Recent Updates to the Regence Group Medical Policy Manual

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Regence Medical Policy Update, October 1, 2016
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*
Intensity Modulated Radiotherapy (IMRT) of the Thorax	Significant reformatting and clarifications made to the policy criteria. New requirements for histogram analysis and the term curative treatment was added to the criteria for specific indications. IMRT may be considered medically necessary for individuals with large breasts in order to avoid or minimize hot spots when policy criteria is met. A list of information needed for review was updated in the Policy Guidelines section. Effective Date: January 1, 2017	Medicine, Policy No. 136	N/A	N/A
Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer	IMRT for anaplastic thyroid carcinoma and locoregional recurrence may be considered medically necessary. In addition, IMRT for treatment of other thyroid cancers may be considered medically necessary when the tumor is in close proximity to organs at risk and dose/volume histograms demonstrate the need for IMRT. The policy title was updated to reflect the newer terminology of radiotherapy. Effective Date: December 1, 2016	Medicine, Policy No. 138	N/A	N/A
Radioembolization for Primary and Metastatic Tumors of the Liver	Specified that hepatocellular carcinoma (criteria I.B.) and intrahepatic cholangiocarcinoma (criteria I.E.) must be primary. Effective Date: December 1, 2016	Medicine, Policy No. 140	N/A	N/A
Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors	Change term in title from “Radiation Therapy” to “Radiotherapy". Change criteria to only allow IMRT when the tumor is in close proximity to organs at risk. Added a Policy Guidelines section with a list of information needed for review, definition of at-risk organs, and an IMRT dose constraint reference. Effective Date: December 1, 2016	Medicine, Policy No. 147	N/A	N/A
Intensity Modulated Radiotherapy (IMRT of the Prostate	One addition to the policy requiring 90-day notification that states IMRT for treatment of prostate cancer, including palliative treatment, at radiation doses less than 60 Gy is considered not medically necessary. Effective Date: November 1, 2016	Medicine, Policy No. 137	N/A	Code is already on the PreAuth list
Electrical Bone Growth Stimulators (Osteogenic Stimulation)	Reorganized the criteria to combine noninvasive indications. Effective Date: October 1, 2016	Durable Medical Equipment, Policy No. 83.11	N/A	N/A
Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis	Clarified the criteria for abdomen and pelvis which states that IMRT may be considered medically necessary when the tumor is in close proximity to organs at risk and dose/volume histograms demonstrate a need for IMRT. The title was updated to reflect the newer terminology of radiotherapy. A list of information needed for review was updated to align with the revised policy criteria. Effective Date: October 1, 2016	Medicine, Policy No. 139	N/A	N/A
MRI-Guided Focused Ultrasound (MRgFUS)	Clarified our investigational criterion on the use of MRgFUS for the treatment of movement disorders. Effective Date: October 1, 2016	Surgery, Policy No. 139	N/A	N/A
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis	Criteria clarified that stents to treat recurrent polyposis are investigational. Effective Date: October 1, 2016	Surgery, Policy No. 198	N/A	N/A
Prefabricated Oral Appliances for Obstructive Sleep Apnea	New policy that considers prefabricated oral appliances investigational for the treatment of obstructive sleep apnea. Effective Date: September 1, 2016	Allied Health, Policy No. 36	Add investigational denial to HCPCS E0485 and remove from the AIM list of codes to review	Remove code E0485 from AIM list of codes
Cooling Devices Used in the Home Setting	Modify criteria to clarify noncoverage for the indication of compression only. Effective Date: September 1, 2016	Durable Medical Equipment, Policy No. 07	N/A	N/A
Evaluating the Utility of Genetic Panels	Added additional investigational panels and removed several panels. Effective Date: September 1, 2016	Genetic Testing, Policy No. 64	N/A	N/A
Radioembolization for Primary and Metastatic Tumors of the Liver	Added medical necessity criteria (I.C.2.) for the use of radioembolization for unresectable hepatic metastases from melanoma (cutaneous and ocular/uveal). Clarified language in policy criteria for unresectable hepatic metastases. Effective Date: September 1, 2016	Medicine, Policy No. 140	N/A	N/A
Cosmetic and Reconstructive Surgery	No significant policy criteria changes. However, the policy criteria was reorganized to clarify medical necessity by procedure. Effective Date: September 1, 2016	Surgery, Policy No. 12	N/A	N/A
Reduction Mammaplasty	Added new criterion that reduction mammaplasty as a preparatory first stage procedure preceding a nipple-sparing mastectomy may be considered medically necessary when policy criteria are met. Additional criterion added that reduction mammaplasty for gynecomastia is considered not medically necessary. Effective Date: September 1, 2016	Surgery, Policy No. 60	N/A	N/A
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions	Clarified criterion to consider third-generation ACI therapies are investigational. Effective Date: September 1, 2016	Surgery, Policy No. 87	N/A	N/A
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy	Policy scope clarified to include ablation and sclerotherapy as treatment of pelvic congestion syndrome and varicoceles. Effective Date: September 1, 2016	Surgery, Policy No. 147	N/A	Title change
Plasma Exchange (Plasmapheresis)	Criteria changes to consider additional indications medically necessary. Effective Date: August 19, 2016	Medicine, Policy No. 05	N/A	N/A
Sequencing-based Tests to Determine Fetal Aneuploidies and Microdeletions from Maternal Plasma DNA	Scope of the policy has changed. Fetal trisomy aneuploidy (T13, T18, and T21) screening criteria was removed from the policy. Criteria added to state that testing for fetal sex chromosome anueploidies is considered investigational. Effective Date: August 1, 2016	Genetic Testing, Policy No. 44	Delete CPT codes 81420, 81507, and 0009M from policy and remove preauth edit	Delete CPT codes 81420, 81507, and 0009M from policy and remove from the preauth website
Vitamin D Testing	Added osteopenia with specific ICD-10 codes, M85.80 and M85.88, to Appendix I. Effective Date: August 1, 2016	Laboratory, Policy No. 52	Add ICD 10 dx codes M85.80 and M85.88 as covered dx for code 82306	N/A
Intensity Modulated Radiotherapy (IMRT of the Prostate	Existing policy criteria liberalized. The list of information needed for review was updated. Effective Date: August 1, 2016	Medicine, Policy No. 137	N/A	Policy name changed on the PreAuth website
Implantable Bone-Conduction and Bone-Anchored Hearing Aids	Adding criteria to address replacements and upgrades. Effective Date: August 1, 2016	Surgery, Policy No. 121	N/A	N/A
Myoelectric Prosthetic Components for the Upper Limb	Policy update that a prosthesis with individually powered digits may be considered medically necessary when criteria are met. Effective Date: July 1, 2016	Durable Medical Equipment, Policy No. 80	Investigational denial on code L6880 termed and preauth added to this code effective 7/1/2016.	Investigational denial on code L6880 termed and preauth added to this code effective 7/1/2016.
Molecular Markers in Fine Needle Aspirates of the Thyroid	Criteria clarified to state that when the criteria for Afirma are not met, Afirma is considered not medically necessary and that all other gene expression classifiers, including but not limited to ThyraMIR are considered investigational. Effective Date: July 1, 2016	Genetic Testing, Policy No. 49	N/A	N/A
New and Emerging Medical Technologies and Procedures	Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T. Effective Date: July 1, 2016	Medicine, Policy No. 149	Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T.	Added new investigational codes to the policy: 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, and 0445T. HCPCS code C9743 was removed and replaced with 0438T.
Single Photon Emission Computed Tomography (SPECT) of the Brain	Added additional investigational indications and expanded the scope of the policy to brain imaging for a variety of neurologic, psychiatric, psychological, and other nononcologic indications. Effective Date: July 1, 2016	Radiology, Policy No. 44	N/A	N/A
Endometrial Ablation	Criterion now requires pre-procedural sampling regardless of age or unopposed estrogen exposure for initial and repeat ablation. Criterion now requires pre-procedural imaging report for initial and repeat ablation. Effective Date: July 1, 2016	Surgery, Policy No. 01	N/A	N/A
Cosmetic and Reconstructive Surgery	Clarified blepharoplasty criteria requirements for visual field examinations. Effective Date: July 1, 2016	Surgery, Policy No. 12	N/A	N/A
Varicose Vein Treatment	Clarified and updated the general criteria requirements including but not limited to the use of unna boot and compression wraps, documentation of conservative therapy and documentation requirements for imaging studies. Clarified and updated the criteria for additional treatment sessions and imaging. Clarified treatments that don’t meet medically necessity criteria are considered not medically necessary. Added criteria that considers sclerotherapy of vulvar varices as not medically necessary. Effective Date: July 1, 2016	Surgery, Policy No. 104	N/A	N/A
Artificial Intervertebral Disc	Allow simultaneous two level disc replacement in addition to the removal of the exclusion of prior fusion at the same or any adjacent level. Effective Date: July 1, 2016	Surgery, Policy No. 127	N/A	N/A
Lumbar Spinal Fusion	Added that multi-session fusions are medically necessary for severe spinal deformities. Clarified medication use to state trial of at least two prescription analgesics or non-steroidal antiinflammatories unless contraindicated. Removed requirement for comprehensive evaluation by other providers including behavioral health. Effective Date: July 1, 2016	Surgery, Policy No. 187	N/A	N/A
Supplement to MCG™ Discharge Criteria for Residential Treatment	The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines. Effective Date: June 1, 2016	Behavioral Health, Policy No. 21	N/A	N/A
Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care	The MCG supplemental policy criteria were not changed but the MCG guidelines referenced were changed from the MCG Level of Care Guidelines to the MCG Care Guidelines. Effective Date: June 1, 2016	Behavioral Health, Policy No. 23	N/A	N/A
Bariatric Surgery	Criteria changed to only require one comorbidity for patients with a BMI equal to or greater than 35. Added investigational criteria for laparoscopic duodenal switch with single anastomosis. Removed sleeve gastrectomy as a reoperation procedure for lap band conversion. Added gastric balloon as an example of an investigational endoscopic procedure. Effective Date: June 1, 2016	Surgery, Policy No. 58	N/A	N/A
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome	Added pediatric patients to the investigational and not medically necessary criteria. Effective Date: June 1, 2016	Surgery, Policy No. 166	N/A	Change name of policy on preauth website
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia	Added language to allogeneic hematopoietic stem-cell transplantation criteria specifying chemotherapy is planned to achieve complete remission. Added additional clarification to criteria. Effective Date: June 1, 2016	Transplant, Policy No. 45.28	N/A	N/A
Genetic Testing for CADASIL Syndrome	Changed criteria to consider genetic testing medically necessary to confirm a diagnosis of CADASIL syndrome when criteria are met. Effective Date: May 1, 2016	Genetic Testing, Policy No. 51	N/A	N/A
Dopamine Transporter Single-Photon Emission Computed Tomography	New policy which considers the use of DAT-SPECT investigational for all indications. Effective Date: May 1, 2016	Radiology, Policy No. 57	Continue preauth requirement on code 78607. Add investigational denial to code A9584.	Add policy to preauth website.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy	Significant update to the policy to consider additional indications as medically necessary. In addition, existing criteria was updated with further criteria changes. Effective Date: May 1, 2016	Surgery, Policy No. 16	N/A	N/A
Liver Transplant	Clarified the investigational criteria for retransplantation. Effective Date: May 1, 2016	Transplant, Policy No. 05	N/A	N/A
The following is a list of recently archived policies:
Enhanced External counterpulsation (EECP)		Archive Effective Date: October 1, 2016		Medicine, Policy No. 66
Acoustic Cardiography		Archive Effective Date: October 1, 2016		Medicine, Policy No. 114
T-Wave Alternans		Archive Effective Date: September 1, 2016		Medicine, Policy No. 88
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)		Archive Effective Date: September 1, 2016		Surgery, Policy No. 177
Systems Pathology in Prostate Cancer		Archive Effective Date: July 1, 2016		Laboratory, Policy No. 61
Manipulation Under Anesthesia for the Treatment of Pain		Archive Effective Date: July 1, 2016		Medicine, Policy No. 130


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.