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Medical Policy
Regence Medical Policy Update, May 1, 2020
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

Identification of Microorganisms Using Nucleic Acid Probes

Added Gardnerella vaginalis testing as investigational.

Effective Date: August 1, 2020

Genetic Testing, Policy No. 85 Adding investigational denial to CPT codes 87510 and 87511 N/A
New and Emerging Medical Technologies and Procedures

Added CPT code 0465T as always investigational.

Effective Date: August 1, 2020

Medicine, Policy No. 149 Adding investigational denial to CPT code 0465T N/A
Intensity Modulated Radiotherapy (IMRT) of the THorax, Abdomen, Pelvis, and Extremities

Changing policy title.

Adding criteria for review of soft tissue sarcomas.

Effective Date: June 1, 2020

Medicine, Policy No. 165 N/A Updating title on preauth website.
Evaluating the Utility of Genetic Panels

Removed four panels from policy.

Effective Date: May 1, 2020

Genetic Testing, Policy No. 64 N/A N/A
Identification of Microorganisms Using Nucleic Acid Probes

Removed Chlamydophila pneumonia from investigational criterion.

Removed  nucleic acid gastrointestinal pathogen panels from policy.

Effective Date: May 1, 2020

Genetic Testing, Policy No. 85 Changed CPT codes 87485 and 87486 from investigational to medically necessary. N/A
New and Emerging Medical Technologies and Procedures

Added suction-assisted protein lipectomy to existing CPT code 38999 for this policy.

Effective Date: May 1, 2020

Medicine, Policy No. 149 N/A N/A
Surgical Treatments for Hyperhidrosis

Clarified primary craniofacial hyperhidrosis from secondary gustatory hyperhidrosis and removed “secondary fungal or bacterial infection” from recurrent skin maceration as a medical complication supporting surgical treatment.

Added a coding note that procedure codes 11450 and 11451 should not be reported for hyperhidrosis.

Effective Date: May 1, 2020

Surgery, Policy No. 165 Updated systems to override the preauth requirement on code 32664 unless one of these hyperhidrosis diagnoses is found on the claim: L74.510, L74.511, L74.512, L74.513, L74.519, L74.52, and R61 Updated the preauth page to read: Code 32664 only requires preauthorization for hyperhidrosis diagnoses L74.510, L74.511, L74.512, L74.513, L74.519, L74.52, and R61
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

Changed criteria to consider autologous transplant investigational in pediatric patients.

Effective Date: May 1, 2020

Transplant, Policy No. 45.36 N/A N/A
Insulin Infusion Pumps, Automated Insulin Deliver and Artificial Pancreas Device Systems

Changed policy title.

Clarified the device terminology.

Removed the requirement for the member to experience at least two nocturnal hypoglycemic events prior to considering an artificial pancreas device system as medically necessary.

Effective Date: April 1, 2020

Durable Medical Equipment, Policy No. 77 N/A Updated the policy title on the Preauth website.
Evaluating the Utility of Genetic Panels

Added 17 new investigational panels. Removed 15 panels.

Effective Date: April 1, 2020

Genetic Testing, Policy No. 64 Add new CPT codes 0170U and 0171U with investigational denial. N/A
Whole Exome and Whole Genome Sequencing

Whole exome sequencing may now be considered medically necessary for pediatric patients when policy criteria are met.

Effective Date: April 1, 2020

Genetic Testing, Policy No. 76 Add preauth requirement to CPT codes 81415 and 81416 for this policy. Add codes 81415 and 81416 to the preauth site for this medical policy.
Myocardial Strain Imaging

New investigational policy.

Effective Date: April 1, 2020

Medicine, Policy No. 168 Added new CPT code 93356 with investigational denial edit. N/A
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

Change a subset of indications from investigational to not medically necessary.

Effective Date: April 1, 2020

Surgery, Policy No. 134 N/A N/A
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome

Added criteria for testing to confirm BRCA variants found through direct-to-consumer testing and BRIP1, RAD51C, and RAD51D testing for hereditary ovarian cancer risk.

Effective Date: March 1, 2020

Genetic Testing, Policy No. 02 N/A Updating title on preauth website.
Femoroacetabular Impingement Surgery

Removed criteria requiring no evidence of severe chondral damage. Removed criteria requiring documentation of activity modification to avoid symptoms.

Effective Date: March 1, 2020

Surgery, Policy No. 160 N/A N/A
Microwave Tumor Ablation

Added medical necessity criteria for microwave tumor ablation for some lung tumors.

Effective Date: March 1, 2020

Surgery, Policy No. 189 N/A N/A
Ablation of Primary and Metastatic Liver Tumors

Removed criteria requiring goal of treatment to be curative.

Effective Date: March 1, 2020

Surgery, Policy No. 204 N/A N/A
Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies

Changed policy title.

Added copy number variation testing to policy.

Effective Date: January 1, 2020

Genetic Testing, Policy No. 58 New CPT code 0156U added to the policy with preauth required. Changed policy title and added code 0156U on the preauth website for this policy.
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)

Removed reference to non-squamous cell-type cancer from EGFR testing.

Effective Date: January 1, 2020

Genetic Testing, Policy No. 56 N/A N/A
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR

Changed policy title.

Added MTHFR testing for thrombophilia to policy.

Effective Date: January 1, 2020

Genetic Testing, Policy No. 65 N/A Changed policy title on the preauth website for this policy.
Identification of Microorganisms Using Nucleic Acid Probes

Added semi-quantitative testing to policy.

Effective Date: January 1, 2020

Genetic Testing, Policy No. 85 New CPT code 0151U added to the policy with investigational denial. N/A
Urine Drug Testing for Substance Use and Pain Management

Updated policy to reflect that the rolling calendar year limit is based on the first date that a claim for the service is received and not on the actual date of service.

Effective Date: January 1, 2020

Laboratory, Policy No. 68 Added new CPT codes 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, and 0150U to the policy with a not medically necessary denial edit. N/A
New and Emerging Medical Technologies and Procedures

In accordance with the 2020 1st quarter code updates:

  • Added new investigational medical technologies
  • Removed deleted codes

Effective Date: January 1, 2020

Medicine, Policy No. 149 Added new CPT codes 0139U, 0563T, 0567T, 0568T, 0569T, 0570T, 0582T, C1824, and C2596 with investigational denial edits to this policy. Removed deleted CPT codes 0205T , 0249T, 0341T, 0377T from this policy. NOTE: see entry for new policy SUR219 that address the replacement code 46948 (replaces 0249T). N/A
Gender Affirming Interventions for Gender Dysphoria

Removed the requirement for 12 months of continuous hormone therapy prior to breast augmentation.

Updated criteria to remove psychotherapy and hormone therapy, which are either medically necessary or if the member’s coverage includes a pharmacy benefit, it may have a Pharmacy review requirement.

Effective Date: January 1, 2020

Medicine, Policy No. 153 Added CPT 67950 to this policy and continue preauth requirement. Added unlisted CPT codes 19499, 31899, and 40799 to this policy and continue to review these unlisted codes. Removed deleted CPT code 19304 from the policy. Added CPT 67950 on the preauth website for this policy.
Implantable Cardioverter Defibrillator

Added extravascular (substernal) ICDs to policy.

Effective Date: January 1, 2020

Surgery, Policy No. 17 Added new CPT codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T with investigational denial edit to this policy. N/A
Bariatric Surgery

Reorganized criteria with no change to criteria intent.

Effective Date: January 1, 2020

Surgery, Policy No. 58 Added CPT code 43820 with preauth requirement to this policy. Added CPT code 43820 to the preauth website for this policy.
Percutaneous Angioplasty and Stenting of Veins

Removed age requirement from pulmonary artery stenosis criterion.

Added symptomatic venous occlusion due to electrical device lead or central line placement to medically necessary indications.

Effective Date: January 1, 2020

Surgery, Policy No. 109 N/A N/A
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial

Added criteria to consider the WATCHMAN device medically necessary for stroke prevention in patients who are at increased risk for stroke and have contraindications to long-term anticoagulation therapy.

Effective Date: January 1, 2020

Surgery, Policy No. 195 Removed investigational denial on code 33340 and added preauth requirement. Added CPT code 33340 to the preauth website for this policy.
Transanal Hemorrhoidal Dearterialization

New investigational policy.

Effective Date: January 1, 2020

Surgery, Policy No. 219 Added new CPT code 46948 with investigational denial for this policy. N/A
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes

Added risk of Lynch syndrome based on prediction models to policy criteria.

Effective Date: December 1, 2019

Genetic Testing, Policy No. 06 N/A N/A
Evaluating the Utility of Genetic Panels

Added twenty-one new investigational panels to the policy.

Removed three panels from the policy.

Effective Date: December 1, 2019

Genetic Testing, Policy No. 64 N/A N/A
The following is a list of recently archived policies:
Suprachoroidal Delivery of Pharmacological Agents Archive Effective Date: May 1, 2020 Medicine, Policy No. 132
Programmable Pneumatic Compression Pumps Archive Effective Date: February 1, 2020 Durable Medical Equipment, Policy No. 78
Tumor Treating Fields Therapy Archive Effective Date: February 1, 2020 Durable Medical Equipment, Policy No. 85
Genetic Testing for Cardiac Ion Channelopathies Archive Effective Date: February 1, 2020 Genetic Testing, Policy No. 07
Genetic Testing for Inherited Thrombophilia Archive Effective Date: February 1, 2020 Genetic Testing, Policy No. 47
Genetic Testing for Hereditary Hemochromatosis Archive Effective Date: February 1, 2020 Genetic Testing, Policy No. 48
Single Photon Emission Computed Tomography (SPECT) of the Brain Archive Effective Date: January 1, 2020 Radiology, Policy No. 44
Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT) Archive Effective Date: January 1, 2020 Radiology, Policy No. 57