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Medical Policy
Regence Medical Policy Update, July 7, 2017
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

Sphenopalatine Ganglion Block for Headache and Pain

New medical policy that will consider sphenopalatine ganglion block investigational for all indications.

Effective Date: October 1, 2017
Medicine, Policy No. 160

Adding investigational denial on code 64505.

Continue to review unlisted code 64999.
N/A
Ablation of Primary and Metastatic Liver Tumors

Adding percutaneous ethanol injection and cryoablation to ablative techniques.

Effective Date: October 1, 2017

Surgery, Policy No. 204 Adding preauth to codes 47371, 47381, and 47383. Adding codes 47371, 47381, and 47383 to the preauth website.
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Moved liver tumors into new policy, Ablation of Primary and Metastatic Liver Tumors, Surgery, Policy No. 204.

Effective Date: October 1, 2017

Surgery, Policy No. 132 Moving codes 47371, 47381, and 47383 to new medical policy SUR204. N/A
Genetic Testing for Myeloid Neoplasms and Leukemia

Adding criteria for genetic testing associated with acute myeloid leukemia.

Effective Date: September 1, 2017

Genetic Testing, Policy No. 59 Adding preauth to code 81310 Adding codes 81218, 81245, 81246, 81272, 81273, and 81310 to the preauth website
Whole Exome and Whole Genome Sequencing

New policy which will consider chromosomal microarray analysis (CMA) testing as medically necessary in patients undergoing invasive diagnostic prenatal fetal testing.

Effective Date: August 1, 2017

Genetic Testing, Policy No. 76 N/A N/A
Implantable Cardioverter Defibrillator

Clarifying criteria regarding subcutaneous ICD placement when repeat transvenous ICD placement is contra-indicated.

Effective Date: August 1, 2017

Surgery, Policy No. 17 N/A N/A
Artificial Intervertebral Disc

Adding to the imaging criteria that if the request is for a second level disc replacement, then imaging must be within 6 months. Clarifying that hybrid construct is medically necessary when policy criteria are met.

Effective Date: August 1, 2017

Surgery, Policy No. 127 N/A N/A
Hematopoietic Cell Transplantation for Amyloid Light-Chain (AL) Amyloidosis or Waldenström Macroglobulinemia

Changing the policy title. Adding criteria stating that cell transplantation is considered not medically necessary to treat chemoresistant Waldenström macroglobulinemia and is considered investigational as a first-line treatment for the disease.

Effective Date: August 1, 2017

Transplant, Policy No. 45.40 N/A N/A
Wearable Cardioverter-Defibrillators Added medically necessary criteria for wearable cardioverter-defibrillators in patients at risk of arrhythmic death and as a bridge to definitive therapy (e.g., cardiac transplant).

Effective Date: July 7, 2017

Durable Medical Equipment, Policy No. 61 N/A Name change on preauth website.
Noninvasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Policy liberalized for TE which may be considered medically necessary.

Effective Date: July 7, 2017

Radiology, Policy No. 56 Investigational denial removed from code 0346T N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed seven panels.

Effective Date: July 1, 2017

Genetic Testing, Policy No. 64 Adding quarterly code update new codes 0008U and 0010U effective 8/1/2017. N/A
Cosmetic and Reconstructive Surgery

Effective Date: July 1, 2017

Surgery, Policy No. 12 Adding CPT codes 49654 and 49656 to this medical policy with PreAuth requirement. Adding CPT codes 49654 and 49656 to the PreAuth website for this medical policy.
Radiofrequency Ablation of Tumors (RFA)

Moved liver tumors into new policy, Ablation of Primary and Metastatic Liver Tumors, Surgery, Policy No. 204.

Effective Date: July 1, 2017

Surgery, Policy No. 92 Moved codes 47370, 47380, and 47382 to new medical policy SUR204. Removed codes 47370, 47380, and 47382 from this medical policy on the preauth website.
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

Changed policy title. Clarified policy scope to include High Intensity Focused Ultrasound (HIFU).

Effective Date: July 1, 2017

Surgery, Policy No. 139 Added preauth to new 7/1/2017 code C9747. Added policy to the preauth website for new 7/1/2017 code C9747.
Microwave Tumor Ablation

Moved liver tumors into new policy, Ablation of Primary and Metastatic Liver Tumors, Surgery, Policy No. 204.

Effective Date: July 1, 2017

Surgery, Policy No. 189 Moved codes 47382, and 47399 to new medical policy SUR204. Removed code 47382 from this medical policy on the preauth website.
Ablation of Primary and Metastatic Liver Tumors Effective Date: July 1, 2017 Surgery, Policy No. 204 Added codes 47370, 47380, 47382, and 47399 to this new medical policy and continue preauth on these codes. Continue to review unlisted code 47399. Added policy to preauth website with codes 47370, 47380, 47382.
Balloon Dilation of the Eustachian Tube

New investigational policy for balloon dilation of the eustachian tube.

Effective Date: July 1, 2017

Surgery, Policy No. 206 Added preauth to new 7/1/2017 code C9745. Review unlisted code 67999. Added new policy to the preauth website with code C9745.
Transgender Services

Clarified age requirement in surgical criteria regarding Female-to-Male breast surgery.

Effective Date: June 9, 2017

Medicine, Policy No. 153 N/A N/A
Gene Expression Profiling for Melanoma

Refocused policy to gene expression testing in melanoma.
Added criteria which finds testing for patients with uveal melanoma may be considered medically necessary when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 29 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Use of the Afirma GEC is considered investigational when medical necessity criteria are not met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 49 N/A N/A
Genetic Testing for CADASIL Syndrome

Added criteria on genetic testing for adults with relatives that have CADASIL syndrome, which may be considered medically necessary when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 51 N/A N/A
Genetic Testing for Myeloid Neoplasms and Leukemia

Expanded scope of policy.
Clarified title and description. Moved criteria for BCR-ABL kinase domain mutation testing into this policy.

Updated policy criteria to include CALR testing when criteria are met.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 59 Change edit on code 81219 to add preauth.

Change policy name on preauth list.

Add codes 81170, 81219, and 81401 to the preauth website.
Genetic Testing for Rett Syndrome Specify the genes that may be medically necessary for the testing of Rett syndrome and include guidance on panel testing.

Effective Date: June 1, 2017

Genetic Testing, Policy No. 68 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Criteria added to define adverse pathologic findings and remove persistently detectable PSA levels. Added adaptive radiotherapy as investigational.

Effective Date: June 1, 2017

Medicine, Policy No. 137 N/A N/A
Radioembolization for Primary and Metastatic Tumors of the Liver

Clarified the criteria regarding systemic therapy for unresectable hepatic metastases from neuroendocrine tumors.

Effective Date: June 1, 2017

Medicine, Policy No. 140 N/A N/A
Endometrial Ablation Added requirement for contraindication to non-contraceptive progestins.

Effective Date: June 1, 2017

Surgery, Policy No. 01 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Changed policy criteria to consider high frequency spinal cord stimulation as medically necessary when criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 45 Remove investigational denial, and review code C1822. N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Symptomatic osteoporotic vertebral fractures that are less than six weeks in duration may be considered medically necessary when policy criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 107 N/A N/A
Percutaneous Axial Anterior Lumbar Fusion

Revised policy title and criteria terminology to Percutaneous Axial Lumbosacral Interbody Fusion.

Effective Date: June 1, 2017

Surgery, Policy No. 157 N/A N/A
Lumbar Spinal Fusion

Updated policy to consider in-situ instrumented spinal fusion surgery with bone grafting as medically necessary when policy criteria are met.

Effective Date: June 1, 2017

Surgery, Policy No. 187 N/A N/A
Vagus Nerve Blocking Therapy for Obesity

Moved codes for vagus nerve blocking therapy into this new policy with no change to investigational criteria.

Effective Date: June 1, 2017

Surgery, Policy No. 200 Continue investigational denial on codes 0312T, 0313T, 0314T, 0315T, 0316T, 0317T N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Added two diagnostic codes (F84.5 Asperger’s syndrome and F84.9 Pervasive developmental disorder, unspecified) to the criteria.

Effective Date: May 5, 2017

Behavioral Health, Policy No. 18 Code H2020 will be mapped to the diagnosis codes added to the medical policy. Add CPT H2020 to the preauth list.
Genetic Testing for Hereditary Hearing Loss

Created criteria for nonsyndromic (NSHL) and syndromic hearing loss and clarified the use of single gene testing and multigene panel testing.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 36 N/A N/A
Chromosomal Microarray Analysis (CMA) and Next-generation Sequencing Panels for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies

Changed the policy title. Updated criteria to state that CMA testing in adults is considered investigational. Removed CMA testing in the prenatal setting which is now addressed in a new policy.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 58 N/A N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and removed two panels.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 64 N/A N/A
Invasive Prenatal (Fetal) Diagnostic Testing Using Chromosomal Microarray Analysis (CMA)

New policy which considers chromosomal microarray analysis (CMA) testing as medically necessary in patients undergoing invasive diagnostic prenatal fetal testing.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 78 Add codes 81228, 81229, 81405, and 81470 to this new medical policy. No change to current edits on these codes. Add this medical policy and codes 81228, 81229, 81405, and 81470 to the pre-authorization website.
Chromosomal Microarray Analysis (CMA) for the Evaluation of Products of Conception and Pregnancy Loss

New policy which considers chromosomal microarray analysis (CMA) testing medically necessary for the evaluation of products of conception and pregnancy loss when policy criteria are met.

Effective Date: May 1, 2017

Genetic Testing, Policy No. 79 Add codes 81228, 81229, 81479, 88299, and 88271 to this new medical policy. No change to current edits on these codes. Add this medical policy and codes 81228 and 81229 to the pre-authorization list
Orthopedic Applications of Stem-Cell Therapy

No medical policy criteria changes.

Effective Date: May 1, 2017

Medicine, Policy No. 142 Add this medical policy to the pre-authorization website.  Codes 38206, 38232, and 38241 will be reviewed using this policy. Add this medical policy and codes 38206, 38232, and 38241 to the pre-authorization list.
New and Emerging Medical Technologies and Procedures Effective Date: May 1, 2017 Medicine, Policy No. 149 N/A N/A
Single Photon Emission Computed Tomography (SPECT) of the Brain

Removed epilepsy and seizure disorders from the list of investigational indications.

Effective Date: May 1, 2017

Radiology, Policy No. 44 N/A N/A
Varicose Vein Treatment

Added language to the policy criteria for endovenous ablation stating "throughout the segment to be ablated" for vein measurement. Added guidance to the coding table for various procedures and relevant codes. Updated the list of information needed for review to specify venous study measurement locations.

Effective Date: May 1, 2017

Surgery, Policy No. 104 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

This is a correction to what was reported for a 4/1/2017 effective date. Corrections will be effective as identified in the following columns.

Surgery, Policy No. 110

Previously reported:
“Added code 43236 with investigational denial.”

Corrected to now report:
“Liberalized investigational denial on codes 43192 and 43201 to require Preauth effective 2/1/2017.

Added code 43236 with preauth required effective 5/1/2017.”

Preauth website updated with codes 43192 and 43201 effective 2/1/2017.

Code 43236 will be added to the Preauth website effective 5/1/2017.
Endobronchial and Intrabronchial Valves

Changed the policy title. Clarified that policy addresses intrabronchial valves in addition to endobronchial valves.

Effective Date: May 1, 2017

Surgery, Policy No. 184 N/A N/A
Tumor Treating Fields Therapy for Glioblastoma Policy title changed. Added criteria to address the software used to optimize tumor treating fields (TTF) therapy.

Effective Date: April 1, 2017

Durable Medical Equipment, Policy No. 85

Added CPT code 77299 to the policy with no change to the current edits.

Added CPT code 77261 to the policy with no clinical edits but a coding note added to the medical policy that this is not the correct code to use for the NovoTAL system software program.
Policy title updated to match the medical policy title change.
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Added PALB2 testing as medically necessary when policy criteria are met.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 02 N/A N/A
Cytochrome p450 Genotyping

Clarified that testing for mutations in more than one CYP450 gene is considered investigational.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 10 N/A N/A
Genetic Testing for FMR1 Mutations (including Fragile X Syndrome)

Clarified wording in criterion related to Fragile X ataxia/tremor.

Effective Date: April 1, 2017

Genetic Testing, Policy No. 43 N/A N/A
Cosmetic and Reconstructive Surgery

Added treatment session criteria to blepharoplasty. Modified panniculectomy criteria.

Clarified blepharoplasty criterion II. C.  for the visual field assessment. Clarified criteria for the use of the component separation technique for ventral hernia repair. Added and clarified criteria for surgical repair of diastasis recti and abdominoplasty.

Effective Date: April 1, 2017

Surgery, Policy No. 12 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Added criteria for high frequency stimulation. Added language to the body of the policy to describe high frequency stimulation devices, including the Senza® system and corresponding HF10™ therapy.

Effective Date: April 1, 2017

Surgery, Policy No. 45 Change HCPCS code C1822 from reviewed to investigational denial. Change HCPCS code C1822 from reviewed to investigational denial.
Varicose Vein Treatment

Additional vein diameter measurement locations were added for ligation/stripping and endovenous ablation. For endovenous ablation, criterion added for clinical documentation that all incompetent segments of the same vein will be treated in the same session. Also, sclerotherapy for the upper extremities is considered investigational.

Effective Date: April 1, 2017

Surgery, Policy No. 104 N/A N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

Correction entered, see above entry for SUR110.

Added code with investigational denial.

Effective Date: April 1, 2017

Surgery, Policy No. 110 Added code 43236 with investigational denial. N/A
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Updated procedure names throughout policy including title and criteria usage.

Effective Date: April 1, 2017

Surgery, Policy No. 118 N/A N/A
Femoroacetabular Impingement Surgery

Removed imaging requirement for radiologist review. Added physical therapy and intra-articular injections, unless contraindicated, to the conservative treatment requirements. Added additional language that requested procedures must be consistent with the documented anatomical abnormalities. Added capsular plication, capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAI surgery, as components of and incidental to the FAI procedure.

Effective Date: April 1, 2017

Surgery, Policy No. 160 N/A N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome

Criteria restructured and reorganized. Clarified the medically necessary procedures in the policy and addressed partial glossectomy as one of these procedures. Revised CPAP trial requirements.

Effective Date: April 1, 2017

Surgery, Policy No. 166 Added CPT code 64568 with no change to the current edits Added CPT code 64568
Charged Particle (Proton or Helium Ion) Radiotherapy Change to consider pediatric malignant solid tumors medically necessary and clarified the criteria for ocular, cervical spinal cord, and skull base tumors.

Effective Date: March 1, 2017

Medicine, Policy No. 49 N/A N/A
In Vivo Analysis of Colorectal Polyps

Clarified criterion to indicate that policy applies to in vivo analysis of any colorectal lesions.

Effective Date: March 1, 2017

Medicine, Policy No. 104 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate Change criteria to consider locally advanced prostate cancer, prior radiation to the planned target volume, and tumors close to organs at risk as medically necessary when policy criteria are met.

Effective Date: March 1, 2017

Medicine, Policy No. 137 N/A N/A
Endometrial Ablation Clarified several criteria required and concomitant procedures. Updated contraindications to contraceptives to align with Centers for Disease Control and Prevention.

Effective Date: March 1, 2017

Surgery, Policy No. 01 N/A N/A
Gastroesophageal Reflux Surgery Clarified hiatal hernia types in criteria for medically necessary and investigational indications.

Effective Date: March 1, 2017

Surgery, Policy No. 186 N/A N/A
Evaluating the Utility of Genetic Panels

Added additional investigational panels and updated the name of one panel.

Effective Date: February 1, 2017

Genetic Testing, Policy No. 64 N/A N/A
Analysis of Proteomic and Metabolomic Patterns for Early Detection of Cancer

Expanded the scope of the policy to address metabolomic tests which are considered investigational.

Effective Date: February 1, 2017

Laboratory, Policy No. 41 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 138 N/A N/A
Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Clarified the criteria language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 139 N/A N/A
Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

Add criteria that IMRT is medically necessary when there is documented prior radiation treatment to the planned target volume. Clarified the language regarding the need for submitted histogram analysis.

Effective Date: February 1, 2017

Medicine, Policy No. 147 N/A N/A
Bariatric Surgery

Clarified reoperation criteria; added parietal cell separating gastrojejunostomy and AspireAssist device to investigational procedures; specified that sleeve gastrectomy and adjustable gastric banding are only medically necessary in the absence of GERD and takedown of fundoplication; separated out general criteria for reference throughout the policy.

Provided clarification for hiatal hernia repair, specifying the procedure includes either repair of sliding or paraesophageal hernia.

Effective Date: February 1, 2017

Surgery, Policy No. 58

Add preauth to code 43860.

HCPCS code S2083 does not require preauth, but coverage is available only for members with bariatric surgery benefits.

Add code 43860 to the preauth list for this policy.

Remove preauth on code S2083

The following is a list of recently archived policies:
Prostatic Urethral Lift

Archive Effective Date: July 1, 2017

NOTE: New Clinical Position Statement addressing prostatic urethral lift; see Prostatic Urethral Lift.

Surgery, Policy No. 197
Sympathetic Electrical Stimulation Therapy Archive Effective Date: July 1, 2017 Durable Medical Equipment, Policy No. 83.08
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia Archive Effective Date: June 1, 2017 Genetic Testing, Policy No. 27
Computed Tomography (CT) Perfusion Imaging of the Brain Archive Effective Date: March 1, 2017 Radiology, Policy No. 54
Thermal Capsulorrhaphy as a Treatment of Joint Instability Archive Effective Date: March 1, 2017 Surgery, Policy No. 100
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Archive Effective Date: February 1, 2017 Surgery, Policy No. 170