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Medical Policy
Regence Medical Policy Update, September 1, 2021
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

Ventral Hernia Repair

Updating the criteria to state component separation technique may be considered medically necessary in the repair of midline abdominal wall defects, including ventral and incisional hernias, when they are greater than or equal to 10 centimeters in width.

Adding a description of the component separation technique to the Policy Guidelines section and a coding note to the Policy Criteria.

Effective Date: December 1, 2021

Surgery, Policy No. 12.03 N/A N/A
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

Added BioDFence® [Q4140] and AmnioBand®, particulate [Q4168] to list of investigational products.

Effective Date: November 1, 2021

Medicine, Policy No. 170 For CPT codes Q4140, and Q4168 change edit to remove preauth and add and investigational denial for this policy. Removing CPT codes Q4140 and Q4168 from the PreAuth website for this policy.
Treatment of Adult Sepsis

New Medical Policy based on Clinical Position Statement CPS03. Statements were added to the new policy to add clarity, but with no change from the intent of the clinical position statement.

Effective Date: November 1, 2021

Medicine, Policy No. 172 N/A N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Adding requirement for clinical justification for the length and frequency of treatment and observation.

Effective Date: October 1, 2021

Behavioral Health, Policy No. 18 N/A N/A
Identification of Microorganisms Using Nucleic Acid Probes

Removed nucleic acid testing for G. vaginalis from the policy.

Effective Date: September 1, 2021

Genetic Testing, Policy No. 85

Removed CPT codes 81513, 81514, 87510, 87511 and always not medically necessary edit on these codes for this policy.

For CPT code 87512 change edit from always not medically necessary to investigational.
N/A
Laboratory Tests for Heart, Kidney, and Lung Transplant Rejection

Revised policy title –  previously Laboratory Tests for Heart and Kidney Transplant Rejection.

Added heart and lung transplant as investigational indications for the use of peripheral blood measurement of dd-cfDNA.

Effective Date: September 1, 2021

Laboratory, Policy No. 51 N/A N/A
Measurement of Serum Antibodies to Selected Biologic Agents

Editing criteria to clarify intent is to specifically address serum antidrug antibody testing.

Effective Date: September 1, 2021

Laboratory, Policy No. 65 Adding CPT codes 80145, 80230, 80280 with preauth edit Adding CPT codes 80145, 80230, 80280 to the preauth website
Gender Affirming Interventions for Gender Dysphoria

Changed the length of prior hormone therapy and time living in a role congruent with the patient’s identity from 12 months to 6 months, consistent with the DSM-5.

Removed Criterion I.A.2. regarding the patient’s capacity to make fully informed decisions, as this is addressed with the mental health professionals criterion.

Effective Date: September 1, 2021

Medicine, Policy No. 153 Added CPT code 54405 with no edit. N/A
Skin Lesion Imaging and Spectroscopy

New policy addressing investigational skin lesion evaluation technologies.

Effective Date: September 1, 2021

Medicine, Policy No. 174 Add CPT codes 0470T, 0471T, 0658T, 96931, 96932, 96933, 96934, 96935, 96936 with no change to the investigational edits. N/A
Radiofrequency Ablation (RFA) of Tumors Other than Liver

Added new medically necessary criteria for RFA for symptomatic uterine fibroids.

Effective Date: September 1, 2021

Surgery, Policy No. 92 For CPT codes 58674, 0404T, term investigational denial and add preauth requirement for this policy. Added CPT codes 58674, 0404T to the preauth website for this policy.
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome
  • Added atrial fibrillation to the list of associated symptoms.
  • Edited to clarify adjustment in sleep position is required only when the sleep study shows resolution of sleep apnea when non-supine.
  • Added an adequate trial of a custom-made mandibular repositioning appliance must be completed when the patient is an appropriate candidate for the appliance before surgical intervention. An adequate trial is at least 90 consecutive days of continuous (at least 5 nights per week) use of the appliance.
  • Added patients with PAP failure or with PAP intolerance may meet PAP trial requirement when criteria are met, and PAP refusal is a not medically necessary indication
  • Added “and telegnathic” to note at top of Policy Criteria to read “Some member contracts have specific benefit limitations for orthognathic and telegnathic surgery”.
  • Clarified the definition of hypopnea in the body of the policy to state thresholds of either CMS or AASM scoring systems are acceptable

Effective Date: September 1, 2021

Surgery, Policy No. 166 N/A N/A
Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle-Foot Orthoses

Updating policy has title.

Adding an investigational criterion to the policy for microprocessor-controlled lower extremity orthoses.

Effective Date: August 1, 2021

Durable Medical Equipment, Policy No. 81 N/A N/A
Bronchial Valves

Changed policy title (previously titled Endobronchial and Intrabronchial Valves)

Revised to state that bronchial valves may be considered medically necessary for the treatment of severe emphysema in select patients when policy criteria are met.

Effective Date: August 1, 2021
Surgery, Policy No. 184 For CPT codes 31647, 31648, 31649, and 31651 change edit to term the investigational denial and add preauth for this policy. Add CPT codes 31647, 31648, 31649, and 31651 to the PreAuth website for this policy.
Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation

Changed policy title (previously titled Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin)

Incorporated medical policy Peripheral Subcutaneous Field Stimulation (Surgery #188)

Peripheral nerve stimulation and peripheral nerve field stimulation continue to be considered investigational for all indications, including but not limited to chronic pain, postoperative and post-traumatic pain.

Effective Date: August 1, 2021

Surgery, Policy No. 205 N/A N/A
Evaluating the Utility of Genetic Panels

Added 16 investigational panels to the policy, removed six panels, and edited eight panels to reflect changes in the test name.

Effective Date: July 1, 2021

Genetic Testing, Policy No. 64 CPT code 81327 is being removed from this policy and adding to new medical policy GT86. See that entry for details associated with that code in the new policy. N/A
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss

Changed Title

Added a criterion to consider the use of next-generation sequencing (NGS) aneuploidy testing for products of conception or for pregnancy loss investigational.

Effective Date: July 1, 2021

Genetic Testing, Policy No. 79 Added new CPT code 0252U to this policy with an investigational denial. Title updated on the PreAuth website for this policy.
Serologic Genetic and Molecular Screening for Colorectal Cancer

New medical policy addresses testing for methylated DNA and gene expression testing for colon cancer screening or recurrence monitoring, which remains investigational

Effective Date: July 1, 2021

Genetic Testing, Policy No. 86

Added to this policy:

  • New HCPCS code G0327 with an investigational denial.
  • CPT code 0229U and continue
  • investigational denial.
  • CPT code 81327 and change from preauth requirement to investigational denial.
Code 81327 will be removed from the GT20 and GT64 medical policies, and removed from the preauth website for these two policies. This is due to moving this code into the new policy GT86, and changing the preauth edit to an investigational denial based on the new medical policy criteria.
In Vitro Chemoresistance and Chemosensitivity Assays

Added chemosensitivity test from Kiyatec (CPT 0248U) to policy.

Effective Date: July 1, 2021

Laboratory, Policy No. 06 Added new CPT code 0248U to this policy with an investigational denial. N/A
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders Adding 36 initial treatment sessions when medical necessity criteria is met and criteria for treatment continuation.

Effective Date: July 1, 2021

Medicine, Policy No. 148 N/A N/A
New and Emerging Medical Technologies and Procedures

Effective Date: July 1, 2021

Medicine, Policy No. 149 Added new CPT codes 0640T, 0641T, 0642T, 0645T, 0646T, 0648T, 0649T, 0656T, 0657T, 0658T, 0660T, 0661T, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T, and new HCPCS C1761 to this policy with an investigational denial. N/A
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products New policy addressing bioengineered skin and soft tissue substitutes and amniotic products.

Effective Date: July 1, 2021

Medicine, Policy No. 170 Added HCPCS codes A6460, A6461, C1849, Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4140, Q4151, Q4154, Q4159, Q4168, Q4186, Q4187 with Preauth requirement for this policy. Added HCPCS codes C9356, C9358, C9360, C9363, C9364, Q4103, Q4104, Q4108, Q4110, Q4111, Q4112, Q4113, Q4115, Q4117, Q4118, Q4121, Q4123, Q4124, Q4125, Q4126, Q4127, Q4130, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4152, Q4153, Q4155, Q4156, Q4157, Q4158, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4169, Q4170, Q4171, Q4172, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4228, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4254, Q4255 with investigational denial that will bypass pending POS = 23 for professional providers or revenue codes 0450-0459 – Emergency Room Hospital claims; when one of the ICD10 dx codes are present on the claim. Added CPT codes 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777 with investigational denial when one of the skin substitute codes is denied as investigational. Added CPT codes A6460, A6461, C1849, Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4140, Q4151, Q4154, Q4159, Q4168, Q4186, Q4187 to the Preauth website for this policy
Hyperoxemic Reperfusion Therapy

New investigational policy in alignment with the Q3 2021 quarterly code update addressing the use of hyperoxemic reperfusion therapy.

Effective Date: July 1, 2021

Medicine, Policy No. 173 Added new CPT code 0659T to this policy with an investigational denial. N/A
Varicose Vein Treatment

Removed investigational statement for sclerotherapy of the great saphenous vein from the saphenous femoral junction to the knee.

Effective Date: July 1, 2021

Surgery, Policy No. 104 N/A N/A
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome Adding new requirement for documentation of upper airway collapse or obstruction as a reasonable cause of obstructive sleep apnea for the following procedures: hyoid myotomy and suspension, mandible osteotomy with or without genioglossus advancement, palatopharyngoplasty (e.g., uvulopalatopharyngoplasty [UPPP] and uvulopharyngoplasty), and partial glossectomy. Documentation of obstruction will continue to be required for mandibular-maxillary advancement (MMA) requests.

Effective Date: July 1, 2021

Surgery, Policy No. 166 N/A N/A
Transcatheter Aortic-Valve Implantation for Aortic Stenosis New policy addressing transcatheter aortic valve implantation for aortic stenosis.

Effective Date: July 1, 2021

Surgery, Policy No. 201 Add preauth to CPT codes 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369 for this new medical policy. Add CPT codes 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369 to the preauth website for this new policy.
Focal Laser Ablation of Prostate Cancer

New medical policy addresses focal laser therapy for localized prostate cancer

Effective Date: July 1, 2021

Surgery, Policy No. 222 Added new CPT code 0655T to this policy with an investigational denial. N/A
Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment

Added clarifications regarding knee orthoses (KOs) and the applicable reasonable useful lifetime (RUL).

Effective Date: June 1, 2021

Durable Medical Equipment, Policy No. 75 N/A N/A
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

Clarified FDA-approval information and added hyperlinks to FDA approval resources.

Effective Date: June 1, 2021

Durable Medical Equipment, Policy No. 88 N/A N/A
Genetic Testing for Myeloid Neoplasms and Leukemia

Updated policy to address targeted panel testing for myeloid neoplasms, including acute myeloid leukemia and myelodysplastic syndromes, as well as non-targeted hematologic malignancy panels.

Effective Date: June 1, 2021

Genetic Testing, Policy No. 59 Remove CPT codes 0023U, 0046U, 0049U, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334 from this policy and remove preauth edit for these codes from this policy. Remove CPT codes 0023U, 0046U, 0049U, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334 from the preauth website for this policy.
Evaluating the Utility of Genetic Panels

Added 14 investigational panel tests and removed 15 tests.

Effective Date: June 1, 2021

Genetic Testing, Policy No. 64 N/A N/A
Bariatric Surgery

Added criteria for conversion of sleeve to bypass that may be considered medically necessary.

Effective Date: June 1, 2021

Surgery, Policy No. 58 N/A N/A
Durable Medical Equipment, Prosthetic and Orthotic, Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment

Revised policy and title to clarify the scope with respect to "upgrade" requests.

Effective Date: May 1, 2021

Durable Medical Equipment, Policy No. 75 N/A N/A
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

Revised policy to clarify the scope with respect to "upgrade" requests.

Effective Date: May 1, 2021

Durable Medical Equipment, Policy No. 88 N/A N/A
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome

Added medical necessity criterion for germline BRCA1/2 testing if tumor testing indicates that a variant is present in the tumor tissue.

Effective Date: May 1, 2021

Genetic Testing, Policy No. 02 N/A N/A
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Added the use of the Breast Cancer Index for making decisions regarding extended endocrine therapy (beyond 5 years).

Made additional minor edits for clarity.

Effective Date: May 1, 2021

Genetic Testing, Policy No. 42 N/A N/A
Bariatric Surgery

Updated policy criteria to allow for endoscopic findings for obstruction or strictures.
Added age and sex percentiles for pediatric populations.

Added additional clarifications for documentation of pre-operative training and pre-operative evaluation.

Effective Date: May 1, 2021

Surgery, Policy No. 58 Changed CPT code 43842 from a pend for review to always not medically necessary edit, as this procedure is no longer the standard of care. N/A
Surgical Treatments for Hyperhidrosis

Editing policy criteria to require a trial of specific nonsurgical approaches before surgical intervention

Adding requirement of secondary bacterial or fungal infection when recurrent skin maceration is present.

Adding functional impairment to the list of medical complications indicating consideration of surgical intervention.

Effective Date: May 1, 2021

Surgery, Policy No. 165 N/A N/A
Transurethral Water Vapor Thermal Therapy of the Prostate

Added medically necessary criteria.

Effective Date: May 1, 2021

Surgery, Policy No. 210 Changed CPT code 53854 edit from investigational to preauth required for this policy. Added CPT code 53854 to the preauth website for this policy.
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Adding indications that will be considered not medically necessary.

Effective Date: May 1, 2021

Transplant, Policy No. 45.36 N/A N/A
External Trigeminal Nerve Stimulation for the Treatment of Attention Deficit Hyperactivity Disorder

New investigational policy.

Effective Date: April 1, 2021

Durable Medical Equipment, Policy No. 83.14 Add new CPT codes K1016, K1017 with investigational denial. N/A
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

New medical policy to provide transparency with respect to the health plan's position for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). This policy brings the health plan into alignment with Medicare guidance, which is national.

Effective Date: April 1, 2021
Durable Medical Equipment, Policy No. 88 N/A N/A
Evaluating the Utility of Genetic Panels

Added 13 new investigational panels.
Removed 29 panels

Edited eight panels to reflect changes in the test name.

Effective Date: April 1, 2021

Genetic Testing, Policy No. 64 Add CPT 0242U as investigational to this policy. N/A
Maternal Serum Analysis for Risk of Preterm Birth New investigational policy.

Effective Date: April 1, 2021

Laboratory, Policy No. 75 Add CPT 0247U as investigational to this policy. N/A
Hyperbaric Oxygen Therapy

Adding a not medically necessary inverse statement when criteria for non-healing diabetic wounds of the lower extremities are not met.

Effective Date: April 1, 2021

Medicine, Policy No. 14 N/A N/A
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk

Adding requirement for Dose-Volume Histograms (DVH) to be submitted in color.

Effective Date: April 1, 2021

Medicine, Policy No. 167 N/A N/A
Implantable Peripheral Nerve Stimulatino for Chronic Pain of Peripheral Nerve Origin

Added SPRINT system to noted investigational devices.

Added statements to regulatory section that approved devices are not intended to treat pain in the craniofacial region.

Effective Date: April 1, 2021

Surgery, Policy No. 205 N/A N/A
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant

Adding a not medically necessary statement for when policy criteria are not met.

Effective Date: April 1, 2021

Transplant, Policy No. 45.03 N/A N/A
The following is a list of recently archived policies:
Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Effective Date: August 1, 2021 Genetic Testing, Policy No. 60
Peripheral Subcutaneous Field Stimulation Effective Date: August 1, 2021 Surgery, Policy No. 188
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions Effective Date: June 1, 2021 Durable Medical Equipment, Policy No. 45
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy Effective Date: June 1, 2021 Genetic Testing, Policy No. 72
Laboratory and Genetic Testing for use of Thiopurines Effective Date: June 1, 2021 Laboratory, Policy No. 70