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Medical Policy
Regence Medical Policy Update, January 1, 2019
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

Transurethral Water Vapor Thermal Therapy of the Prostate New policy considering transurethral water vapor thermal therapy investigational.

Effective Date: April 1, 2019

Surgery, Policy No. 210 Add investigational denial to new code 53854. Continue review on unlisted code 53899. N/A
Sacroiliac Joint Fusion

This entry is here to document a coding/implementation change and preauthorization change.

Effective Date: March 1, 2019

Surgery, Policy No. 193 Add preauthorization requirement to code 27279. Add code 27279 to the preauth website.
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

New policy considering the insertion of an absorbable lateral nasal implant for the treatment of symptomatic nasal valve collapse investigational.

Effective Date: March 1, 2019

Surgery, Policy No. 209 Add investigational denial to code C9749. Continue review on unlisted code 30999. N/A
Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes)

Updated policy title.

Added AFF2 (FMR2) testing for fragile XE syndrome which is investigational.

Effective Date: January 1, 2019

Genetic Testing, Policy No. 43 Add investigational denial to new codes 81171, 81172. Updated policy title on the Preauth website.
Evaluating the Utility of Genetic Panels

Added 12 new investigational panels and removed one panel.

Effective Date: January 1, 2019

Genetic Testing, Policy No. 64 N/A N/A
Urine Drug Testing for Substance Use and Pain Management

Reformatted and clarified criteria for readability, with no changes to intent. Added 0082U as always not medically necessary with the annual code update process.

Effective Date: January 1, 2019

Laboratory, Policy No. 68 N/A N/A
Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow

Added criterion addressing synthetic bone grafts that require autologous bone marrow.

Effective Date: January 1, 2019

Medicine, Policy No. 142 N/A Updated policy title on the Preauth website.
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies and removed several in accordance with the annual code updates.

Effective Date: January 1, 2019

Medicine, Policy No. 149

Added investigational denial to new codes 0512T, 0513T, 0515T, 0516T, 0517T, 0518T, 0519T, 0520T, 0521T, 0522T, 0533T, 0534T, 0535T, 0536T, 0541T, 0542T, 33274, 33275, C9752, C9753.

Deleted codes 0337T, 0387T, 0388T, 0389T, 0390T, 0391T.
N/A
Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT)

Policy changed to consider DAT-SPECT potentially medically necessary for certain indications when criteria are met.

Effective Date: January 1, 2019

Radiology, Policy No. 57 N/A N/A

Cosmetic and Reconstructive Surgery

Moved the two cosmetic services out of SUR12 and into the following new individual policies:

Note: The separation of these indications into individual policies did not result in a change to policy criteria intent.

Effective Date: January 1, 2019

Surgery, Policy No.s:

12
12.04 (new)
12.06 (new)
CPT codes will be removed from SUR12 and added to the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication. N/A
Varicose Vein Treatment

Updated the policy criteria.

Effective Date: January 1, 2019

Surgery, Policy No. 104 N/A N/A
Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids

Updated policy title.

Added newly available devices and addressed replacement supplies in alignment with the Oregon Hearing Mandate.

Effective Date: January 1, 2019

Surgery, Policy No. 121 N/A Updated policy title on the Preauth website.
Genetic Testing for Epilepsy

New policy addressing genetic testing for epilepsy.

Effective Date: December 1, 2018

Genetic Testing, Policy No. 80 Continue to review unlisted code 81479. Continue the preauth requirement on codes 81401, 81403, 81404, 81405, 81406, and 81407. Added new policy with codes 81401, 81403, 81404, 81405, 81406, and 81407 to the preauth website.
Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Changed policy title. Added circulating tumor/cell-free DNA to the investigational statement.

Effective Date: December 1, 2018

Laboratory, Policy No. 46 N/A N/A
Charged-Particle (Proton) Radiotherapy

Added an investigational statement for charged particle irradiation for stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT)/stereotactic ablative radiotherapy (SABR).
Clarified the location of central nervous system tumors that meet medical necessity criteria.

To ensure proper documentation is submitted regarding CNS tumors, clarified the policy guidelines regarding the documentation required.

Effective Date: December 1, 2018

Medicine, Policy No. 49 Continue preauth requirement on 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340. Added codes 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340, to the preauth website.
Transgender Services

Clarified the policy criteria.

Effective Date: December 1, 2018

Medicine, Policy No. 153 N/A N/A
Bariatric Surgery

Updated the medically necessary critieria in three sections of the policy: general criteria, procedures and reoperation with revision.

Effective Date: December 1, 2018

Surgery, Policy No. 58 N/A N/A
Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome

Changed policy title. Added review of TP53 genetic testing.

Effective Date: November 1, 2018

Genetic Testing, Policy No. 02 N/A Updated policy title on preauth website.
Reproductive Carrier Screening for Genetic Diseases

Changed policy title.

Effective Date: November 1, 2018

Genetic Testing, Policy No. 81 N/A Updated policy title on preauth website.
Hyperbaric Oxygen Pressurization (HBOT)

Added to the list of medically necessary indications.

Effective Date: November 1, 2018

Medicine, Policy No. 14 N/A N/A
Lumbar Spinal Fusion

Updated policy criteria statements, specifically with regard to neurogenic claudication, and clinical tools as a measure of disability. Updated policy guidelines to clarify documentation required for submission to support policy criteria.

Effective Date: November 1, 2018

Surgery, Policy No. 187 N/A N/A
Myoelectric Prosthetic and Orthotic Components for the Upper Limb

Changing policy title.
Adding investigational criteria for upper-limb prosthetic components with both sensor and myoelectric control and for myoelectric controlled upper-limb orthoses.

Effective Date: October 1, 2018

Durable Medical Equipment, Policy No. 80 Adding code L6693 with preauth edit. Adding code L6693 with preauth edit. Changing the policy title on the preauth website.
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer

Changed policy title. Added microRNA expression testing to policy.

Effective Date: October 1, 2018

Genetic Testing, Policy No. 13 Add new CPT code 0069U to this medical policy as part of the quarterly code updates. N/A
Genetic and Molecular Diagnostic Testing

Added criteria to address review of a genetic panel test when the always investigational position of Evaluating the Utility of Genetic Panels (#64) does not apply.

Effective Date: October 1, 2018

Genetic Testing, Policy No. 20 N/A N/A
Evaluating the Utility of Genetic Panels

Added 12 new genetic panel tests to policy.

Effective Date: October 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Analysis of Proteomic and Metabolomic Patterns for Early Detection or Assessing Risk of Cancer

Changed policy title. Added clarification that policy includes testing for cancer risk.

Effective Date: October 1, 2018

Laboratory, Policy No. 41 Add new CPT code 0067U to this medical policy as part of the quarterly code updates. Delete CPT codes 81500, 81503, and 0002U from this medical policy. N/A
Urine Drug Testing for Substance Use and Pain Management

Removed 0020U from presumptive testing criterion as part of annual code set update process. Clarified definitive testing codes in not medically necessary criterion.

Effective Date: October 1, 2018

Laboratory, Policy No. 68 Removed deleted CPT code 0020U as part of the quarterly code updates. N/A
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

Changed policy title. Added urinary testing for colonic polyps to policy.

Effective Date: October 1, 2018

Laboratory, Policy No. 72 Add code 0002U and continue the investigational edit on this code. N/A
Molecular Testing in the Management of Pulmonary Nodules

New policy addressing proteomic and gene expression testing for lung nodules.

Effective Date: October 1, 2018

Laboratory, Policy No. 73 Continue no edit on code 83520 (code not specific) and continue to review unlisted code 64999. N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax

Changed policy to address partial breast irradiation with the same criteria as whole breast irradiation.

Effective Date: October 1, 2018

Medicine, Policy No. 136 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Prostate

Defined adverse pathological findings in criterion II.A. using widely accepted definition.

Effective Date: October 1, 2018

Medicine, Policy No. 137 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Central Nervous System (CNS)

Changed policy title. Removing vertebral tumors from this policy, as they are addressed in other relevant IMRT policies.

Effective Date: October 1, 2018

Medicine, Policy No. 147 N/A Policy title updated on the PreAuth list
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies in accordance with the 4th quarter code update.

Effective Date: October 1, 2018

Medicine, Policy No. 149 Added CPT codes 0062U, 0063U, 0068U to this medical policy as part of the quarterly code updates. N/A
Endometrial Ablation

Updated criteria regarding hormonal therapy. Clarified documentation requirements.

Effective Date: October 1, 2018

Surgery, Policy No. 01 N/A N/A
Cosmetic and Reconstructive Surgery

Maintained services that are always cosmetic in Cosmetic and Reconstructive Surgery, Surgery 12. Separated services that could be potentially medically necessary into the following new individual policies:

Note: The separation of these indications into individual policies did not result in a change to policy criteria intent.

Effective Date: October 1, 2018

Surgery, Policy No.s:

12
12.01 (new)
12.02 (new)
12.03 (new)
12.05 (new)
12.28 (new)
12.34 (new)
12.50 (new)


CPT codes will be removed from SUR12 and added to the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication. The preauth website will be updated to reflect the new separate cosmetic and reconstructive surgery medical policies as appropriate to their indication.
Percutaneous Angioplasty and Stenting of Veins

Added inferior vena cava syndrome to the medically necessary indications.

Effective Date: October 1, 2018

Surgery, Policy No. 109 N/A N/A
Intracardiac Ischemia Monitoring

New investigational policy addressing intracardiac ischemia monitoring.

Effective Date: October 1, 2018

Surgery, Policy No. 208 Add CPT codes 33999 and 93799, and HCPCS code C9750 to this investigational medical policy. N/A
Evaluating the Utility of Genetic Panels

Added 12 new investigational panels and removed 1 panel.

Effective Date: September 1, 2018

Genetic Testing, Policy No. 64 N/A Added code 81413 to preauth website for this medical policy.
Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancers and Thyroid Cancer

Expanding the scope of the policy to address other cancers including, but not limited to skin cancers in the region.

Effective Date: September 1, 2018

Medicine, Policy No. 138 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Revised criteria related to the Karnofsky performance score requirements.

Effective Date: September 1, 2018

Surgery, Policy No. 16 N/A N/A
Implantable Bone Conduction and Bone-Anchored Hearing Aids

Adding audiology criteria for bilateral implantation.

Effective Date: September 1, 2018

Surgery, Policy No. 121 N/A N/A
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation

Updated policy criteria to state that Magnetic resonance (MR) guided focused ultrasound (MRgFUS) may be considered medically necessary for medicine-refractory essential tremors (clinical documentation must be submitted for review).

Effective Date: September 1, 2018

Surgery, Policy No. 139 Removed investigational edit on code 0398T and added preauthorization requirement. Added code 0398T to the preauth website for this medical policy.
Sepsis

New clinical position statement that defines sepsis based on professional organization guidelines and indicates the response and documentation expected.

Effective Date: August 1, 2018

Clinical Position Statement, No. 03 N/A N/A
BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy

Added resectable stage III melanoma to criteria.

Effective Date: August 1, 2018

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

Slight modification to policy title.Updated criteria to allow testing in any individual with primary breast cancer, stage I, II, or III.

Effective Date: August 1, 2018

Genetic Testing, Policy No. 42 N/A Update title on the preauth website
Immunological Cellular Therapies and Gene Therapies

Updated policy title. Updated background information to clarify scope. Added note that LUXTURNA is not addressed by this policy; see Medication Policy Manual for therapies not addressed in this policy.

Effective Date: August 1, 2018

Medicine, Policy No. 42 N/A N/A
Cosmetic and Reconstructive Surgery Added new criteria for rhinoplasty.

Effective Date: August 1, 2018

Surgery, Policy No. 12 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Revised criteria regarding metastases to CNS.

Effective Date: July 18, 2018

Surgery, Policy No. 16 N/A N/A
Cooling Devices Used in the Home Setting

Clarified phrasing in criteria to include circulating and noncirculating to the active and passive descriptions, respectively.

Effective Date: July 1, 2018

Durable Medical Equipment, Policy No. 07 N/A N/A
Molecular Markers in Fine Needle Aspirates of the Thyroid

Updated medical necessity statement to include ThyroSeq®, ThyGenX®, and ThyraMIR when criteria are met.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 49 Remove investigational edit on codes 0018U and 0026U, and add preauth edit. Add codes 0018U and 0026U to the preauth website.
Evaluating the Utility of Genetic Panels

Added two new investigational panels and removed 16 panels.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 64 Remove investigational denial from codes 81410 and 81411 with move to the new medical policy GT77. N/A
Genetic Testing for Heritable Disorders of Connective Tissue

New policy addresses genetic testing for heritable disorders of connective tissue. Criteria for symptomatic individuals, and relatives of those with a known disorder describes when testing may be considered medically necessary. Policy Guidelines specify clinical documentation requirements.

Effective Date: July 1, 2018

Genetic Testing, Policy No. 77 New policy adds codes 81405 an 81408 with a preauth edit. Codes 81410 and 81411 are added to this policy with no edit. Add medical policy to the preauth website for codes 81405 and 81408.
Urine Drug Testing for Substance Use and Pain Management

Updated criteria to:

  • Allow specific codes for presumptive and definitive testing when up to 15 units are billed per type of testing, per year
  • Deny G0482 and G0483 as not medically necessary

Effective Date: July 1, 2018

Laboratory, Policy No. 68 Limiting both presumptive and definitive testing to specific codes (five for presumptive; three for definitive), one code per date of service by the same or different provider, and 15 codes for each type of testing, per year. N/A
Charged-Particle (Proton) Radiotherapy

Changed policy title.

Changed to consider charged particle therapy such as proton beam therapy medically necessary for central nervous system tumors which extend to 10mm or less from the optic chiasm, brain stem, or cervical spinal cord and for reirradiation of head and neck and central nervous system tumors.

Effective Date: July 1, 2018

Medicine, Policy No. 49 N/A Update policy title on the preauth website.
Implantable Cardioverter Defibrillator

Added several new indications for transvenous ICD placement. Removed requirement for specific contraindications for a transvenous ICD to the subcutaneous ICD criteria.

Effective Date: July 1, 2018

Surgery, Policy No. 17 N/A N/A
Spinal Cord and Dorsal Root Ganglion Stimulation

Change to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 45 N/A N/A
Sacral Nerve Neuromodulation/ Stimulation for Pelvic Floor Dysfunction

Change policy title.

Change criteria to allow simultaneous preauthorization for temporary and permanent devices. No separate preauthorization is required.

Effective Date: July 1, 2018

Surgery, Policy No. 134 N/A Change title of medical policy on preauth website.
Sacroiliac Joint Fusion

Use of minimally invasive titanium triangular implants to fuse or stabilize the sacroiliac joint may be considered medically necessary when criteria are met.

Effective Date: July 1, 2018

Surgery, Policy No. 193 Remove investigational denial on code 27279. N/A
The following is a list of recently archived policies:
Intraocular Radiation Thearpy for Age-Related Macular Degeneration Archive Effective Date: January 1, 2019 Medicine, Policy No. 134
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care Archive Effective Date: November 1, 2018 Behavioral Health, Policy No. 23
Genetic Testing for Li-Fraumeni Syndrome

Archive Effective Date: November 1, 2018

NOTE: Criteria that was previously reviewed using GT82 was moved to GT02.

Genetic Testing, Policy No. 82
Percutaneous Tibial Nerve Stimulation Archive Effective Date: October 1, 2018 Surgery, Policy No. 154