Regence
Medical Policy Update, September 1, 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 |
|
Coding / Implementation 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 |
| Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening |
Removed Cologuard® test from policy.
Effective Date: September 1, 2017 |
Genetic Testing, Policy No. 12 |
Removed preauthorization from code 81528 |
Removed code 81528 from preauth website |
| 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 |
| Evaluating the Utility of Genetic Panels |
Added additional investigational panels. Removed one panel.
Effective Date: September 1, 2017 |
Genetic Testing, Policy No. 64 |
Removed preauthorization from code 81301 for this policy |
Removed code 81301 from preauth website for this policy |
| Reduction Mammaplasty |
Clarified criteria regarding documented pain from macromastia.
Effective Date: September 1, 2017 |
Surgery, Policy No. 60 |
N/A |
N/A |
| Deep Brain Stimulation |
Clarified criteria for dystonia and tremor.
Effective Date: September 1, 2017 |
Surgery, Policy No. 84 |
N/A |
N/A |
| Genetic Testing for Rett Syndrome |
Removed gender-specific diagnostic testing criteria, and added additional targeted carrier testing criteria in related females.
Effective Date: August 1, 2017 |
Genetic Testing, Policy No. 68 |
N/A |
N/A |
| 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 |
| Urine Drug Testing for Substance Abuse and Chronic Pain |
Added new code 0007U to policy criteria.
Effective Date: August 1, 2017 |
Laboratory, Policy No. 68 |
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 |
| Automated Percutaneous and Percutaneous Endoscopic Discectomy |
Updated the policy title and corresponding criteria terminology.
Effective Date: August 1, 2017 |
Surgery, Policy No. 145 |
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 |
| The following
is a list of recently archived policies: |
| Epithelial Cell Cytology in Breast Cancer Risk Asessment and High Risk Patient Management (Ductal Lavage and Suction Collection Systems) |
Archive Effective Date: August 1, 2017 |
Medicine, Policy No. 93 |
| 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 |
