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Medical Policy
Regence Medical Policy Update, August 1, 2014
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 #

Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Failed joint fusion following arthrodesis changed from medically necessary to investigational.

Effective Date: March 1, 2014

Durable Medical Equipment, Policy No. 83.11
Genetic Testing for Inherited Susceptibility to Colon Cancer

Removed criteria regarding gene testing in patients with a diagnosis of classical FAP.

Effective Date: March 1, 2014

Genetic Testing, Policy No. 06
Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA

Revised criteria to address additional aneuploidies, fetal sex determination, and microdeletion syndromes.

Effective Date: March 1, 2014

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

Added new investigational panels.

Effective Date: March 1, 2014

Genetic Testing, Policy No. 64
Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture (AmniSure® and ROM Plus® Tests)

Clarified that investigational criterion applies to all placental rapid immunoassays.

Effective Date: March 1, 2014

Laboratory, Policy No. 57
Cochlear Implant

Added clarification regarding repeat hearing tests and trials of hearing aids.

Effective Date: March 1, 2014

Surgery, Policy No. 08
Ventricular Assist Devices and Total Artificial Hearts

Clarified that total artificial heart criteria include patients being evaluated for candidacy for heart transplant.

Effective Date: March 1, 2014

Surgery, Policy No. 52
Percutaneous Vertebroplasty and Kyphoplasty

Medical necessity status of vertebroplasty changed to investigational.

Effective Date: March 1, 2014

Surgery, Policy No. 107
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction

Reduced minimum test stimulation trial period 1 week. Added criteria clarifications.

Effective Date: March 1, 2014

Surgery, Policy No. 134
Orthognathic Surgery

For required documentation, added written report of radiographs when available.

Effective Date: March 1, 2014

Surgery, Policy No. 137
Aqueous Shunts and Stents for Glaucoma

Criteria changed to consider the iStent Micro-Bypass medically necessary when criteria are met.

Effective Date: March 1, 2014

Surgery, Policy No. 164
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

Clarified criteria regarding the number of biopsies which constitute saturation biopsy.

Effective Date: March 1, 2014

Surgery, Policy No. 170
Gastric Reflux Surgery

Added clarification that medical necessity criteria apply to initial and repeat fundoplasty. Added criteria regarding fundoplasty performed in conjunction with paraesophageal hiatal hernia repair or esophageal myotomy.

Effective Date: March 1, 2014

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

Deleted Panorama prenatal panel (Natera).

Effective Date: April 1, 2014

Genetic Testing, Policy No. 64
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 65
Genetic Testing for Lactase Insufficiency

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 67
Genetic Testing for Rett Syndrome

New policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 68
Genetic Testing for Duchenne and Becker Muscular Dystrophy

New policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 69
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 70
Microarray-based Gene Expression Analysis for Prostate Cancer

New investigational policy.

Effective Date: April 1, 2014

Genetic Testing, Policy No. 71
New and Emerging Medical Technologies and Procedures

New investigational procedures added to the policy.

Effective Date: April 1, 2014

Medicine, Policy No. 149
Spinal Cord Stimulation for Treatment of Pain

Added cancer-related pain to list of investigational indications.

Effective Date: April 1, 2014

Surgery, Policy No. 45
Gastric Electrical Stimulation

Revised criteria related to nutritional status.

Effective Date: April 1, 2014

Surgery, Policy No. 111
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome in Adults

Added clarification that policy applies to adult patients.

Effective Date: April 1, 2014

Surgery, Policy No. 166
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

New investigational policy.

Effective Date: April 1, 2014

Surgery, Policy No. 190
Genetic Testing for Familial Alzheimer's Disease

Added TREM2 gene to investigational list.

Effective Date: May 1, 2014

Genetic Testing, Policy No. 01
Evaluating the Utility of Genetic Panels

Added new panel tests to policy.

Effective Date: May 1, 2014

Genetic Testing, Policy No. 64
Vitamin D Testing

Medical necessity criteria clarified and policy appendices updated to include additional covered indications.

Effective Date: May 1, 2014

Laboratory, Policy No. 52

Gastric Reflux Surgery

Criteria added regarding fundoplication in patients with pulmonary fibrosis.

Effective Date: May 1, 2014

Surgery, Policy No. 186
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Added new investigational criteria to policy.

Effective Date: June 1, 2014

Genetic Testing, Policy No. 42
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Esophagus, Small Bowel, and Colon

Criteria clarified regarding capsule endoscopy in patients with ulcerative colitis and acute upper GI bleeding.

Effective Date: June 1, 2014

Radiology, Policy No. 38
Percutaneous Vertebroplasty and Kyphoplasty

Added medical necessity criteria for vertebroplasty. Added vertebral body stenting to list of investigational techniques.

Effective Date: June 1, 2014

Surgery, Policy No. 107
Surgical Treatments for Hyperhidrosis

Added radiofrequency ablation for palmar hyperhidrosis as investigational.

Effective Date: June 1, 2014

Surgery, Policy No. 165
Lumbar Spinal Fusion

Added investigational criterion for staged fusion.

Effective Date: June 1, 2014

Surgery, Policy No. 187
Heart Transplant

Added medical necessity criterion on retransplantation.

Effective Date: June 1, 2014

Transplant, Policy No. 02
Heart/Lung Transplant

Added medical necessity criterion for retransplantation.

Effective Date: June 1, 2014

Transplant, Policy No. 03
Lung and Lobar Lung Transplant

Added medical necessity criterion on retransplantation.

Effective Date: June 1, 2014

Transplant, Policy No. 08
Small Bowel/Liver and Multivisceral Transplant

Added medical necessity criteria for retransplantation.

Effective Date: June 1, 2014

Transplant, Policy No. 18
Biofeedback Removed reference to dyssynergia-type constipation in children.

Effective Date: July 1, 2014

Allied Health, Policy No. 32
Tumor-Treatment Fields Therapy for Glioblastoma

New investigational policy.

Effective Date: July 1, 2014

Durable Medical Equipment, Policy No. 85
Cytochrome p450 Genotyping Added investigational criterion for dosing of anti-tuberculosis medications.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 10
Preimplantation Genetic Testing

Clarification of medically necessary criteria.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 18
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia

Added policy criteria for acute lymphoblastic leukemia.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 27
Genetic Testing, including Chromosomal Microarray Analysis (CMA) and Next Generation Sequencing Panels, for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum Disorders

Added medical neccesity criteria, investigational criteria, and a not medically necessary criterion that addresses CMA testing in children and for prenatal indications.

Effective Date: July 1, 2014

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

Added new investigational panels.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 64
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

New investigational policy.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 66
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy New genetic testing policy for hypertrophic cardiomyopathy.

Effective Date: July 1, 2014

Genetic Testing, Policy No. 72
Measurement of Serum Antibodies to Infliximab and Adalimumab

Added adalimumab antibody testing as investigational.

Effective Date: July 1, 2014

Laboratory, Policy No. 65
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

Added left atrial pressure monitoring as investigational.

Effective Date: July 1, 2014

Medicine, Policy No. 33
New and Emerging Medical Technologies and Procedures

Added new investigational procedures: (0347T-0354T, 0356T, 0358T)

Effective Date: July 1, 2014

Medicine, Policy No. 149
Implantable Cardioverter Defibrillator

Added criterion for patients with LMNA gene mutations. Added clarifications: 1) secondary prevention criterion applies after exclusion of reversible causes of patient's condition; 2) policy addresses only initial device implantation.

Effective Date: July 1, 2014

Surgery, Policy No. 17
Bariatric Surgery

Criteria clarified regarding reoperation in cases of band migration or slippage.

Effective Date: July 1, 2014

Surgery, Policy No. 58

Liver Transplant

Criteria clarified for patients with polcyctic disease of the liver.

Effective Date: July 1, 2014

Transplant, Policy No. 05
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
New and Emerging Medical Technologies and Procedures

New investigational procedures added to the policy.

Effective Date: September 1, 2014

Medicine, Policy No. 149
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

The following is a list of recently archived policies:
Occupational Therapy (OT)

Archive Effective Date:
February 1, 2014

Utilization Mangaement, Policy No. 04
Physical Therapy (PT) Archive Effective Date:
February 1, 2014
Utilization Mangaement, Policy No. 06
Speech Therapy (ST) Archive Effective Date:
February 1, 2014
Utilization Mangaement, Policy No. 09
Home Uterine Activity Monitoring (HUAM) Archive Effective Date:
May 1, 2014
Maternity, Policy No. 04
Sublingual Immunotherapy as a Technique of Allergen Specific Thearpy Archive Effective Date:
May 6, 2014
Medicine, Policy No. 121
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