to state the use of ECMO for cardiac or respiratory failure that does not meet medical necessity criteria will be considered not medically necessary; use of ECMO for other indications will remain investigational.

Effective Date: March 1, 2022

Medicine, Policy No. 152 N/A N/A
Radiofrequency Ablation (RFA) of Tumors Other than Liver

Added medically necessary criteria for symptomatic benign thyroid nodules.

Effective Date: March 1, 2022

Surgery, Policy No. 92 N/A N/A
Dental and Orthodontic Treatment for Craniofacial Anomalies

Adding medical necessity guidance for contracts in Washington, Idaho and Utah that provide orthodontic benefits for craniofacial anomalies.

Effective Date: February 1, 2022

Allied Health, Policy No. 33 N/A N/A
Neurofeedback

New medical policy states that neurofeedback is considered investigational for all indications.

Effective Date: February 1, 2022

Medicine, Policy No. 65 Adding codes 90875, 90876, and 90901 to this medical policy, but no clinical edits added to the codes. N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Removed investigational criterion for preliminary biopsy testing

Clarified that in rare situations it may be necessary to test biopsy samples after full pathologic evaluation of the tumor has been performed. Testing biopsy samples prior to full pathologic evaluation of the tumor does not meet medical necessity criteria.

Effective Date: January 1, 2022

Genetic Testing, Policy No. 42 N/A N/A
Evaluating the Utility of Genetic Panels Added 22 new investigational panels and removed 10 panels.

Effective Date: January 1, 2022

Genetic Testing, Policy No. 64 Adding new CPT code 81349 with preauth edit. Adding new CPT code 81349 with preauth edit to the preauth website.
Genetic Testing for Duchenne and Becker Muscular Dystrophy

Removed criteria related to reproductive carrier screening for these disorders, as this is now addressed specifically in Genetic Testing Policy, No. 81.

Effective Date: January 1, 2022

Genetic Testing, Policy No. 69 N/A N/A
Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities

Title changed. Previously: Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA)

Updated policy to include more general language related to testing for chromosome abnormalities.

Effective Date: January 1, 2022

Genetic Testing, Policy No. 78 Adding new CPT code 81349 with preauth edit for this policy. Adding new CPT code 81349 to the preauth website for this policy.
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss

Effective Date: January 1, 2022

Genetic Testing, Policy No. 79 Adding new CPT code 81349 with preauth edit for this policy. Adding new CPT code 81349 to the preauth website for this policy.
Reproductive Carrier Screening for Genetic Diseases

Added medically necessary criterion for the DMD gene for muscular dystrophy. Removed language related to “expanded” panels and replacing it with “non-targeted.” In addition, non-targeted carrier panel testing may be considered medically necessary when all genes/disorders in the panel meet medical necessity criteria, including a carrier frequency threshold of 1/200 based on ACMG recommendations.

Effective Date: January 1, 2022

Genetic Testing, Policy No. 81 Adding CPT code 81161 to this policy and continue preauth requirement. Adding CPT code 81161 on the preauth website for this policy.
Laboratory Tests for Organ Transplant Rejection

Title changed. Previously: Laboratory Tests for Heart, Kidney, and Lung Transplant Rejection

Added liver and small-bowel transplantation to the investigational criterion for the measurement of immune response of recipient lymphocytes to donor lymphocytes in cell culture to assess the likelihood of acute cellular rejection.

Effective Date: January 1, 2022

Laboratory, Policy No. 51 Add new CPT code 81560 with investigational denial for this policy. N/A
Investigational Gene Expression and Multianalyte Testing

New policy addresses investigational gene expression and multianalyte testing that is not addressed in other policies.

Effective Date: January 1, 2022

Laboratory, Policy No. 77

Adding new CPT codes 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U to this policy with investigational edits.

Adding CPT codes 0258U, 81479, 81599 with no change to existing edits.
N/A
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders

Added criterion requiring patient to be 18 or older, consistent with the Food and Drug Administration (FDA)-approved indications for relevant transcranial magnetic stimulation (TMS) devices

Effective Date: January 1, 2022

Medicine, Policy No. 148 N/A N/A
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the 2022 annual code update to address new investigational medical technologies and remove deleted codes.

Effective Date: January 1, 2022

Medicine, Policy No. 149

Remove 2021 deleted CPT codes 0356T, 0548T, 0549T, 0550T, 0551T, and deleted HCPCS codes C9752, C9753

Add new CPT codes 0672T, 0674T, 0675T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0686T, 0687T, 0688T, 0697T, 0698T, 0704T, 0705T, 0706T
N/A
Gender Affirming Interventions for Gender Dysphoria

Add criteria specific to member contracts subject to Washington’s Gender Affirming Treatment Act (SSB 5313). Removed list of procedures and change age requirements based on the Act, which states that a “health carrier may not deny or limit coverage for gender affirming treatment” when a request is for treatment(s) as prescribed by the treating provider because of, related to, or consistent with a person's gender expression or identity and is prescribed in accordance with accepted standards of care.

For member contracts subject to the Act, the policy criteria continue to require a gender dysphoria diagnosis and a recommendation of surgery by two mental health professionals and six months of both hormone therapy and living in a role that is congruent with the patient’s identity.

Updated language regarding breast/chest surgeries.

Effective Date: January 1, 2022

Medicine, Policy No. 153 Add CPT codes 54400, 54401, 54405 and HCPCS code C2622 to this policy with preauth. Add CPT codes 54400, 54401, 54405 and HCPCS code C2622 to the preauth website for this policy.
Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid

Added hippocampal-avoiding intensity-modulated radiotherapy for individuals with brain metastases as a medically necessary indication when criteria are met.

Effective Date: January 1, 2022

Medicine, Policy No. 164 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Added unresectable cervical cancer and vulvar and vaginal cancer as medically necessary indications.

Effective Date: January 1, 2022

Medicine, Policy No. 165 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer

Added accelerated partial breast irradiation as a medically necessary indication.

Effective Date: January 1, 2022

Medicine, Policy No. 166 N/A N/A
Skin Lesion Imaging and Spectroscopy

Added “fluorescent biotag imaging” to the policy which is investigational.

Effective Date: January 1, 2022

Medicine, Policy No. 174 Add new CPT codes 0700T, 0701T to this policy with investigational edit. N/A
Periurethral Transperineal Adjustable Balloon Continence Device

New policy addresses the use of a transperineally implanted periurethral volume-adjustable balloon device which continues to be considered investigational as a treatment for urinary incontinence.

Effective Date: January 1, 2022

Medicine, Policy No. 176 Add new CPT codes 53451, 53452, 53453, 53454 to this policy with investigational edit. N/A
Laser Interstitial Thermal Therapy

New policy stating laser interstitial thermal therapy (LITT) may be considered medically necessary for the treatment of refractory epilepsy when criteria are met and is considered investigational for all other neurological indications, including but not limited to treatment of primary or metastatic brain tumors or radiation necrosis.

Effective Date: January 1, 2022

Medicine, Policy No. 177

Add new CPT codes 61736, 61737 to this policy with preauth edit.

Add CPT code 64999 and continue existing edit.
Add new CPT codes 61736, 61737 to the preauth website for this policy.
Bariatric Surgery

Added coverage for biliopancreatic bypass with duodenal switch in adult patients with BMI ≥50.

Effective Date: January 1, 2022

Surgery, Policy No. 58 For CPT Code 43845 remove the pend edit and add preauth for this policy. Add CPT Code 43845 to the preauth website for this policy.
Percutaneous Angioplasty and Stenting of Veins

Added treatment of portal vein stenosis in a liver transplant recipient to the list of indications for percutaneous transluminal angioplasty, with or without stenting, that may be considered medically necessary.

Effective Date: January 1, 2022

Surgery, Policy No. 109 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

Added reirradiation of head and neck cancers as a medically necessary indication.

Effective Date: January 1, 2022

Surgery, Policy No. 213 Add CPT codes 77301, 77338 to this policy and keep the preauth edit. Add CPT codes 77301, 77338 to the preauth website for this policy.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Added reirradiation of head and neck cancers as a medically necessary indication.

Effective Date: January 1, 2022

Surgery, Policy No. 214 Add CPT codes 77301, 77338 to this policy and keep the preauth edit. Add CPT codes 77301, 77338 to the preauth website for this policy.
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve

New investigational medical policy addressing intraosseous radiofrequency ablation of the basivertebral nerve.

Effective Date: January 1, 2022

Surgery, Policy No. 225 Add new CPT codes 64628, 64629 to this policy with investigational edit. N/A
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

No notification for policy content, but for the code changes to this policy and the preauth website.

Effective Date: December 1, 2021

Medicine, Policy No. 100 Add CPT codes 38205, 38206, 38240, 38241 to this policy and continue preauth requirement for these codes. Add CPT codes 38205, 38206, 38240, 38241 to the preauth website for this policy.
Endometrial Ablation

Added other pelvic imaging as an option in addition to previously required hysteroscopy, sonohysterography, or pelvic ultrasound.

Effective Date: December 1, 2021

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

Updating the criteria to state component separation technique may be considered medically necessary in the repair of midline abdominal wall defects, including ventral and incisional hernias, when they are greater than or equal to 10 centimeters in width.

Adding a description of the component separation technique to the Policy Guidelines section and a coding note to the Policy Criteria.

Effective Date: December 1, 2021

Surgery, Policy No. 12.03 N/A N/A
Extracranial Carotid Angioplasty and Stenting

Updated policy to consider treatment with carotid angioplasty/stenting (CAS) to be potentially medically necessary for asymptomatic patients with documented stenosis of 80% or greater.

Effective Date: December 1, 2021

Surgery, Policy No. 93 N/A N/A
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

MRgFUS may be considered medically necessary for pain palliation in adults with metastatic bone cancer for whom radiotherapy has failed or who are not candidates for radiotherapy. MRgFUS continues to be considered investigational for the treatment of Parkinson's Disease.

Effective Date: December 1, 2021

Surgery, Policy No. 139 N/A N/A
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

Minor edit to the definition of hypopnea in the background section.

Effective Date: December 1, 2021

Surgery, Policy No. 166 N/A N/A
Cryoablation for Chronic Rhinitis

New policy addresses cryoablation for chronic rhinitis which is considered investigational.

Effective Date: December 1, 2021

Surgery, Policy No. 224 Add CPT codes 30999, 31299, and continue to review the unlisted codes, and add HCPCS code C9771 to this new policy with no change to the investigational denial. N/A
The following is a list of recently archived policies:
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy Effective Date: January 1, 2022 Genetic Testing, Policy No. 32
Gene Expression Testing for Psoriasis Effective Date: January 1, 2022 Genetic Testing, Policy No. 87