Regence
Medical Policy Update, January 1, 2015 |
|
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 |
|
| Single-nucleotide Polymorphisms (SNPs) to Predict Risk of Nonfamilial Breast Cancer |
Added OncoVue® and BREVAGen™ as an investigational criterion to predict breast cancer risk.
Effective Date: August 1, 2014 |
Genetic Testing, Policy No. 23 |
| Genetic Testing for PTEN Hamartoma Tumor Syndrome |
Removed prenatal testing indication from investigational criterion.
Effective Date: August 1, 2014 |
Genetic Testing, Policy No. 63 |
| Evaluating the Utility of Genetic Panels |
Addition of new investigational panels.
Effective Date: August 1, 2014 |
Genetic Testing, Policy No. 64 |
| Laboratory Tests for Heart Transplant Rejection |
Clarified the invesitgational criterion on the use of peripheral blood genetic profiling tests.
Effective Date: August 1, 2014 |
Laboratory, Policy No. 51 |
| Vagus Nerve Stimulation |
Added new investigational criterion for non-implantable vegas nerve stimulation.
Effective Date: August 1, 2014 |
Surgery, Policy No. 74 |
| Electrical Stimulation and Electromagnetic Therapy for the Treatment of Arthritis |
Expanded policy and title from "pulsed" to any electrical stimulation. Added a new investigational treatment.
Effective Date: September 1, 2014 |
Durable Medical Equipment, Policy No. 83.10 |
| Genetic Testing for Hereditary Breast and/or Ovarian Cancer |
Minor changes to criteria. Effective Date: September 1, 2014 |
Genetic Testing, Policy No. 02 |
| Evaluating the Utility of Genetic Panels |
Addition of genetic panel tests. Effective Date: September 1, 2014 |
Genetic Testing, Policy No. 64 |
| Fetal RHD Genotyping Using Maternal Plasma |
New investigational policy. Effective Date: September 1, 2014 |
Genetic Testing, Policy No. 74 |
| Vectra DA Blood Test for Rheumatoid Arthritis |
New investigational policy. Effective Date: September 1, 2014 |
Laboratory, Policy No. 67 |
| Charged Particle (Proton or Helium Ion) Radiation Therapy |
Added definition of clinically localized prostate cancer. Added investigational indication. Effective Date: September 1, 2014 |
Medicine, Policy No. 49 |
| Low-Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions |
Added additional indications to investigational criteria. Effective Date: September 1, 2014 |
Medicine, Policy No. 105 |
| Optical Coherence Tomography (OCT) of the Anterior Eye Segment |
Clarified investigational status is for all indications. Effective Date: September 1, 2014 |
Medicine, Policy No. 133 |
| Outpatient Cardiac Telemetry |
Added investigational indication. Effective Date: September 1, 2014 |
Medicine, Policy No. 135 |
| New and Emerging Medical Technologies and Procedures |
New investigational procedures added to the policy.
Added new investigational procedures: (0310T and 0241T)
Effective Date: September 1, 2014 |
Medicine, Policy No. 149 |
| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy |
Addition of investigational criterion.
Effective Date: September 1, 2014 |
Surgery, Policy No. 16 |
| Endoscopic Radiofrequency Ablation or Cryoablation of Barrett's Esophagus |
Changed RFA for low-grade dysplasia from invsestigational to medically necessary when criteria are met.
Effective Date: September 1, 2014 |
Surgery, Policy No. 173 |
| Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures) |
Added investigational indication, new criterion for on-pump maze, and clarified "symptomatic" definition.
Effective Date: September 1, 2014 |
Surgery, Policy No. 177 |
| Bariatric Surgery |
Criteria clarified regarding reoperation procedures.
Effective Date: September 10, 2014 |
Surgery, Policy No. 58 |
| Genetic Cancer Susceptibility Panels Using Next Generation Sequencing |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 73 |
| Genetic Testing for Macular Degeneration |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 75 |
| Whole Exome Sequencing |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 76 |
| Confocal Laser Endomicroscopy |
New investigational policy.
Effective Date: October 1, 2014 |
Medicine, Policy No. 151 |
| Reduction Mammaplasty |
Added criteria indicating reduction mammaplasty is not medically necessary when criteria are not met.
Effective Date: October 1, 2014 |
Surgery, Policy No. 60 |
| Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) |
Added clarification that investigational criteria applies to all indications.
Effective Date: October 1, 2014 |
Surgery, Policy No. 131 |
| Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) |
Clarified definition of advanced NSCLC.
Effective Date: November 1, 2014 |
Genetic Testing, Policy No. 56 |
| Evaluating the Utility of Genetic Panels |
Addition of new panel tests.
Effective Date: November 1, 2014 |
Genetic Testing, Policy No. 64 |
| Intensity Modulated Radiation Therapy (IMRT) of the Thorax |
Added general criteria for thoracic tumors.
Effective Date: November 1, 2014 |
Medicine, Policy No. 136 |
| Cosmetic and Reconstructive Surgery |
Liberalization of blepharoplasty and brow ptosis criteria.
Effective Date: November 1, 2014 |
Surgery, Policy No. 12 |
| Varicose Vein Treatment |
Added criteria for minimum vein diameter in mm and incompetence in seconds on venous imaging studies. Added microwave and steam injection ablation, and endovenous glue as investigational treatments.
Effective Date: November 1, 2014 |
Surgery, Policy No. 104 |
| Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence |
Added fecal incontinence.
Effective Date: December 1, 2014 |
Allied Health, Policy No. 04 |
| Artificial Pancreas Device System (APDS) |
Removed criteria regarding CGM devices.
Effective Date: December 1, 2014 |
Durable Medical Equipment, Policy No. 77 |
| Powered Knee Prosthesis, or Powered Ankle-Foot Prosthesis, and Microprocessor-Controlled Ankle-Foot Prosthesis |
Clarified terminology.
Effective Date: December 1, 2014 |
Durable Medical Equipment, Policy No. 81 |
| Cytochrome p450 Genotyping |
Addition of medical necessity criterion for the selection and dosing of eliglustat.
Effective Date: December 1, 2014 |
Genetic Testing, Policy No. 10 |
| Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer |
Addition of Prosigna test.
Effective Date: December 1, 2014 |
Genetic Testing, Policy No. 42 |
| Hyperbaric Oxygen Therapy (HBOT) |
Investigational list clarified.
Effective Date: December 1, 2014 |
Medicine, Policy No. 14 |
| New and Emerging Medical Technologies and Procedures |
Added device and manufacturer names to criteria.
Effective Date: December 1, 2014 |
Medicine, Policy No. 149 |
| Cochlear Implant |
Added investigational hybrid device.
Effective Date: December 1, 2014 |
Surgery, Policy No. 08 |
| Extracranial Carotid Angioplasty/Stenting |
Added CPT 37217 which will require preauthorization.
Effective Date: December 1, 2014 |
Surgery, Policy No. 93 |
| Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures) |
Off-pump criteria clarified.
Effective Date: December 1, 2014 |
Surgery, Policy No. 177 |
| Bronchial Thermoplasty |
Clarified investigational indications for bronchial thermoplasty.
Effective Date: December 1, 2014 |
Surgery, Policy No. 178 |
| Applied Behavior Analysis for the Treatment of Autism |
Policy updated.
Effective Date: See policy for dates. |
Mental Health, Policy No. 18 |
| Electrical Bone Growth Stimulators (Osteogenic Stimulation) |
Restricted stimulation as an adjunct to cervical spine fusion performed at more than two levels. Criteria added regarding coverage for simulation for adjunct fusion to be applied postoperatively. Added new investigational criteria regarding stress fracture.
Effective Date: January 1, 2015 |
Durable Medical Equipment, Policy No. 83.11 |
| JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms |
Clarified criteria.
Effective Date: January 1, 2015 |
Genetic Testing, Policy No. 59 |
| Evaluating the Utility of Genetic Panels |
Added, updated and deleted genetic panel tests. Deletion of Prosigna gene expression assay.
Effective Date: January 1, 2015 |
Genetic Testing, Policy No. 64 |
| Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults |
New investigational policy.
Effective Date: January 1, 2015 |
Medicine, Policy No. 152 |
| Transgendered Services |
New policy addressing medical and surgical treatments of gender dysphoria in transgender individuals.
Effective Date: January 1, 2015 |
Medicine, Policy No. 153 |
| Lumbar Spinal Fusion |
Added investigational staged fusion and criteria for abstinence from smoking.
Effective Date: January 1, 2015 |
Surgery, Policy No. 187 |
| Sublingual Immunotherapy as a Technique of Allergen Specific Therapy |
New investigational policy.
Effective Date: March 1, 2015 |
Medicine, Policy No. 121 |
| The following
is a list of recently archived policies: |
| Non-BRCA Breast Cancer Risk Assessment (OncoVue®) |
Archive Effective Date:
August 1, 2014 |
Genetic Testing, Policy No. 03 |
| Meniscal Allografts and Synthetic Meniscus Implants |
Archive Effective Date:
August 1, 2014 |
Surgery, Policy No. 71 |
| Hip Resurfacing |
Archive Effective Date:
August 1, 2014 |
Surgery, Policy No. 113 |
| Wireless Pressure Sensors in Endovascular Aneurysm Repair |
Archive Effective Date:
September 1, 2014 |
Surgery, Policy No. 163 |
| Wheelchairs |
Archive Effective Date:
December 1, 2014 |
Durable Medical Equipment, Policy No. 37 |
| Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus |
Archive Effective Date:
January 1, 2015 |
Surgery, Policy No. 173 |
