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Medical Policy
Regence Medical Policy Update, January 1, 2021
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

General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

New medical policy to provide transparency with respect to the health plan's position for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). This policy brings the health plan into alignment with Medicare guidance, which is national.

Effective Date: April 1, 2021
Durable Medical Equipment, Policy No. 88 N/A N/A
Hyperbaric Oxygen Therapy

Adding a not medically necessary inverse statement when criteria for non-healing diabetic wounds of the lower extremities are not met.

Effective Date: April 1, 2021

Medicine, Policy No. 14 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk

Adding requirement for Dose-Volume Histograms (DVH) to be submitted in color.

Effective Date: April 1, 2021

Medicine, Policy No. 167 N/A N/A
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant

Adding a not medically necessary statement for when policy criteria are not met.

Effective Date: April 1, 2021

Transplant, Policy No. 45.03 N/A N/A
Powered Knee Prosthesis, Powered Ankle-Foot Prosthesis, Microprocessor-Controlled Ankle-Foot Prosthesis, and Microprocessor-Controlled Knee Prosthesis

Added medically necessary and not medically necessary criteria for review of replacement microprocessor-controlled knees.

Effective Date: March 1, 2021

Durable Medical Equipment, Policy No. 81 N/A N/A
Gastric Electrical Stimulation

Adding medically necessary and not medically necessary criteria to address revision and replacement of a gastric electrical stimulation device.

Effective Date: March 1, 2021

Surgery, Policy No. 111 Add preauth to CPT code 64595 for this policy. Add CPT code 64595 to the preauth website for this policy.
Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver

Changing policy title.

Adding criteria to consider cryoablation medically necessary for malignant dermatologic lesions, uveal melanoma, and cervical intraepithelial neoplasia.

Rewording investigational criterion to make it clearer that it applies to all indications that do not meet medical necessity criteria.

Effective Date: March 1, 2021

Surgery, Policy No. 132 Adding CPT codes 17260, 17261, 17262, 17263, 17264, 17266, 17270, 17271, 17272, 17273, 17274, 17276, 17280, 17281, 17282, 17283, 17284, 17286, 57511 to the policy with no clinical edits; informational only. N/A
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

Adding medically necessary and not medically necessary criteria to address revision and replacement of a sacral nerve neuromodulation device.

Effective Date: March 1, 2021

Surgery, Policy No. 134 Add preauth to CPT codes 64585, 64595 for this policy. Add CPT code 64585, 64595 to the preauth website for this policy.
Occipital Nerve Stimulation

No change to the medical policy, only to the edit on codes already in the policy.

Effective Date: March 1, 2021

Surgery, Policy No. 174 Add preauth to CPT codes 64569, 64585 for this policy. Add CPT code 64569, 64585 to the preauth website for this policy.
Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin

No change to the medical policy, only to the edit on codes already in the policy.

Effective Date: March 1, 2021

Surgery, Policy No. 205 Add preauth to CPT codes 64585, 64595 for this policy. Add CPT code 64585, 64595 to the preauth website for this policy.
Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome

Adding criterion that states third or higher autologous hematopoietic cell transplantation in the treatment of multiple myeloma is investigational.

Effective Date: March 1, 2021

Transplant, Policy No. 45.22 N/A N/A
Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia

Added a not medically necessary criterion for when Criterion I. is not met.

Effective Date: February 1, 2021

Transplant, Policy No. 45.31 N/A N/A
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma Added a not medically necessary criterion for when Criterion I. is not met.

Effective Date: February 1, 2021

Transplant, Policy No. 45.33 N/A N/A
Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems

Edited policy to include coverage for new FDA-approved artificial pancreas device for children ages 2-6 years.

Liberalized of the Policy Criteria requiring insulin pump therapy for 3, rather than 6 months.

Effective Date: January 1, 2021

Durable Medical Equipment, Policy No. 77 N/A N/A
Myoelectric Prosthetic and Orthotic Components for the Upper Limb

Adding criteria for review of replacement of myoelectric upper limb prostheses.

Effective Date: January 1, 2021

Durable Medical Equipment, Policy No. 80 N/A N/A
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Revising criteria to state electrical bone growth stimulation is considered not medically necessary for the following indications: fresh fractures, stress fractures, spondylolysis, failed (non-spinal) joint fusions, or osteonecrosis, and as an adjunct to spinal fusion or for fracture nonunion not meeting policy criteria.

Adding skeletal maturity criteria.

Adding criteria that tobacco-free status is required.

Effective Date: January 1, 2021

Durable Medical Equipment, Policy No. 83.11 N/A N/A
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome

Removed criteria requirement for signed provider order

Clarified criteria related to USPSTF-recommended risk assessment

Added additional medical necessity criteria for individuals with prostate cancer.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 02 Added new CPT codes 0235U, 81351, 81352 with a preauth requirement, and CPT code 81353 with no edit, in alignment with the annual code updates effective 1/1/2021. Added new CPT codes 0235U, 81351, 81352 with a preauth requirement to the preauth list for this policy.
Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes)

Removed reproductive carrier screening from policy, as this is now addressed in another policy.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 43 N/A N/A
Diagnostic Genetic Testing for α-Thalassemia

Removed reproductive carrier screening from policy, as this is now addressed in another policy.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 52 N/A N/A
Molecular Testing for Interstitial Lung Disease

New policy addresses gene expression testing for interstitial lung disease.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 55 Added new CPT code 81554 with investigational denial, in alignment with the annual code updates effective 1/1/2021 N/A
Evaluating the Utility of Genetic Panels

Added nine new investigational panels, removed nine panels, and changed six panels to reflect changes in the test name.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 64 N/A N/A
Genetic Testing for Epilepsy

Restructuring the criteria.

Expanding the age for testing to include patients whose onset occurred before age 18.

Adding “not medically necessary” criteria for the following, which were previously considered investigational: Patients who do not have severe seizures affecting daily functioning and/or interictal EEG abnormalities, Patients who have not had EEG and neuroimaging (CT or MRI), When another clinical syndrome has been identified that would explain a patient’s symptoms, Targeted reproductive carrier testing when policy criteria are not met

Effective Date: January 1, 2021

Genetic Testing, Policy No. 80 N/A N/A
Reproductive Carrier Screening for Genetic Diseases

Updated policy to address carrier testing for disorders that have a high carrier rate in certain populations.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 81 Added CPT codes 81243, 81244 with continued preauth and new CPT code 0236U with no edit. Added CPT codes 81243, 81244 to the preauth site for this medical policy.
Identification of Microorganisms Using Nucleic Acid Probes

Added panel language to investigational criterion addressing Gardnerella vaginalis testing.

Effective Date: January 1, 2021

Genetic Testing, Policy No. 85 Added new CPT codes 81513, 81514 with investigational denial, in alignment with the annual code updates effective 1/1/2021. N/A
Drug Testing for Substance Use and Pain Management

Added new code 0227U to criteria.

Effective Date: January 1, 2021

Laboratory, Policy No. 68 Added new CPT code 0227U which will have the rule of 1 unit/day, 15 units/year, in alignment with the annual code updates effective 1/1/2021. N/A
Protein Biomarkers and Multi-analyte Biomarker Tests for Screening, Detection, and/or Management of Prostate Cancer

Added multi-analyte biomarker tests to policy, including PanGIA test (Genetics Institute of America).

Effective Date: January 1, 2021

Laboratory, Policy No. 69 Added new CPT code 0228U with investigational denial, in alignment with the annual code updates effective 1/1/2021. N/A
Manipulation Under Anesthesia

Developed new policy for transparency on the health plan's position for manipulation under anesthesia.

Effective Date: January 1, 2021

Medicine, Policy No. 130 Added CPT codes 22505, 21073, 23700, 27275, 27570, 27860, 24300, 25259, 26340, 27198 with no edit. N/A
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the 2021 annual code update to:

  • Address new investigational medical technologies, and
  • Remove deleted codes.

Effective Date: January 1, 2021

Medicine, Policy No. 149 Added new CPT codes 0620T, 0621T, 0622T, 0623T, 0624T, 0625T, 0626T, 0627T, 0628T, 0629T, 0630T, 0631T, 0632T, 0639T, C9771, C9772, C9773, C9774, C9775 with investigational edit, revised the description on CPT code 0601T, and removed deleted CPT codes 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0400T, 0401T, 0405T, in alignment with the annual code updates effective 1/1/2021. Added code 0601U with investigational edit to this policy. N/A
Vestibular Evoked Myogenic Potential Testing

New policy for vestibular evoked myogenic potential testing which is considered investigational.

Effective Date: January 1, 2021

Medicine, Policy No. 169 Added CPT codes 92517, 92518 with investigation denial, in alignment with the annual code updates effective 1/1/2021. Added CPT codes 92519 with investigational denial. Added CPT code 92700 with unlisted code review. N/A
Cone Beam Breast Computed Tomography for Breast Cancer Diagnosis

New policy considering cone beam computed tomography (CT) investigational for imaging of the breast.

Effective Date: January 1, 2021

Radiology, Policy No. 59 Added new CPT codes 0633T, 0634T, 0635T, 0636T, 0637T, 0638T with investigational denial, in alignment with the annual code updates effective 1/1/2021. N/A
Endometrial Ablation

Changing criteria such that for repeat endometrial ablation, endometrial sampling or D&C must be performed following the prior endometrial ablation.

Effective Date: January 1, 2021

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

Adding criteria addressing revision and replacement of spinal cord or dorsal root ganglion stimulators.

Adding not medically necessary criteria addressing specific indications for spinal cord or dorsal root ganglion stimulation, which were previously investigational.

Effective Date: January 1, 2021

Surgery, Policy No. 45 N/A N/A
Vagus Nerve Stimulation

Adding criteria to address stimulator replacements.

Effective Date: January 1, 2021

Surgery, Policy No. 74 Add CPT code 64569 with preauth requirement. Add CPT code 64569 to preauth list.
Extracranial Carotid Angioplasty and Stenting

Added stenting for extracranial carotid dissection to criteria.

Effective Date: January 1, 2021

Surgery, Policy No. 93 N/A N/A
Percutaneous Angioplasty and Stenting of Veins

Liberalized policy criteria to cover percutaneous transluminal angioplasty as an adjunct to prior or concurrent ipsilateral first rib resection for venous thoracic outlet syndrome, previously limited to proximal upper extremity venous thrombosis.

Effective Date: January 1, 2021

Surgery, Policy No. 109 N/A N/A
Balloon Dilation of the Eustachian Tube

Added medical necessity criteria for the use of balloon dilation of the Eustachian tube in select patients.

Effective Date: January 1, 2021

Surgery, Policy No. 206 Added new CPT codes 69705, 69706 with preauth requirement and deleted HCPCS code C9745, in alignment with the annual code updates effective 1/1/2021. Added new CPT codes 69705, 69706 to the preauth website for this policy.
Responsive Neurostimulation

Added statement that replacement or revision is medically necessary after a responsive neurostimulation device has been placed.

Effective Date: January 1, 2021

Surgery, Policy No. 216 N/A N/A
Durable Medical Equipment, Prosthetic and Orthotic Upgrades, Replacements, Duplicates, and Repairs New medical policy (replacing prior clinical position statement). Expanded the criteria to bring into alignment with Medicare guidance, which is national in scope.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 75 N/A N/A
Electrical Stimulation for the Treatment of Wounds

Changed policy title.

Removed content related to electromagnetic therapy, which will be addressed in DME83.13 Electromagnetic Therapy.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 83.09 Remove HCPCS code E0761 from this policy and add to new medical policy DME 83.13 that will address electromagnetic therapy. N/A
Electrical Stimulation for the Treatment of Arthritis

Changed policy title.

Removed review of electromagnetic therapy from policy, which will be reviewed in DME83.13 Electromagnetic Therapy.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 83.10 N/A N/A
Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

Changing ultrasonic bone growth stimulation from investigational to not medically necessary for the following indications: fractures or nonunion of bones of the axial skeleton (skull and vertebrae), fractures due to bone pathology or tumor/malignancy, and failed joint fusion following arthrodesis.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 83.12 N/A N/A
Electromagnetic Therapy

New Medical Policy supports investigational determination for electromagnetic therapy. This technology was previously described in separate Medical Policies DME83.09 and DME83.10.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 83.13 Add HCPCS codes E0761, E0769, G0295, G0329 and continue investigational denial. N/A
Postsurgical Home Use of Limb Compression Devices

Replaces Clinical Position Statement for this indication. See larger communication for the change for all Clinical Position Statements.

Effective Date: December 1, 2020

Durable Medical Equipment, Policy No. 90 N/A N/A
COVID-19 Testing

Added testing for travel or recreational purposes (e.g., for camp, sports, or social events) and testing to determine the need for personal protective equipment (PPE).

Effective Date: December 1, 2020

Laboratory, Policy No. 74 N/A N/A
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders

Added a criterion to consider TMS for major depressive disorder not medically necessary when criteria are not met, which was previously considered investigational.

Effective Date: December 1, 2020

Medicine, Policy No. 148 N/A N/A
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults

Added a not medically necessary statement for when contraindications are present, which were previously considered investigational.

Effective Date: December 1, 2020

Medicine, Policy No. 152 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Added treatment of cervical cancer post-hysterectomy as a medically necessary indication.

Effective Date: December 1, 2020

Medicine, Policy No. 165 N/A N/A
Pectus Excavatum

Change the policy criteria to allow either MRI or CT to be used to calculate the Haller index.

Effective Date: December 1, 2020

Surgery, Policy No. 12.02 N/A N/A
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

Added clarifying criterion stating mastopexy is considered cosmetic when medical necessity criteria are not met.

Effective Date: December 1, 2020

Surgery, Policy No. 40 N/A N/A
Oxygen Concentrators

New medical policy replaces Clinical Position Statement CPS04, which is being archived when this policy becomes effective.

Effective Date: November 1, 2020

Durable Medical Equipment, Policy No. 91 N/A N/A
Evaluating the Utility of Genetic Panels

Added 15 new panels, removed 25 panels, and edited 18 panels to reflect changes in the test name or laboratory

Effective Date: November 1, 2020

Genetic Testing, Policy No. 64 N/A N/A
COVID-19 Testing Added travel to the list of testing purposes that are not reimbursable.

Effective Date: October 6, 2020

Laboratory, Policy No. 74 Added five new CPT codes 0540U, 0241U, 87636, 87637, 87811, deleted 1 CPT code 87450, and revised the description on two CPT codes 87426, 87449, all related to late update to the Q4 code updates. N/A
Powered Exoskeleton for Ambulation

New policy addressing powered exoskeleton devices.

Effective Date: October 1, 2020

Durable Medical Equipment, Policy No. 89 Continue review of unlisted HCPCS code E1399. Add new HCPCS code K1007 as investigational to this policy. N/A
Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer

Policy had title change.

Expanded the scope of the policy to include bladder cancer and added the Decipher® Bladder test to the list of investigational tests.

Effective Date: October 1, 2020

Genetic Testing, Policy No. 17 Added new CPT code 0016M. N/A
Evaluating the Utility of Genetic Panels

Added 23 new investigational panels, removed five panels that are no longer commercially available, and updated 11 panels to reflect test name changes.

Effective Date: October 1, 2020

Genetic Testing, Policy No. 64 Added new CPT codes 0216U, 0217U as investigational to this policy. N/A
Biochemical and Cellular Markers of Alzheimer’s Disease

Policy title changed.

Added skin cell (fibroblast) testing for Alzheimer's disease to the policy along with the new codes for this testing (0206U and 0207U).

Effective Date: October 1, 2020

Laboratory, Policy No. 22 Added new CPT codes 0206U, 0207U as investigational to this policy. N/A
Drug Testing for Substance Use and Pain Management

Changed policy title.

Added oral fluid and hair drug testing to policy as investigational.

Effective Date: October 1, 2020

Laboratory, Policy No. 68 Adding CPT codes 0011U, 0116U, P2031 to this policy as investigational. N/A
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

Added urinary testing for adrenal tumors to the policy.

Effective Date: October 1, 2020

Laboratory, Policy No. 72 Added new CPT code 0015M to this policy. N/A
Whole Body Hyperthermia

New investigational policy for whole body hyperthermia.

Effective Date: October 1, 2020

Medicine, Policy No. 15 Added CPT codes 77600, 77605, 77610, 77615, 77620 to this policy with no edit or preauth requirement N/A
Low-Level Laser Therapy

Title of policy changed from Low-Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions to Low-Level Laser Therapy, with no change to intent.

Effective Date: October 1, 2020

Medicine, Policy No. 105 N/A N/A
Gender Affirming Interventions for Gender Dysphoria

Adding revision to a previous gender affirming surgery because of dissatisfaction with the appearance to the list of not medically necessary interventions.

Effective Date: October 1, 2020

Medicine, Policy No. 153 N/A N/A
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Changed policy title.

Added language clarifying the documentation of visual field loss:

  • Photographs documenting pupillary obstruction must be taken in the pupillary plane with gaze straight ahead.
  • Visual field examinations must include 0-20 degrees as well as above 20 degrees documenting specific points seen and not seen.

Effective Date: October 1, 2020

Surgery, Policy No. 12.05 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Clarified tumor stage for non-small cell lung cancer (NSCLC).

Effective Date: October 1, 2020

Surgery, Policy No. 214 N/A N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Updated criteria to simplify and streamline.

Removed the prior-authorization requirement for Commercial members aged 17 and younger.

Effective Date: September 1, 2020

Behavioral Health, Policy No. 18 Prior authorization requirement is being removed for Commercial members aged 17 and younger. Add bullet to entry for this policy on the preauth page to read: Prior authorization is only required for members age 18 and older. Please call our Provider Contact Center if you are uncertain if pre-authorization is required for a member.
Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

Discontinuing use of MCG criteria for ultrasound bone growth stimulation, which will now be reviewed using the plan’s medical policy.

Ultrasonic bone growth stimulators are considered medically necessary for the treatment of fracture nonunion/delayed union when policy criteria are met. Two serial imaging studies during the most recent three-month period showing evidence of nonunion or nonhealing is required.

Ultrasound bone growth stimulation is considered not medically necessary for the treatment of fresh or stress fractures, consistent with previous criteria.

Ultrasound bone growth stimulation is considered investigational for all other conditions, including osteotomy, which had previously been covered under MCG criteria.

Added medical necessity for certain fresh fractures when policy criteria are met.

Effective Date: September 1, 2020

Durable Medical Equipment, Policy No. 83.12 Continue the preauth requirement on CPT code 20979 and HCPCS code E0760. Add new policy to the preauth website with CPT code 20979 and HCPCS code E0760 requiring preauth.
Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Clarified the policy to list the Enhanced Liver Fibrosis™ (ELF) Test and the LiverFASt™ Test as investigational.

Effective Date: September 1, 2020

Laboratory, Policy No. 47 N/A N/A
Pectus Excavatum

Added clarification that the Haller CT scan index should be measured at end-inspiration.

Effective Date: September 1, 2020

Surgery, Policy No. 12.02 Add new quarterly code update CPT codes 0225U, 0226U, 86408, 86409 to this policy N/A

COVID-19 Testing

Added neutralizing antibody testing to the policy with associated codes.

Added pharmacists as ordering providers.

Effective Date: August 10, 2020

Laboratory, Policy No. 74

N/A N/A
Identification of Microorganisms Using Nucleic Acid Probes

Added Gardnerella vaginalis testing as investigational.

Effective Date: August 1, 2020

Genetic Testing, Policy No. 85 Adding investigational denial to CPT codes 87510 and 87511 N/A
Measurement of Serum Antibodies to Selected Biologic Agents

Changed policy title.

Testing for serum antibodies to infliximab and adalimumab and biosimilars, either alone or in combination tests including serum drug levels, may be considered medically necessary in patients with inflammatory bowel disease when there is evidence of loss of response. Testing is not medically necessary when there has not been a loss of response to the medication.

Effective Date: August 1, 2020

Laboratory, Policy No. 65 Adding unlisted CPT code 80299 to this policy and continue to review. N/A
New and Emerging Medical Technologies and Procedures

Added CPT code 0465T as always investigational.

Removed CPT 38999, which will be addressed by the new policy SUR220.

Effective Date: August 1, 2020

Medicine, Policy No. 149

Adding investigational denial to CPT code 0465T

Moved CPT code 38999 from this medical policy to new policy SUR220, and continue to review.

N/A
Surgical Treatments for Lymphedema and Lipedema

New policy addressing the surgical treatment of lymphedema and lipedema which includes investigational statements for both microsurgery techniques and liposuction techniques.

Effective Date: August 1, 2020

Surgery, Policy No. 220 Add CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 38999 to this new medical policy with an investigational denial when a specific lymphedema or lipedema ICD-10 diagnosis is found on the claim. N/A
The following is a list of recently archived policies:
Dry Needling

Effective Date: January 1, 2021

NOTE: this Clinical Position Statement was developed into a medical policy that was effective 1/1/2021.

Clinical Position Statement, No. CPSMED39
Targeted Phototherapy for the Treatment of Psoriasis

Effective Date: January 1, 2021

NOTE: this Clinical Position Statement was developed into a medical policy that was effective 1/1/2021.

Clinical Position Statement, No. CPSMED98
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

Effective Date: December 1, 2020

NOTE: this Clinical Position Statement was developed into a medical policy that was effective 12/1/2020.

Clinical Position Statement, No. CPS02
Durable Medical Equipment Upgrades, Replacements and Duplicates

Effective Date: December 1, 2020

NOTE: this Clinical Position Statement was developed into a medical policy that was effective 12/1/2020.

Clinical Position Statement, No. CPSDME75
Oxygen Concentrators

Effective Date: November 1, 2020

NOTE: this Clinical Position Statement was developed into a medical policy that was effective 11/1/2020.

Clinical Position Statement, No. CPS04