Regence
Medical Policy Update, November 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. |
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Policy Name |
Summary
of Policy or Change |
|
Coding / Implementation Change
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| 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 |
| Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders |
Policy updated. Please see the 4/1/2019 Provider Newsletter for the implementation plan around this update.
Effective Date: July 1, 2019 |
Behavioral Health, Policy No. 18 |
Add PreAuth for codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 |
Policy added to the Preauth website. |
| Chromosomal Microarray Analysis (CMA) for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies |
Title changed.
Added testing of adults for the same indications as testing of pediatric patients to the medical necessity criteria.
Effective Date: July 1, 2019 |
Genetic Testing, Policy No. 58 |
N/A |
Policy title updated on the preauth list. |
| Evaluating the Utility of Genetic Panels |
Added 13 new investigational panels and removed four panels.
Effective Date: July 1, 2019 |
Genetic Testing, Policy No. 64 |
N/A |
N/A |
| Laboratory Tests for Heart and Kidney Transplant Rejection |
Title changed.
Added donor-derived cell-free DNA testing for kidney transplant to policy.
Effective Date: July 1, 2019 |
Laboratory, Policy No. 51 |
New codes that are effective 7/1/2019 added to the policy - 0087U and 0088U. |
N/A |
| New and Emerging Medical Technologies and Procedures |
Added new investigational medical technologies in accordance with the 3rd quarter code update.
Moved codes related to phrenic nerve stimulation for central sleep apnea to new medical policy Surgery, Policy No. 212.
Effective Date: July 1, 2019 |
Medicine, Policy No. 149 |
New codes that are effective 7/1/2019 added to the policy - 0543T, 0544T, 0545T, 0547T, 0548T, 0549T, 0550T, 0551T, 0553T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T, 0560T, 0561T, 0562T.
Deleted code that was effective 7/1/2019 from the policy – C9746.
Moved codes to the new investigational policy Surgery 212 - 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T. |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
Updated title, description, and format of criteria.
Added new criteria for endometrial ablation.
Effective Date: July 1, 2019 |
Medicine, Policy No. 153 |
Add preauth to codes 17999, 19316, 19318, 19324, 19325, 19350, L8600, 58353, 58356, 58563 for this medical policy. |
Update preauth list in alignment with policy changes. Add codes 17999, 19316, 19318, 19324, 19325, 19350, L8600, 58353, 58356, 58563 to the preauth list for this medical policy. |
| Spinal Cord and Dorsal Root Ganglion Stimulation |
Added coverage for dorsal root ganglion stimulation when criteria are met.
Effective Date: July 1, 2019 |
Surgery, Policy No. 45 |
N/A |
N/A |
| Varicose Vein Treatment |
Added criteria for use of endovenous glue/adhesives for the treatment of varicose veins.
Effective Date: July 1, 2019 |
Surgery, Policy No. 104 |
N/A |
N/A |
| Phrenic Nerve Stimulation for Central Sleep Apnea |
New investigational policy addressing phrenic nerve stimulation for central sleep apnea.
Effective Date: July 1, 2019 |
Surgery, Policy No. 212 |
Add CPT codes 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T and continue investigational denial, and add HCPCS code C1823 with preauth to this new medical policy. |
Add new policy to the preauth list for code C1823. |
| Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms |
Merged criteria for reduced intensity conditioning (RIC) and myeloablative regimens. Added a criterion that states a myeloablative transplant after RIC is considered investigational.
Effective Date: July 1, 2019 |
Transplant, Policy No. 45.24 |
N/A |
N/A |
| Hematopoietic Cell Transplantation for Hodgkin Lymphoma |
Policy criteria statements updated, specifically with regard to reduced-intensity conditioning, a second allogeneic hematopoietic cell transplant (HCT), and tandem HCT.
Effective Date: July 1, 2019 |
Transplant, Policy No. 45.30 |
N/A |
N/A |
| Programmable Pneumatic Compression Pumps |
Added criteria for coverage of single- or multi-chamber programmable pumps.
Effective Date: June 1, 2019 |
Durable Medical Equipment, Policy No. 78 |
Liberalized edit on code E0652 from always denying as not medically necessary to now requiring preauth |
Added code E0652 to the preauth list for this policy. |
| Genetic Testing for Alzheimer's Disease |
Notification based on changes to coding/implementation and Preauth change. See the last two columns.
Effective Date: June 1, 2019 |
Genetic Testing, Policy No. 01 |
Remove preauth from code 88363. |
Remove code 88363 from the preauth list. |
| Genetic Testing for Inherited Susceptibility to Colon Cancer |
Notification based on changes to coding/implementation and Preauth change. See the last two columns.
Effective Date: June 1, 2019 |
Genetic Testing, Policy No. 06 |
Remove preauth from code 88363. |
Remove code 88363 from the preauth list. |
| KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer |
Notification based on changes to coding/implementation and Preauth change. See the last two columns.
Effective Date: June 1, 2019 |
Genetic Testing, Policy No. 13 |
Remove preauth from code 88363. |
Remove code 88363 from the preauth list. |
| Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) |
Added KRAS and NTRK gene fusion testing to medical necessity criteria.
Effective Date: June 1, 2019 |
Genetic Testing, Policy No. 56 |
Remove preauth from code 88363. |
Remove code 88363 from the preauth list. |
| Vagus Nerve Stimulation |
Changed number of required antiepileptic drugs in criteria from 4 to 2.
Effective Date: June 1, 2019 |
Surgery, Policy No. 74 |
N/A |
N/A |
| The following
is a list of recently archived policies: |
| 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 |
