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Medical Policy
Regence Medical Policy Update, May 23, 2015
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 #

Cosmetic and Reconstructive Surgery

Added new medical necessity criteria regarding panniculectomy.

Effective Date: August 1, 2015

Surgery, Policy No. 12
Surgeries for Snoring and Obstructive Sleep Apnea Syndrome in Adults

Defined "adult" as 18 and older. Added hypoglossal nerve stimulation as investigational. Removed requirement for failure of maximum treatment of underlying disease.

Effective Date: July 1, 2015

Surgery, Policy No. 166
Isolated Small Bowel Transplant

Added retransplant. Criteria for patients who tolerate TPN now applies to any age.

Effective Date: July 1, 2015

Transplant, Policy No. 09
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

New coverage criteria added Removed criteria for testing in minors.

Effective Date: May 23, 2015

Genetic Testing, Policy No. 02
New: Behavioral Health Section of the Manual

Moved the Mental Health section of the manual (Mental Health, Policy No.s 14, 16, 18) and one Utilization Management policy (Utilization Management, Policy No. 14) to this new section of the manual

Effective Date: May 1, 2015

Behavioral Health, Policy No.s 14, 16, 18, and 21
Sequencing-based Tests to Determine Fetal Aneuploidies from Maternal Plasma DNA

Clarified criteria and changed the title.

Effective Date: May 1, 2015

Genetic Testing, Policy No. 44
Evaluating the Utility of Genetic Panels

Added new investigational panel tests.

Effective Date: May 1, 2015

Genetic Testing, Policy No. 64
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction

Added overactive bladder and post rectal surgery to criteria.

Effective Date: May 1, 2015

Surgery, Policy No. 134
Sacroiliac Joint Fusion

New policy with investigational and medical necessity criteria.

Effective Date: May 1, 2015

Surgery, Policy No. 193
Genetic and Molecular Diagnostic Testing

Criteria change to include panel testing and a list of required information for review was added.

Effective Date: April 1, 2015

Genetic Testing, Policy No. 20
Evaluating the Utility of Genetic Panels Added and deleted genetic panel tests.

Effective Date: April 1, 2015

Genetic Testing, Policy No. 64
New and Emerging Medical Technologies and Procedures

Codes 0075T, 0076T, 0329T, and C9742 were added to the policy.

Effective Date: April 1, 2015

Medicine, Policy No. 149
Spinal Cord Stimulation

Added heart failure as investigational indication.

Effective Date: April 1, 2015

Surgery, Policy No. 45
Bariatric Surgery

Criteria clarified regarding reoperation and gastric banding procedures.

Effective Date: April 1, 2015

Surgery, Policy No. 58
Baroreflex Stimulation Devices

Added heart failure as investigational. Noted member contract may apply to treatment of consequences of noncovered services.

Effective Date: April 1, 2015

Surgery, Policy No. 183
Administrative Guidelines to Determine Dental vs Medical Services

Clarified general anesthesia/facility criterion.

Effective Date: March 1, 2015

Allied Health, Policy No. 35
Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Updated policy criteria with additional populations including invasive and ductal carcinoma in situ being considered as breast cancer.

Effective Date: March 1, 2015

Genetic Testing, Policy No. 02
KRAS, NRAS, and BRAF Mutation Analysis in Colorectal Cancer

Added NRAS to investigational criterion.

Effective Date: March 1, 2015

Genetic Testing, Policy No. 13
Genetic Testing for Hereditary Hearing Loss

New policy.

Effective Date: March 1, 2015

Genetic Testing, Policy No. 36
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Criteria change.

Effective Date: March 1, 2015

Genetic Testing, Policy No. 42
Evaluating the Utility of Genetic Panels Added new panel tests.

Effective Date: March 1, 2015

Genetic Testing, Policy No. 64
Laboratory and Genetic Testing for Use of 5-Fluorouracil (5-FU) in Patients with Cancer Policy expanded to include genetic mutation testing (e.g., TheraGuide).

Effective Date: March 1, 2015

Laboratory, Policy No. 64
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy

New investigational policy.

Effective Date: March 1, 2015

Medicine, Policy No. 121
New and Emerging Medical Technologies and Procedures

Codes 44705 and G0455 removed from MED149 and moved to a new policy.

Effective Date: March 1, 2015

Medicine, Policy No. 149
Fecal Microbiota Transplantation

New policy.

Effective Date: March 1, 2015

Medicine, Policy No 154
Applied Behavior Analysis for the Treatment of Autism

Modified criteria and added a list of required information for review.

Effective Date: March 1, 2015

Mental Health, Policy No. 18
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

Clarified criterion definition of saturation biopsy as not limited to 20 or more core tissue samples.

Effective Date: March 1, 2015

Surgery, Policy No. 170
Gastroesophageal Reflux Surgery

Revised criteria regarding fundoplication in conjunction with paraesophageal hiatal hernia repair and achalasia.

Effective Date: March 1, 2015
Surgery, Policy No. 186
Biofeedback

Added investigational indications.

Effective Date: February 1, 2015

Allied Health, Policy No. 32
Genetic Testing for Inherited Susceptibility to Colon Cancer

Added criterion regarding comprehensive panel testing.

Effective Date: February 1, 2015

Genetic Testing, Policy No. 06
BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy

Clarified patient diagnosis within criteria.

Effective Date: February 1, 2015

Genetic Testing, Policy No. 41
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC) Added criteria for additional genes.

Effective Date: February 1, 2015

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

Added, updated and deleted genetic panel tests.

Effective Date: February 1, 2015

Genetic Testing, Policy No. 64
Outpatient Cardiac Telemetry

Criterion clarified.

Effective Date: February 1, 2015

Medicine, Policy No. 135
New and Emerging Medical Technologies and Procedures

Code 27279 replaced 0334T; 33418-33419 replaced 0343T-0344T; 0377T replaced C9735; codes 0299T-0300T, 0378T-0379T, 0381T-0391T, 52441, 52442, 91200 added to the policy.

Effective Date: February 1, 2015

Medicine, Policy No. 149
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Restricted stimulation as an adjunct to cervical spine fusion performed at more than two levels. Criteria added regarding coverage for simulation for adjunct fusion to be applied postoperatively. Added new investigational criteria regarding stress fracture.

Effective Date: January 1, 2015

Durable Medical Equipment, Policy No. 83.11
JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms

Clarified criteria.

Effective Date: January 1, 2015
Genetic Testing, Policy No. 59
Evaluating the Utility of Genetic Panels

Added, updated and deleted genetic panel tests. Deletion of Prosigna gene expression assay.

Effective Date: January 1, 2015
Genetic Testing, Policy No. 64
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults

New investigational policy.

Effective Date: January 1, 2015

Medicine, Policy No. 152
Transgendered Services

New policy addressing medical and surgical treatments of gender dysphoria in transgender individuals.

Effective Date: January 1, 2015

Medicine, Policy No. 153
Lumbar Spinal Fusion

Added investigational staged fusion and criteria for abstinence from smoking.

Effective Date: January 1, 2015

Surgery, Policy No. 187
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Added fecal incontinence.

Effective Date: December 1, 2014

Allied Health, Policy No. 04
Artificial Pancreas Device System (APDS)

Removed criteria regarding CGM devices.

Effective Date: December 1, 2014

Durable Medical Equipment, Policy No. 77
Powered Knee Prosthesis, or Powered Ankle-Foot Prosthesis, and Microprocessor-Controlled Ankle-Foot Prosthesis

Clarified terminology.

Effective Date: December 1, 2014

Durable Medical Equipment, Policy No. 81
Cytochrome p450 Genotyping

Addition of medical necessity criterion for the selection and dosing of eliglustat.

Effective Date: December 1, 2014

Genetic Testing, Policy No. 10
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Addition of Prosigna test.

Effective Date: December 1, 2014

Genetic Testing, Policy No. 42
Hyperbaric Oxygen Therapy (HBOT)

Investigational list clarified.

Effective Date: December 1, 2014

Medicine, Policy No. 14
New and Emerging Medical Technologies and Procedures

Added device and manufacturer names to criteria.

Effective Date: December 1, 2014

Medicine, Policy No. 149
Cochlear Implant

Added investigational hybrid device.

Effective Date: December 1, 2014

Surgery, Policy No. 08
Extracranial Carotid Angioplasty/Stenting

Added CPT 37217 which will require preauthorization.

Effective Date: December 1, 2014

Surgery, Policy No. 93
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)

Off-pump criteria clarified.

Effective Date: December 1, 2014

Surgery, Policy No. 177
Bronchial Thermoplasty

Clarified investigational indications for bronchial thermoplasty.

Effective Date: December 1, 2014

Surgery, Policy No. 178
Applied Behavior Analysis for the Treatment of Autism

Policy updated.

Effective Date: See policy for dates.

Mental Health, Policy No. 18
The following is a list of recently archived policies:
Mental Health Section of the Manual and one Utilization Mangement Policy

Not technically archived, but rather moved to the Behavioral Health Section of the Manual
Effective: May 1, 2015

Mental Health, Policy No.s 14, 16, 18; and Utilization Management, Policy No. 14
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Archive Effective Date:
January 1, 2015
Surgery, Policy No. 173
KRAS Mutation Analysis in Non-Small Cell Lung Cancer (NSCLC)

Archive Effective Date:
January 1, 2015

NOTE: Criteria for this test added to GT56

Genetic Testing, Policy No. 14