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Medical Policy
Regence Medical Policy Update, October 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

Biofeedback

New medical policy addressing biofeedback with investigational and medically necessity criteria.

Effective Date: January 1, 2023

Allied Health, Policy No. 32

Adding CPT codes 90875, 90876, 90901, 90911, HCPCS code E0746 and ICD-10-PCS code GZC9ZZZ to this new medical policy with no clinical edits or preauth requirement at this time.

N/A
Definitive Lower Limb Prostheses New policy with medical necessity criteria for lower limb prostheses.

Effective Date: December 1, 2022

Durable Medical Equipment, Policy No. 18 Adding HCPCS codes L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987 with preauth edit for this policy. Adding HCPCS codes L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987 to the preauth website for this policy.
Pectus Excavatum and Carinatum Surgery

Policy title changed from Pectus Excavatum

Surgical treatment of pectus carinatum added to policy.

Effective Date: December 1, 2022

Surgery, Policy No. 12.02 N/A N/A
Hypoglossal Nerve Stimulation Hypoglossal nerve stimulation is considered not medically necessary in adults with obstructive sleep apnea (OSA) when medically necessary criteria are not met, including continuous positive airway pressure refusal. Definitions of Mild (greater than or equal to 1), Moderate (5 to 10) and Severe (greater than or equal to 10) OSA in children have been updated.

Effective Date: November 1, 2022

Surgery, Policy No. 215 Adding CPT code C1767 to this medical policy N/A
Surgical Site of Service – Hospital Outpatient

New medical policy includes medical necessity criteria for hospital outpatient surgical site of service; when criteria are not met for selected gastrointestinal procedures (e.g., endoscopy, colonoscopy), use of a hospital outpatient department for surgical services instead of an ambulatory surgery center (ASC) will be considered not medically necessary.

Note: In addition to the site of service, the services performed may require pre-authorization; check our pre-authorization lists to confirm.

Effective Date: November 1, 2022

Utilization Management, Policy No. 19 Adding CPT codes 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, and 43254 with preauth requirement for outpatient facility only Adding CPT codes 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, and 43254 to the preauth website for this medical policy
Management of Heart Failure in Adults

No changes to the guideline recommendation. Updated hyperlink to guideline.

Effective Date: October 1, 2022

Clinical Practice Guideline N/A N/A
Negative Pressure Wound Therapy in the Outpatient Setting

Added the required components of the comprehensive wound care to the criteria without change to intent. These were previously listed in the Policy Guidelines section of the policy.

Effective Date: October 1, 2022

Durable Medical Equipment, Policy No. 42 N/A N/A
Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer

Added SelectMDx and miR-Sentinal tests to policy criteria.

Effective Date: October 1, 2022

Genetic Testing, Policy No. 17 Added new CPT codes 0339U, 0343U with investigational denial N/A
Evaluating the Utility of Genetic Panels

Added 34 new investigational tests to policy.

Effective Date: October 1, 2022

Genetic Testing, Policy No. 64 Added new CPT codes 0347U, 0348U, 0349U, 0350U with investigational denial. N/A
Biochemical and Cellular Markers of Alzheimer’s Disease

Added blood biomarker testing to the policy.

Effective Date: October 1, 2022

Laboratory, Policy No. 22 Added new CPT code 0346U with investigational denial N/A
Investigational Gene Expression and Multianalyte Testing

Added four new investigational tests to the policy.

Effective Date: October 1, 2022

Laboratory, Policy No. 77 Added new CPT codes 0332U, 0342U, 0344U, 0351U with investigational denial N/A
Ventral (Including Incisional) Hernia Repair

Revising medical policy title; policy was previously called Ventral Hernia Repair

Adding definition regarding hernia associated pain and documentation requirements.

Updating policy guidelines regarding component separation technique.

Updating throughout to clarify the policy applies to incisional ventral hernias.

Effective Date: October 1, 2022

Surgery, Policy No. 12.03 N/A N/A
Leadless Cardiac Pacemakers

Adding Aveir system to policy as investigational.

Effective Date: October 1, 2022

Surgery, Policy No. 217 N/A N/A
Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Continue to recommend the VA/DOD guidelines as a comprehensive evidence-based guideline, with minor changes to the title, hyperlink, and year for the most recent edition.

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Management of Chronic Noncancer Pain with Opioids in Adults Continue to recommend the HHS TIPS publication as a comprehensive evidence-based guideline. 

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Screening and Management of Substance Use Disorders in Adults Continue to recommend the VA/DOD guidelines as a comprehensive evidence-based guideline. Updated the USPSTF guideline in other resources to current guideline.

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Gender Affirming Interventions for Gender Dysphoria

Clarified the breast/chest procedures addressed in medical necessity criteria by adding "(i.e., breast augmentation, breast reduction, mastectomy, mastopexy, nipple/areola reconstruction/repositioning)"

Effective Date: September 1, 2022

Medicine, Policy No. 153 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Added criteria requiring require detailed rationale for medical necessity of longer conventionally fractionated regimens for prostate cancer.

Effective Date: September 1, 2022

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

Added criteria requiring require detailed rationale for medical necessity of longer conventionally fractionated regimens for some indications.

Effective Date: September 1, 2022

Medicine, Policy No. 166 N/A N/A
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

To align with contract language, policy has been revised to state reconstructive breast surgery may be considered medically necessary after accidental injury or trauma to the breast resulting in significant malformation. In addition, breast implant replacement may be considered medically necessary when placed during medically necessary reconstructive breast surgery. Language added to clarify that breast revision surgery, including breast implant explantation and/or replacement, following a cosmetic primary breast procedure is considered cosmetic when medical necessity criteria are not met.

Effective Date: September 1, 2022

Surgery, Policy No. 40 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Added schwannomas to the list of medically necessary indications.

Effective Date: September 1, 2022

Surgery, Policy No. 214 N/A N/A
Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing Added CYP2C9 genotyping as potentially medically necessary for patients with relapsing form of multiple sclerosis being considered for treatment with siponimod (Mayzent®).

Effective Date: August 1, 2022

Genetic Testing, Policy No.10 Changed the edit for CPT code 81227, from always investigational to potentially investigational Added CPT code 81227 to the preauth list
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.

7/1/2022: Updated policy to consider sex chromosome aneuploidy testing to be medically necessary for member contracts subject to Washington’s State Board of Health Rule (WAC 246-680).

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.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

Added schwannomas to the list of medically necessary indications.

Effective Date: August 1, 2022

Surgery, Policy No. 213 N/A N/A
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
Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems

Liberalized medical necessity criteria for Insulin infusion pumps.

Effective Date: July 1, 2022

Durable Medical Equipment, Policy No.77 N/A N/A
Noninvasive Prenatal Testing to Determine Fetal Aneuploidies and Microdeletions using Cell-Free DNA

Updated policy to consider sex chromosome aneuploidy testing to be medically necessary for member contracts subject to Washington’s State Board of Health Rule (WAC 246-680).

Effective Date: July 1, 2022

Genetic Testing, Policy No. 44 N/A N/A
Drug Testing for Substance Use and Pain Management

Added new Q3 2022 quarterly code update CPT 0328U to the criteria as not medically necessary.

Effective Date: July 1, 2022

Laboratory, Policy No. 68 Add new CPT 0328U as part of the Q3 code updates as always not medically necessary denial edit. 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
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the Q3 2022 quarterly code update to address new investigational medical technologies, represented by CPT 0714T, 0715T, 0716T, 0723T, 0724T, 0725T, 0726T, 0727T, 0728T, 0729T, 0731T, 0732T, and HCPCS G0308, G0309.

Removed the following codes that are being added to the noted policies:

  • CPT 0621T, 0622 (SUR227)
  • CPT 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T (TRA19)
  • C9781 (SUR226)

Effective Date: July 1, 2022

Medicine, Policy No. 149 Add new 0714T, 0715T, 0716T, 0723T, 0724T, 0725T, 0726T, 0727T, 0728T, 0729T, 0731T, 0732T, and HCPCS G0308, G0309.as part of the Q3 code updates as investigational. N/A
Rhinoplasty

Revised policy criteria to clarify the policy applies to initial or revision rhinoplasty.

Photographs demonstrating obstruction are no longer required.

Advanced imaging remains required to demonstrate bony obstruction.

Effective Date: July 1, 2022

Surgery, Policy No. 12.28 N/A N/A
Subacromial Balloon Placement

New investigational medical policy addressing the use of subacromial balloon spacers.

Effective Date: July 1, 2022

Surgery, Policy No. 226 Add CPT code 23929 with no change to the current clinical edit. Add HCPCS code C9781 which is being moved from MED149 with no change to investigational denial. N/A
Laser Trabeculotomy and Trabeculostomy

New investigational policy addressing excimer laser trabeculostomy/trabeculotomy (ELT) and femtosecond laser trabeculotomy (FLT).

Effective Date: July 1, 2022

Surgery, Policy No. 227 Add CPT codes 0621T, and 0622T with no change to the investigational denial, and new CPT code 0730T as part of the Q3 code updates as investigational. N/A
Uterus Transplant

New investigational policy for uterus transplantation.

Effective Date: July 1, 2022

Transplant, Policy No. 19 Add CPT codes 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, and 0670T with no change to the current investigational denial. N/A
Interferential Current Stimulation

Clarified criteria to state that devices capable of combination therapies (e.g., NexWave™) that provide several modalities (e.g., interferential current stimulation, and neuromuscular electrical stimulation, and transcutaneous electrical stimulation) are considered investigational for all indications.

Effective Date: June 1, 2022

Durable Medical Equipment, Policy No. 83.07 N/A N/A
Digital Health Products

Policy does not apply to products for which coverage is required under state or federal law.

Effective Date: June 1, 2022

Medicine, Policy No. 175 N/A 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.
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Added coverage for the Amplatzer Amulet device when policy criteria are met.

Effective Date: June 1, 2022

Surgery, Policy No. 195 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Updated the criteria to include very low to intermediate risk prostate cancer.

Effective Date: June 1, 2022

Surgery, Policy No. 214 N/A N/A
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
The following is a list of recently archived policies:
None to report in the past six months