Regence
Medical Policy Update, January 1, 2020 |
|
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. |
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|
Policy Name |
Summary
of Policy or Change |
|
Coding / Implementation Change
|
|
| Myocardial Strain Imaging |
New investigational policy.
Effective Date: April 1, 2020 |
Medicine, Policy No. 168 |
Added new CPT code 93356 with investigational denial edit. |
N/A |
| Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies |
Changed policy title.
Added copy number variation testing to policy.
Effective Date: January 1, 2020 |
Genetic Testing, Policy No. 58 |
New CPT code 0156U added to the policy with preauth required. |
Changed policy title and added code 0156U on the preauth website for this policy. |
| Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) |
Removed reference to non-squamous cell-type cancer from EGFR testing.
Effective Date: January 1, 2020 |
Genetic Testing, Policy No. 56 |
N/A |
N/A |
| Genetic Testing for Methionine Metabolism Enzymes, including MTHFR |
Changed policy title.
Added MTHFR testing for thrombophilia to policy.
Effective Date: January 1, 2020 |
Genetic Testing, Policy No. 65 |
N/A |
Changed policy title on the preauth website for this policy. |
| Identification of Microorganisms Using Nucleic Acid Probes |
Added semi-quantitative testing to policy.
Effective Date: January 1, 2020 |
Genetic Testing, Policy No. 85 |
New CPT code 0151U added to the policy with investigational denial. |
N/A |
| Urine Drug Testing for Substance Use and Pain Management |
Updated policy to reflect that the rolling calendar year limit is based on the first date that a claim for the service is received and not on the actual date of service.
Effective Date: January 1, 2020 |
Laboratory, Policy No. 68 |
Added new CPT codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, and 0150U to the policy with a not medically necessary denial edit. |
N/A |
| New and Emerging Medical Technologies and Procedures |
In accordance with the 2020 1st quarter code updates:
- Added new investigational medical technologies
- Removed deleted codes
Effective Date: January 1, 2020 |
Medicine, Policy No. 149 |
Added new CPT codes 0139U, 0563T, 0567T, 0568T, 0569T, 0570T, 0582T, C1824, and C2596 with investigational denial edits to this policy. Removed deleted CPT codes 0205T , 0249T, 0341T, 0377T from this policy. NOTE: see entry for new policy SUR219 that address the replacement code 46948 (replaces 0249T). |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
Removed the requirement for 12 months of continuous hormone therapy prior to breast augmentation.
Updated criteria to remove psychotherapy and hormone therapy, which are either medically necessary or if the member’s coverage includes a pharmacy benefit, it may have a Pharmacy review requirement.
Effective Date: January 1, 2020 |
Medicine, Policy No. 153 |
Added CPT 67950 to this policy and continue preauth requirement. Added unlisted CPT codes 19499, 31899, and 40799 to this policy and continue to review these unlisted codes. Removed deleted CPT code 19304 from the policy. |
Added CPT 67950 on the preauth website for this policy. |
| Implantable Cardioverter Defibrillator |
Added extravascular (substernal) ICDs to policy.
Effective Date: January 1, 2020 |
Surgery, Policy No. 17 |
Added new CPT codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T with investigational denial edit to this policy. |
N/A |
| Bariatric Surgery |
Reorganized criteria with no change to criteria intent.
Effective Date: January 1, 2020 |
Surgery, Policy No. 58 |
Added CPT code 43820 with preauth requirement to this policy. |
Added CPT code 43820 to the preauth website for this policy. |
| Percutaneous Angioplasty and Stenting of Veins |
Removed age requirement from pulmonary artery stenosis criterion.
Added symptomatic venous occlusion due to electrical device lead or central line placement to medically necessary indications.
Effective Date: January 1, 2020 |
Surgery, Policy No. 109 |
N/A |
N/A |
| Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial |
Added criteria to consider the WATCHMAN device medically necessary for stroke prevention in patients who are at increased risk for stroke and have contraindications to long-term anticoagulation therapy.
Effective Date: January 1, 2020 |
Surgery, Policy No. 195 |
Removed investigational denial on code 33340 and added preauth requirement. |
Added CPT code 33340 to the preauth website for this policy. |
| Transanal Hemorrhoidal Dearterialization |
New investigational policy.
Effective Date: January 1, 2020 |
Surgery, Policy No. 219 |
Added new CPT code 46948 with investigational denial for this policy. |
N/A |
| Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes |
Added risk of Lynch syndrome based on prediction models to policy criteria.
Effective Date: December 1, 2019 |
Genetic Testing, Policy No. 06 |
N/A |
N/A |
| Evaluating the Utility of Genetic Panels |
Added twenty-one new investigational panels to the policy.
Removed three panels from the policy.
Effective Date: December 1, 2019 |
Genetic Testing, Policy No. 64 |
N/A |
N/A |
| Power Wheelchairs: Group 3 |
New policy will address group 3 wheelchairs.
Effective Date: November 1, 2019 |
Durable Medical Equipment, Policy No. 37 |
Adding preauthorization to HCPCS codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864 for this new medical policy. |
Adding policy and HCPCS codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864 to the preauth list. |
| Insulin Infusion Pumps and Artificial Pancreas Device Systems |
Policy title changed.
Added medical necessity criteria for insulin infusion pumps.
Effective Date: November 1, 2019 |
Durable Medical Equipment, Policy No. 77 |
Adding preauthorization to HCPCS code E0784. |
Adding policy and HCPCS code E0784 to the preauth list. |
| Noninvasive Ventilators in the Home Setting |
New policy with medical necessity criteria for home use of noninvasive ventilators.
Effective Date: November 1, 2019 |
Durable Medical Equipment, Policy No. 87 |
Adding preauthorization to HCPCS code E0466 for this new medical policy. |
Adding policy and HCPCS code E0466 to the preauth list. |
| Oxygen Concentrators |
New Clinical Position Statement addressing oxygen concentrator use.
Effective Date: November 1, 2019 |
Clinical Position Statement, No. 04 |
N/A |
N/A |
| Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) |
Added fetal tissue testing based on ultrasound-detected anomalies to policy.
Effective Date: November 1, 2019 |
Genetic Testing, Policy No. 78 |
N/A |
N/A |
| Identification of Microorganisms Using Nucleic Acid Probes |
New policy addressing nucleic acid probe testing for microorganisms.
Effective Date: November 1, 2019 |
Genetic Testing, Policy No. 85 |
Adding investigational denial to codes 0097U, 87472, 87482, 87483, 87485, 87486, 87487, 87505, 87506, 87507, 87512, 87525, 87526, 87527, 87530, 87542, 87552, 87557, 87562, 87582, 87592, 87652 |
N/A |
| Hyperbaric Oxygen Therapy |
Changed policy title.
Added coverage criteria for compromised skin grafts and flaps.
Effective Date: November 1, 2019 |
Medicine, Policy No. 14 |
N/A |
Updated policy title on preauth website. |
| New and Emerging Medical Technologies and Procedures |
Moved codes related to leadless cardiac pacemakers to new medical policy Surgery, Policy No. 217.
Effective Date: November 1, 2019 |
Medicine, Policy No. 149 |
Removed CPT codes 33274 and 33275 from this medical policy, and move to new medical policy SUR217. |
N/A |
| Sacroiliac Joint Fusion |
Clarified criteria to allow for easier entry in the Auto Auth program.
Effective Date: November 1, 2019 |
Surgery, Policy No. 193 |
N/A |
N/A |
| Hypoglossal Nerve Stimulation |
Updated criteria for adults to match FDA indications.
Effective Date: November 1, 2019 |
Surgery, Policy No. 215 |
N/A |
N/A |
| Responsive Neurostimulation |
New policy addressing responsive neurostimulation.
Effective Date: November 1, 2019 |
Surgery, Policy No. 216 |
Add CPT codes 61850, 61860, 61863, 61864, 61880, 61885, 61886, 61888, 95970, 95971 and HCPCS codes L8680, L8686 L8688 to this policy with no change to current edits. |
New medical policy added to the preauth website. |
| Leadless Cardiac Pacemakers |
New policy addressing leadless pacemakers.
Effective Date: November 1, 2019 |
Surgery, Policy No. 217 |
Moved codes 33274 and 33275 from MED149 and added to this new medical policy. Removed investigational denial edit on both codes. Liberalized requirement for code 33274 by adding preauth requirement. |
New medical policy added to the preauth website. |
| Evaluating the Utility of Genetic Panels |
Added six new investigational panels to policy.
Effective Date: October 1, 2019 |
Genetic Testing, Policy No. 64 |
Added investigational edit to the following new CPT codes which are effective 10/1/2019: 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U |
N/A |
| Genetic Testing for Neurofibromatosis Type 1 or 2 |
New policy addressing genetic testing for neurofibromatosis.
Effective Date: October 1, 2019 |
Genetic Testing, Policy No. 84 |
No change to preauth edit for CPT codes 81405, 81406, and 81408. |
Added this policy to the preauth website for CPT codes 81405, 81406, and 81408 |
| Measurement of Serum Antibodies to Infliximab, Adalimumab, Ustekinumab, and Vedolizumab |
Policy title changed.
Added measurement of anti-drug antibodies to ustekinumab and vedolizumab to policy.
Effective Date: October 1, 2019 |
Laboratory, Policy No. 65 |
N/A |
N/A |
| New and Emerging Medical Technologies and Procedures |
Added new investigational medical technology in accordance with the 4th quarter code update.
Effective Date: October 1, 2019 |
Medicine, Policy No. 149 |
Added investigational edit to the following new CPT code which is effective 10/1/2019: 0117U |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
No medical policy changes.
Effective Date: October 1, 2019 |
Medicine, Policy No. 153 |
Code change only to add preauth to codes 57291, 57292, 57295, 57296, 57426. |
Add codes 57291, 57292, 57295, 57296, 57426 to the preauth list. |
| Gastroesophageal Reflux Surgery |
Reformatted criteria for readability. Clarified medication trial criteria.
Effective Date: October 1, 2019 |
Surgery, Policy No. 186 |
N/A |
N/A |
| Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder |
Removed Idaho Department of Health and Welfare Habilitative Interventionist certifications requirements, as they are no longer issued.
Effective Date: September 1, 2019 |
Behavioral Health, Policy No. 18 |
N/A |
N/A |
| BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy |
Clarified criteria to refer to BRAF testing as opposed to specific BRAF variant testing.
Effective Date: September 1, 2019 |
Genetic Testing, Policy No. 41 |
N/A |
N/A |
| Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer |
Changed criteria to consider testing to be medically necessary for select patients with 1-3 positive lymph nodes.
Effective Date: September 1, 2019 |
Genetic Testing, Policy No. 42 |
N/A |
N/A |
| Evaluating the Utility of Genetic Panels |
Added one new investigational panel and removed 13 panels.
Effective Date: September 1, 2019 |
Genetic Testing, Policy No. 64 |
Remove preauth on CPT code 81442. |
Remove CPT code 81442 from the preauth list. |
| Allergy and Sensitivity Tests of Uncertain Efficacy |
Title changed.
Clarified the investigational statement for IgA food panel testing.
Effective Date: September 1, 2019 |
Laboratory, Policy No. 01 |
N/A |
N/A |
| Ventral Hernia Repair |
Notification based on changes to coding/implementation and Preauth change. See the last two columns.
Effective Date: September 1, 2019 |
Surgery, Policy No. 12.03 |
Added preauth to code 15734 required only with diagnosis code K43.2 and K43.9 for Component Separation Technique (CST). Add preauth to code 49652 required only with diagnosis code K43.9 for ventral hernia. |
Added code 15734 with note for this code preauth required only with diagnosis code K43.2 and K43.9 for component Separation Technique (CST). Add code 49652 with note for this code preauth required only with diagnosis code K43.9 for ventral hernia. |
| Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder |
Removed preauthorization requirement for initial ABA assessments.
Effective Date: August 1, 2019 |
Behavioral Health, Policy No. 18 |
N/A |
N/A |
| Applied Behavior Analysis Initial Assessment for the Treatment of Autism Spectrum Disorder |
New policy applies to FEP for initial ABA assessments.
Effective Date: August 1, 2019 |
Behavioral Health, Policy No. 33 |
N/A |
N/A |
| Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE) |
Policy title changed.
Moved criteria note into the scope of policy to state that transarterial embolization (TAE), and transarterial chemoembolization (TACE) are considered medically necessary.
No change to radioembolization criteria.
Effective Date: August 1, 2019 |
Medicine, Policy No. 140 |
N/A |
N/A |
| Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid |
One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.
Added new medically necessary indications for thyroid cancer and lymphomas.
Effective Date: August 1, 2019 |
Medicine, Policy No. 164 |
Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. |
Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list. |
| Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, and Pelvis |
One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.
Added new medically necessary indications for gastroesophageal junction cancers, pancreatic cancer, and prostate cancer.
Clarified "significant pulmonary function impairment."
Effective Date: August 1, 2019 |
Medicine, Policy No. 165 |
Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. |
Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list. |
| Intensity Modulated Radiotherapy (IMRT) for Breast Cancer |
One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.
Effective Date: August 1, 2019 |
Medicine, Policy No. 166 |
Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. |
Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list. |
| Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk |
One of four new Intensity Modulated Radiotherapy (IMRT) policies that replaced the previous five IMRT policies which are being archived.
Effective Date: August 1, 2019 |
Medicine, Policy No. 167 |
Continue preauthorization requirement on CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016. |
Added this policy and CPT codes 77301, 77338, 77385, 77386, and HCPCS codes G6015, G6016 to the preauth list. |
| Rhinoplasty |
Revised symptomatic nasal airway obstruction by including "bony" under that criterion element.
Effective Date: August 1, 2019 |
Surgery, Policy No. 12.28 |
N/A |
N/A |
| Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants |
Added breast revision surgery following a cosmetic procedure.
Effective Date: August 1, 2019 |
Surgery, Policy No. 40 |
N/A |
N/A |
| Balloon Ostial Dilation for Treatment of Sinusitis |
Added coverage for balloon sinuplasty for the treatment of acute and chronic sinusitis when policy criteria are met.
Effective Date: August 1, 2019 |
Surgery, Policy No. 153 |
Removed investigational denial and liberalize by adding preauthorization requirement to CPT codes 31295, 31296, 31297, and 31298. Continue to review unlisted code 31299. |
Added CPT codes 31295, 31296, 31297, and 31298 to the preauth list for this policy. |
| Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome |
Policy title changed.
Reformatted the policy.
Removed hypoglossal nerve stimulation, which is now addressed in its own policy, Surgery, Policy No. 215.
Effective Date: August 1, 2019 |
Surgery, Policy No. 166 |
Removed CPT codes 0466T, 0467T, 0468T, 64568 from this medical policy and move to new medical policy SUR215. |
Removed CPT codes 0466T, 64568 from the preauth list for this policy and move to new medical policy SUR215. |
| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites |
One of two new policies replacing Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, Surgery, Policy No. 16.
Added medical necessity criteria for essential tremor.
Effective Date: August 1, 2019 |
Surgery, Policy No. 213 |
Continued the preauthorization requirement on CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340. |
Added this policy and CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340 to the preauth list. |
| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites |
One of two new policies replacing Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, Surgery, Policy No. 16.
Effective Date: August 1, 2019 |
Surgery, Policy No. 214 |
Continued the preauthorization requirement on CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340. |
Added this policy and CPT codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, and HCPCS codes G0339, G0340 to the preauth list. |
| Hypoglossal Nerve Stimulation |
New policy developed for hypoglossal nerve stimulation. Using the current criteria (from SUR166) for adults. New criteria to allow pediatric use when criteria are met.
Effective Date: August 1, 2019 |
Surgery, Policy No. 215 |
Continue preauthorization requirement on CPT codes 0466T, 64568 for this new medical policy. |
Add this policy and CPT codes 0466T, 64568 to the preauth list. |
| Hematopoietic Cell Transplantation for Autoimmune Diseases |
Added medically necessary criteria for autologous Hematopoietic Cell Transplantation for systemic sclerosis/scleroderma.
Effective Date: August 1, 2019 |
Transplant, Policy No. 45.32 |
N/A |
N/A |
| The following
is a list of recently archived policies: |
| Single Photon Emission Computed Tomography (SPECT) of the Brain |
Archive Effective Date: January 1, 2020 |
Radiology, Policy No. 44 |
| Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT) |
Archive Effective Date: January 1, 2020 |
Radiology, Policy No. 57 |
| Hematopoietic Cell Transplantation Index |
Archive Effective Date: November 1, 2019 |
Transplant, Policy No. 45 |
| Electromagnetic Navigation Bronchoscopy |
Archive Effective Date: October 1, 2019 |
Surgery, Policy No. 179 |
| Electrical Stimulation Devices Index |
Archive Effective Date: September 1, 2019 |
Durable Medical Equipment, Policy No. 83 |
Intensity Modulated Radiotherapy (IMRT) of the Thorax
NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies. |
Archive Effective Date: August 1, 2019 |
Medicine, Policy No. 136 |
Intensity Modulated Radiotherapy (IMRT) of the Prostate
NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies. |
Archive Effective Date: August 1, 2019 |
Medicine, Policy No. 137 |
Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancers and Thyroid Cancer
NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies. |
Archive Effective Date: August 1, 2019 |
Medicine, Policy No. 138 |
Intensity Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis
NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies. |
Archive Effective Date: August 1, 2019 |
Medicine, Policy No. 139 |
Intensity Modulated Radiotherapy (IMRT) for Central Nervous System (CNS) Tumors
NOTE: Archived policy replaced by criteria in one of the four new Intensity Modulated Radiotherapy (IMRT) policies. |
Archive Effective Date: August 1, 2019 |
Medicine, Policy No. 147 |
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
NOTE: Archived policy replaced by criteria in one of the two new Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy policies. |
Archive Effective Date: August 1, 2019 |
Surgery, Policy No. 16 |
