Regence Logos
Search: 
spacer
spacer
Medical Policy
Regence Medical Policy Update, September 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

Section and
Policy #

Coding / Implementation Change

PreAuthorization Change

Myoelectric Prosthetic Components for the Upper Limb

Clarified functional needs criteria as activities of daily living that include job functioning but exclude leisure and recreational activities.

Effective Date: December 1, 2015

Durable Medical Equipment, Policy No. 80 Preauth requirement added to codes L6881, L6882 Preauth requirement added to codes L6881, L6882
Cosmetic and Reconstructive Surgery

Clarified blepharoplasty and panniculectomy criteria. New criteria was added to address component separation technique when performed with ventral hernia repair.

Effective Date: December 1, 2015

Surgery, Policy No. 12 N/A N/A
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery

New policy that considers implantable sinus stents investigational for postoperative treatment following endoscopic sinus surgery.

Effective Date: December 1, 2015

Surgery, Policy No. 198 Investigational denial added to code S1090 N/A
Plasma Exchange (Plasmapheresis)

New policy addressing plasma exchange.

Effective Date: November 1, 2015

Medicine, Policy No. 05 New medical policy will have preauth requirement added to code 36514 Preauth requirement added to code 36514
Surface Electromyography (SEMG) Including Paraspinal SEMG Policy criteria changed to consider surface EMG, including paraspinal SEMG, investigational for the diagnosis or treatment of any condition, including back pain, myoclonus or as a component of gait analysis.

Effective Date: November 1, 2015

Medicine, Policy No. 73 N/A Added codes for this policy to the PreAuth site: 96002, 96004
Gait Analysis

Note added to the criteria section to refer to Medical Policy Medicine 73 when surface electromyography is included as a component of gait analysis.

Effective Date: November 1, 2015

Medicine, Policy No. 107 N/A N/A
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

New policy addressing autologous chondrocyte implantation as a treatment of focal articular cartilage lesions.

Effective Date: November 1, 2015

Surgery, Policy No. 87 New medical policy will have preauth requirement added to codes 27412, J7330, and S2112 Preauth added to codes 27412, J7330, S2112
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

New policy which considers peroral endoscopic myotomy to be investigational as a treatment for esophageal achalasia.

Effective Date: November 1, 2015

Surgery, Policy No. 196 N/A N/A
Endovascular Angioplasty and/or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) Added location and size criteria for flow-diverting stents for internal carotid artery aneurysms.

Effective Date: October 1, 2015

Surgery, Policy No. 141 N/A N/A
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care

Informational Note: The implementation of this new medical policy has been changed from 9/1/2015 to 10/1/2015.

After 3 or more residential or inpatient facility admissions for opioid detoxification treatment during the most recent 24 months, additional residential or inpatient admissions may be considered medically necessary only if a clinical rationale based upon the specific member’s particular circumstances clearly establishes a reasonable expectation of effectiveness despite the multiple previous, recent post-admission relapses.

Effective Date: October 1, 2015

Behavioral Health, Policy No. 23 N/A Preauthorization required for all Chemical Dependency Inpatient (CDIP) detoxification effective 9/1/2015
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Added a requirement for a signed provider order for BRCA testing.

Effective Date: September 1, 2015

Genetic Testing, Policy No. 02 N/A N/A
Transgender Services

Note from the Editor: Correction made after notice posted in the September 2015 Medical and Dental Policy Bulletin.

Anticipate update on or before 10/1/2015.

Effective Date: TBD
Medicine, Policy No. 153 N/A N/A
Evaluating the Utility of Genetic Panels

Added new investigational panels to the policy.

Effective Date: September 1, 2015
Genetic Testing, Policy No. 64 N/A N/A
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

Added whole genome sequencing as an investigational indication.

Effective Date: September 1, 2015

Genetic Testing, Policy No. 76 N/A N/A
Radioembolization for Primary and Metastatic Tumors of the Liver

Changed unresectable intrahepatic cholangiocarcinoma from an investigational indication to medically necessary when criteria are met.

Effective Date: September 1, 2015

Medicine, Policy No. 140 N/A N/A
Bariatric Surgery

Clarified the types of providers that can conduct the preoperative evaluation.

Effective Date: September 1, 2015

Surgery, Policy No. 58 N/A N/A
Radiofrequency Ablation of Tumors (RFA)

Removed exclusion criterion regarding transplant candidates with primary liver cancer (I.A.1.e.). Added symptomatic or large (>4 cm) asymptomatic renal angiomyolipoma as medically necessary when criteria are met.

Effective Date: September 1, 2015

Surgery, Policy No. 92 N/A N/A
Varicose Vein Treatment

Terminology for vein diameter measurement location changed from proximal thigh to mid-thigh or below (in segment to be ablated) and from proximal calf to mid-calf.

Effective Date: September 1, 2015

Surgery, Policy No. 104 N/A N/A
Orthognathic Surgery

Policy criteria clarified.

Effective Date: September 1, 2015
Surgery, Policy No. 137 N/A N/A
Genetic Testing for Inherited Susceptibility to Colon Cancer

Policy criteria liberalized to allow for simultaneous testing of genes associated with hereditary colorectal cancer when the clinical utility of each gene is established.

Effective Date: August 1, 2015

Genetic Testing, Policy No. 06 N/A N/A
Sequencing-based Tests to Determine Fetal Aneuploidies from Maternal Plasma DNA

Liberalized policy criteria to state that non-invasive sequencing-based testing using cell-free DNA obtained from maternal plasma is medically necessary in women with singleton pregnancies in the general population, who are undergoing screening for fetal aneuplodies.

Effective Date: August 1, 2015

Genetic Testing, Policy No. 44 N/A N/A
Evaluating the Utility of Genetic Panels

Added/deleted new investigational genetic panel tests.

Effective Date: August 1, 2015

Genetic Testing, Policy No. 64 N/A N/A
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

One new investigational genetic panel added to the policy.

Effective Date: August 1, 2015

Genetic Testing, Policy No. 73 N/A N/A
Charged Particle (Proton or Helium Ion) Radiation Therapy

Clarified that choroidal neovascularization is related to age-related macular degeneration.

Effective Date: August 1, 2015

Medicine, Policy No. 49 N/A N/A
Cosmetic and Reconstructive Surgery

Added new medical necessity criteria regarding panniculectomy.

Effective Date: August 1, 2015

Surgery, Policy No. 12 N/A N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Interim update. Kiva procedure changed from investigational to medically necessary when criteria are met.

Effective Date: August 1, 2015

Surgery, Policy No. 107 N/A N/A
Evaluating the Utility of Genetic Panels Added new investigational panel tests.

Effective Date: July 1, 2015

Genetic Testing, Policy No. 64 N/A N/A
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Addition of two BRCA panel tests to the policy.

Effective Date: July 1, 2015

Genetic Testing, Policy No. 73 N/A N/A

Retinal Prosthesis

(no link provided - informational statement)

Policy moved from the medical policy manual Medicine section (MED123) to the Surgery section (SUR194).

Effective Date: July 1, 2015

Medicine, Policy No. 123 N/A N/A
New and Emerging Medical Technologies and Procedures Codes 0346T and 91200 for elastography moved from MED149 to the RAD56 medical policy.

Effective Date: July 1, 2015

Medicine, Policy No. 149 N/A N/A
Magnetic Resonance Spectroscopy Added multiple sclerosis as an investigational indication.

Effective Date: July 1, 2015

Radiology, Policy No. 27 N/A N/A
Noninvasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease New policy for the use of nonivasive imaging for the evaluation and monitoring of patients with chronic liver disease. This imaging continues to be investigational.

Effective Date: July 1, 2015

Radiology, Policy No. 56 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome in Adults

Defined "adult" as 18 and older. Added hypoglossal nerve stimulation as investigational. Removed requirement for failure of maximum treatment of underlying disease.

Effective Date: July 1, 2015

Surgery, Policy No. 166 N/A N/A
Retinal Prosthesis Policy moved from the medical policy manual section Medicine (MED123) to the Surgery section (SUR194).

Effective Date: July 1, 2015

Surgery, Policy No. 194 N/A N/A
Isolated Small Bowel Transplant

Added retransplant. Criteria for patients who tolerate TPN now applies to any age.

Effective Date: July 1, 2015

Transplant, Policy No. 09 N/A N/A
Supplement to MCG™ Discharge Criteria for Residential Treatment

Policy criterion II. clarified to ensure compliance with American Society of Addiction Medicine guidelines regarding discharge criteria for residential treatment of substance use disorders.

Effective Date: June 1, 2015

Behavioral Health, Policy No. 21 N/A N/A
PathFinderTG® Molecular Testing

Added Barrett's esophagus as investigational indication.

Effective Date: June 1, 2015

Genetic Testing, Policy No. 16 N/A N/A
DecisionDX Gene Expression Assays

Added gene expression profiling of thymoma, pleural mesothelioma, and cutaneous melanoma as investigational.

Effective Date: June 1, 2015

Genetic Testing, Policy No. 29 N/A N/A
Evaluating the Utility of Genetic Panels

Added and removed several genetic panel tests.

Effective Date: June 1, 2015

Genetic Testing, Policy No. 64 N/A N/A
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

New investigational panel tests added to the policy criteria.

Effective Date: June 1, 2015

Genetic Testing, Policy No. 73 N/A N/A
New and Emerging Medical Technologies and Procedures

Codes 0234T-0238T regarding transluminal peripheral atherectomy were added to the policy. Code 0286T regarding near-infrared spectroscopy studies of lower extremity wounds was added to the policy.

Effective Date: June 1, 2015

Medicine, Policy No. 149 N/A N/A
Transgender Services

Added penile prosthesis implantation as a procedure which may be considered medically necessary in Female-to-Male transgender individuals, when criteria are met.

Effective Date: June 1, 2015

Medicine, Policy No. 153 N/A N/A
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Esophagus, Small Bowel, and Colon

Note from the Editor: Correction made after notice posted in the June 2015 Medical and Dental Policy Bulletin. Policy #38 has been archived.

Archive Effective Date: June 1, 2015

Added new investigational indications regarding acute abdominal pain and portal hypertensive enteropathy.

Radiology, Policy No. 38    
Endometrial Ablation

Criterion clarified regarding unsuccessful attempt at endometrial sampling.

Effective Date: June 1, 2015

Surgery, Policy No. 01 N/A N/A
Varicose Vein Treatment

Clarified requirement for documentation of detailed venous study findings and clear, interpretable photographs. Added a note for reporting mechanochemical treatment using CPT code 37799.

Effective Date: June 1, 2015

Surgery, Policy No. 104 N/A N/A
Orthognathic Surgery

Criteria regarding surgery for obstructive sleep apnea clarified.

Effective Date: June 1, 2015

Surgery, Policy No. 137 N/A N/A
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

New coverage criteria added Removed criteria for testing in minors.

Effective Date: May 23, 2015

Genetic Testing, Policy No. 02 N/A N/A
New: Behavioral Health Section of the Manual

Moved the Mental Health section of the manual (Mental Health, Policy No.s 14, 16, 18) and one Utilization Management policy (Utilization Management, Policy No. 14) to this new section of the manual

Effective Date: May 1, 2015

Behavioral Health, Policy No.s 14, 16, 18, and 21 N/A N/A
Sequencing-based Tests to Determine Fetal Aneuploidies from Maternal Plasma DNA

Clarified criteria and changed the title.

Effective Date: May 1, 2015

Genetic Testing, Policy No. 44 N/A N/A
Evaluating the Utility of Genetic Panels

Added new investigational panel tests.

Effective Date: May 1, 2015

Genetic Testing, Policy No. 64 N/A N/A
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction

Added overactive bladder and post rectal surgery to criteria.

Effective Date: May 1, 2015

Surgery, Policy No. 134 N/A N/A
Sacroiliac Joint Fusion

New policy with investigational and medical necessity criteria.

Effective Date: May 1, 2015

Surgery, Policy No. 193 N/A N/A
Genetic and Molecular Diagnostic Testing

Criteria change to include panel testing and a list of required information for review was added.

Effective Date: April 1, 2015

Genetic Testing, Policy No. 20    
Evaluating the Utility of Genetic Panels Added and deleted genetic panel tests.

Effective Date: April 1, 2015

Genetic Testing, Policy No. 64    
New and Emerging Medical Technologies and Procedures

Codes 0075T, 0076T, 0329T, and C9742 were added to the policy.

Effective Date: April 1, 2015

Medicine, Policy No. 149    
Spinal Cord Stimulation

Added heart failure as investigational indication.

Effective Date: April 1, 2015

Surgery, Policy No. 45    
Bariatric Surgery

Criteria clarified regarding reoperation and gastric banding procedures.

Effective Date: April 1, 2015

Surgery, Policy No. 58    
Baroreflex Stimulation Devices

Added heart failure as investigational. Noted member contract may apply to treatment of consequences of noncovered services.

Effective Date: April 1, 2015

Surgery, Policy No. 183    
The following is a list of recently archived policies:
Retinal Prosthesis Not technically archived, but rather moved to the Surgery Section of the Manual
July 1, 2015
Medicine, Policy No. 123
Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes

Archive Effective Date:
June 1, 2015

Laboratory, Policy No. 66
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of teh Esophagus, Small Bowel, and Colon Archive Effective Date:
June 1, 2015
Radiology, Policy No. 38
Transpupillary  Thermotherapy for Treatment of Choroidal Neovascularization Archive Effective Date:
June 1, 2015
Surgery, Policy No. 120
Aqueous Shunts and Stents for Glaucoma Archive Effective Date:
June 1, 2015
Surgery, Policy No. 164
Mental Health Section of the Manual and one Utilization Mangement Policy

Not technically archived, but rather moved to the Behavioral Health Section of the Manual Effective: May 1, 2015

Mental Health, Policy No.s 14, 16, 18; and Utilization Management, Policy No. 14