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Medical Policy
Regence Medical Policy Update, February 1, 2023
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

Biofeedback

Updating for preauth changes for this policy.

Effective Date: April 1, 2023

Allied Health, Policy No. 32

Adding PA edits to CPT codes 90875, 90876, 90901, 90912, 90913 and HCPCS code E0746 for this policy.

A workflow will be created  that will approve all claims with headache dx codes: G43.xx, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, R51 (dx can be in any position).
Adding CPT codes 90875, 90876, 90901, 90912, 90913 and HCPCS code E0746 to the preauth website for this policy.
Neurofeedback

Updating for preauth changes for this policy.

Effective Date: April 1, 2023

Medicine, Policy No. 65 Adding preauth edits to CPT codes 90875, 90876, 90901 for this policy. Adding CPT codes 90875, 90876, 90901 to the preauth website for this policy.
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Updating criteria to reflect at least three months since fracture OR most recent open reduction for treatment of fracture nonunion. Electrical stimulation for the treatment of osteotomy, stress reaction, and bone marrow edema changed from investigational to not medically necessary.

Effective Date: March 1, 2023

Durable Medical Equipment, Policy No. 83.11 N/A N/A
Genetic Testing for Familial Hypercholesterolemia

Added criteria for testing of children for known familial FH-causing variants.

Effective Date: February 1, 2023

Genetic Testing, Policy No. 11 N/A N/A
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)

Simplified criteria for EGFR and BRAF testing which, along with the Oncomine Dx Target test, may now be considered medically necessary for any stage of NSCLC.

Effective Date: February 1, 2023

Genetic Testing, Policy No. 56 N/A N/A
Evaluating the Utility of Genetic Panels

Added 13 new investigational panels.

Removed nine panels.

Effective Date: February 1, 2023

Genetic Testing, Policy No. 64 N/A N/A
Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Revised criteria to reflect circulating tumor DNA (ctDNA) testing may now be considered medically necessary when tumor testing is not possible and the test is needed to select a targeted treatment approved by the U.S. Food and Drug Administration (FDA)

Effective Date: February 1, 2023

Laboratory, Policy No. 46 For CPT codes 0239U, 0326U, term the investigational denial and add preauth for this policy. Add preauth to CPT codes 0239U, 0326U for this policy.
Vitamin D Testing

Updated diagnoses for which testing may be considered medically necessary to include cystic fibrosis, Crohn’s disease, ulcerative colitis, pancreatitis and long-term use of certain medications

Effective Date: February 1, 2023

Laboratory, Policy No. 52

Adding the following diagnosis codes as medically necessary for vitamin D testing:

E84.19, E84.8, E84.9 Cystic fibrosis

K50.00-K50.919 Crohn’s disease

K51.00-K51.919 Ulcerative colitis

K85.00-K85.92 Pancreatitis

Z79.52 and Z79.811
N/A
Biofeedback

New medical policy addressing biofeedback with investigational and medically necessity criteria.

Effective Date: January 1, 2023

Allied Health, Policy No. 32

Adding CPT codes 90875, 90876, 90901, 90911, HCPCS code E0746 and ICD-10-PCS code GZC9ZZZ to this new medical policy with no clinical edits or preauth requirement at this time.

N/A
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes

Updated criteria for Lynch syndrome testing due to family history.

Effective Date: January 1, 2023

Genetic Testing, Policy No. 06 N/A N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing

Policy title changed from Investigational Gene Expression and Multianalyte Testing.

Added three new investigational tests to policy.

Effective Date: January 1, 2023

Laboratory, Policy No. 77 Add new CPT codes 0357U, 0361U, 0362U with investigational denials. N/A
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the Q1 2023 quarterly code update to address new investigational medical technologies.

Effective Date: January 1, 2023

Medicine, Policy No. 149 Add new CPT codes 0738T, 0739T, 0743T, 0744T, 0745T, 0746T, 0747T, 0748T, 0749T, 0750T, 0764T, 0765T, 0770T, 0771T, 0772T, 0773T, 0774T, 0776T, 0779T, 0781T, 0782T to the policy with investigational edits, and remove deleted CPT codes 0475T, 0476T, 0477T, 0478T, 0491T, 0492T, 0493T, 0497T, 0498T, 0499T from this medical policy. N/A
Treatment of Adult Sepsis

Policy criteria were updated to more explicitly address the diagnosis of sepsis.

Effective Date: January 1, 2023

Medicine, Policy No. 172 N/A N/A
Minimally Invasive Treatments of Nasal Valve Collapse or Obstruction

Policy title changed from Absorbable Nasal Implant for Treatment of Nasal Valve Collapse.

Expanded scope of the policy to noninvasive treatments generally, including radiofrequency treatment.

Effective Date: January 1, 2023

Surgery, Policy No. 209 Add CPT 30469 with investigational denial N/A
Shoulder Surgeries

New policy for the FEP line of business addressing shoulder surgeries.

Effective Date: January 1, 2023

Surgery, Policy No. 228 Add CPT codes 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466 to support FEP preauth requirements for these codes. N/A
Guidelines for the Diagnosis and Treatment of Asthmas in Children, Adolescents, and Adults

Continue to recommend the VA/DoD Guideline.

Effective Date: December 1, 2022

Clinical Practice Guideline N/A N/A
Cholesterol Management in Adults

Continue to endorse the American College of Cardiology/American Heart Association Task Force practice guidelines.

Effective Date: December 1, 2022

Clinical Practice Guideline N/A N/A
Treatment for Diabetes in Adults

Continue to endorse the Department of Veterans Affairs and Department of Defense (VA/DoD) practice guidelines.

Effective Date: December 1, 2022

Clinical Practice Guideline N/A N/A
Preventive Services Guideline for Children and Adolescents

Continue to endorse the American Academy of Pediatrics recommendations for well-child schedules and Centers for Disease Control immunization recommendations, and update the immunization recommendations to 2022.

Effective Date: December 1, 2022

Clinical Practice Guideline N/A N/A
Definitive Lower Limb Prostheses New policy with medical necessity criteria for lower limb prostheses.

Effective Date: December 1, 2022

Durable Medical Equipment, Policy No. 18 Adding HCPCS codes L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987 with preauth edit for this policy. Adding HCPCS codes L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987 to the preauth website for this policy.
Reproductive Carrier Screening for Genetic Diseases

Clarified the policy’s criteria by replacing the term “targeted” with “risk-based” and added an explanation of the terms in the Policy Guidelines.

Added language to criteria regarding X-linked disorder risk threshold.

Effective Date: December 1, 2022

Genetic Testing, Policy No. 81 N/A N/A
Digital Therapeutic Products

Policy title changed from Digital Health Products.

Policy scope limited to digital therapeutic products.

Effective Date: December 1, 2022

Medicine, Policy No. 175 N/A Updated title on preauth website.
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder

Policy title changed from Digital Health Products for Attention Deficit Hyperactivity Disorder.

Policy scope is limited to digital therapeutic products.

Effective Date: December 1, 2022

Medicine, Policy No. 175.01 N/A Updated title on preauth website.
Digital Therapeutic Products for Substance Use Disorders

Policy title changed from Digital Health Products for Substance Use Disorders.

Policy scope is limited to digital therapeutic products.

Effective Date: December 1, 2022

Medicine, Policy No. 175.02 N/A Updated title on preauth website.
Pectus Excavatum and Carinatum Surgery

Policy title changed from Pectus Excavatum

Surgical treatment of pectus carinatum added to policy.

Effective Date: December 1, 2022

Surgery, Policy No. 12.02 N/A N/A
Eating Disorder Inpatient Treatment

Revised criteria regarding provider types, family therapy for adults, and staff overseeing programming.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 25 N/A N/A
Eating Disorder Intensive Outpatient

Revised criteria regarding provider types, family therapy for adults, psychiatric evaluation for intensive outpatient programs, and staff overseeing programming.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 26 N/A N/A
Eating Disorder Partial Hospitalization

Revised criteria regarding provider types, family therapy for adults, and staff overseeing programming.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 27 N/A N/A
Eating Disorder Residential Treatment

Revised criteria regarding provider types, family therapy for adults, and staff overseeing programming.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 28 N/A N/A
Psychiatric Inpatient Hospitalization

Revised criteria regarding provider types, family therapy for adults.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 29 N/A N/A
Psychiatric Intensive Outpatient

Revised criteria regarding provider types, family therapy for adults, psychiatric evaluation for intensive outpatient programs.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 30 N/A N/A
Psychiatric Partial Hospitalization

Revised criteria regarding provider types, family therapy for adults.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 31 N/A N/A
Psychiatric Residential Treatment

Revised criteria regarding provider types, family therapy for adults.

Effective Date: November 1, 2022

Behavioral Health, Policy No. 32 N/A N/A
Hypoglossal Nerve Stimulation Hypoglossal nerve stimulation is considered not medically necessary in adults with obstructive sleep apnea (OSA) when medically necessary criteria are not met, including continuous positive airway pressure refusal. Definitions of Mild (greater than or equal to 1), Moderate (5 to 10) and Severe (greater than or equal to 10) OSA in children have been updated.

Effective Date: November 1, 2022

Surgery, Policy No. 215 Adding CPT code C1767 to this medical policy N/A
Surgical Site of Service – Hospital Outpatient

New medical policy includes medical necessity criteria for hospital outpatient surgical site of service; when criteria are not met for selected gastrointestinal procedures (e.g., endoscopy, colonoscopy), use of a hospital outpatient department for surgical services instead of an ambulatory surgery center (ASC) will be considered not medically necessary.

Note: In addition to the site of service, the services performed may require pre-authorization; check our pre-authorization lists to confirm.

Effective Date: November 1, 2022

Utilization Management, Policy No. 19 Adding CPT codes 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, and 43254 with preauth requirement for outpatient facility only Adding CPT codes 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, and 43254 to the preauth website for this medical policy
Management of Heart Failure in Adults

No changes to the guideline recommendation. Updated hyperlink to guideline.

Effective Date: October 1, 2022

Clinical Practice Guideline N/A N/A
Negative Pressure Wound Therapy in the Outpatient Setting

Moved the required components of the comprehensive wound care to the criteria without change to intent; components were previously listed in the Policy Guidelines section.

Effective Date: October 1, 2022

Durable Medical Equipment, Policy No. 42 N/A N/A
Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer

Added SelectMDx and miR-Sentinal tests to policy criteria.

Effective Date: October 1, 2022

Genetic Testing, Policy No. 17 Added new CPT codes 0339U, 0343U with investigational denial N/A
Evaluating the Utility of Genetic Panels

Added 34 new investigational tests to policy.

Effective Date: October 1, 2022

Genetic Testing, Policy No. 64 Added new CPT codes 0347U, 0348U, 0349U, 0350U with investigational denial. N/A
Biochemical and Cellular Markers of Alzheimer’s Disease

Added blood biomarker testing to the policy.

Effective Date: October 1, 2022

Laboratory, Policy No. 22 Added new CPT code 0346U with investigational denial N/A
Investigational Gene Expression and Multianalyte Testing

Added four new investigational tests to the policy.

Effective Date: October 1, 2022

Laboratory, Policy No. 77 Added new CPT codes 0332U, 0342U, 0344U, 0351U with investigational denial N/A
Ventral (Including Incisional) Hernia Repair

Revising medical policy title; policy was previously called Ventral Hernia Repair

Adding definition regarding hernia associated pain and documentation requirements.

Updating policy guidelines regarding component separation technique.

Updating throughout to clarify the policy applies to incisional ventral hernias.

Effective Date: October 1, 2022

Surgery, Policy No. 12.03 N/A N/A
Leadless Cardiac Pacemakers

Adding Aveir system to policy as investigational.

Effective Date: October 1, 2022

Surgery, Policy No. 217 N/A N/A
Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Continue to recommend the VA/DOD guidelines as a comprehensive evidence-based guideline, with minor changes to the title, hyperlink, and year for the most recent edition.

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Management of Chronic Noncancer Pain with Opioids in Adults Continue to recommend the HHS TIPS publication as a comprehensive evidence-based guideline. 

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Screening and Management of Substance Use Disorders in Adults Continue to recommend the VA/DOD guidelines as a comprehensive evidence-based guideline. Updated the USPSTF guideline in other resources to current guideline.

Effective Date: September 1, 2022

Clinical Practice Guideline N/A N/A
Gender Affirming Interventions for Gender Dysphoria

Clarified the breast/chest procedures addressed in medical necessity criteria by adding "(i.e., breast augmentation, breast reduction, mastectomy, mastopexy, nipple/areola reconstruction/repositioning)"

Effective Date: September 1, 2022

Medicine, Policy No. 153 N/A N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Added criteria requiring require detailed rationale for medical necessity of longer conventionally fractionated regimens for prostate cancer.

Effective Date: September 1, 2022

Medicine, Policy No. 165 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer

Added criteria requiring require detailed rationale for medical necessity of longer conventionally fractionated regimens for some indications.

Effective Date: September 1, 2022

Medicine, Policy No. 166 N/A N/A
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

To align with contract language, policy has been revised to state reconstructive breast surgery may be considered medically necessary after accidental injury or trauma to the breast resulting in significant malformation. In addition, breast implant replacement may be considered medically necessary when placed during medically necessary reconstructive breast surgery. Language added to clarify that breast revision surgery, including breast implant explantation and/or replacement, following a cosmetic primary breast procedure is considered cosmetic when medical necessity criteria are not met.

Effective Date: September 1, 2022

Surgery, Policy No. 40 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Added schwannomas to the list of medically necessary indications.

Effective Date: September 1, 2022

Surgery, Policy No. 214 N/A N/A
The following is a list of recently archived policies:
Vagus Nerve Blocking Therapy for Obesity Archive Effective Date: January 1, 2023 Surgery, Policy No. 200