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Medical Policy
Regence Medical Policy Update, May 1, 2018
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

Sepsis

New clinical position statement that defines sepsis based on professional organization guidelines and indicates the response and documentation expected.

Effective Date: August 1, 2018

Clinical Position Statement, No. 03 N/A N/A
Cosmetic and Reconstructive Surgery Added new criteria for rhinoplasty.

Effective Date: August 1, 2018

Surgery, Policy No. 12 N/A N/A
Urine Drug Testing for Substance Use and Pain Management

Updated criteria to:

  • Allow specific codes for presumptive and definitive testing when up to 15 units are billed per type of testing, per year
  • Deny G0482 and G0483 as not medically necessary

Effective Date: July 1, 2018

Laboratory, Policy No. 68 Limiting both presumptive and definitive testing to specific codes (five for presumptive; three for definitive), one code per date of service by the same or different provider, and 15 codes for each type of testing, per year. N/A
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Removed requirements to specific epidermal growth factor receptor (EGFR) variants.

Effective Date: May 1, 2018

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

Added 14 new investigational panels and removed one panel.

Effective Date: May 1, 2018

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

Added clarification to several criteria and detailed Policy Guidelines. Guidelines will aid in transparency of expectations for required documentation to support clinical review.

Effective Date: May 1, 2018

Surgery, Policy No. 58 N/A N/A
Varicose Vein Treatment

Liberalized the criteria to allow sclerotherapy for the great saphenous vein below the knee and decreased stocking compression to a minimum 15-20mmHg. Revised long and short to great and small saphenous veins throughout. Clarified and streamlined additional criteria elements.

Effective Date: May 1, 2018

Surgery, Policy No. 104 N/A N/A
Gastroesophageal Reflux Surgery

Updated one criterion regarding proton pump inhibitor therapy. When a trial of proton pump inhibitor (PPI) therapy is ineffective, contraindicated, or not tolerated, the total trial must be at least 4-months. Clarified definitions of hiatal hernias in Policy Guidelines.

Effective Date: May 1, 2018

Surgery, Policy No. 186 N/A N/A
Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin

New policy for implantable peripheral nerve stimulation (PNS) for chronic pain of peripheral nerve origin (e.g. StimRouter).

Effective Date: May 1, 2018

Surgery, Policy No. 205 Continue preauth on 64555, 64575, and 64590 (this policy is new to the list of policies that address these codes and requires preauth). Continue to review codes 64999, L8680 and L8683 (this policy is new to the list of policies that address these codes and requires review) Add this policy to the preauth website for codes 64555, 64575, and 64590.
Genetic Testing for Alzheimer's Disease

Added genetic testing for autosomal dominant Alzheimer's disease for reproductive decision-making.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 01 N/A N/A
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer

Moved gene expression analysis to this policy; maintaining investigational position.

Effective Date: April 1, 2018

Genetic Testing, Policy No. 17 N/A N/A
Adoptive Immunotherapy

Removed review of CAR-T therapies, as Pharmacy now reviews this category of therapies. See the Pharmacy Medication Manual.

Effective Date: April 1, 2018

Medicine, Policy No. 42 N/A N/A
Transgender Services

See Coding/Implementation Changes and PreAuthorization Changes listed on this row in the columns to follow.

Effective Date: April 1, 2018

Medicine, Policy No. 153 Adding bypass to the preauth requirement on these codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, C1813 unless a transgender dx (F640, F641, F642, F648, F649) is found anywhere on the claim Adding codes 19303, 19304, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262, 58270, 58275, and C1813 to the preauth list for this policy.
Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy

New policy for the RPE65 variant when Luxturna is being considered as a treatment option.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 21 N/A Add this new policy to the preauth website for CPT code 81406.
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer

Replaced “0.6-1 cm” in criteria with “greater than 0.5 to 1 cm” to more clearly align with NCCN’s recommendations.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 42 N/A N/A
Genetic Testing for Mental Health Conditions

New policy that considers genetic testing for mental health conditions, including medication selection, investigational.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 53 N/A N/A
Evaluating the Utility of Genetic Panels

Added 14 new investigational panels and removed four panels.

Effective Date: March 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Laboratory and Genetic Testing for use of Thiopurines

Added NUDT15 genetic testing, which may be considered medically necessary when policy criteria are met.

Effective Date: March 1, 2018

Laboratory, Policy No. 70 Add code 0034U with preauth edit to this policy. Add code 0034U to the preauth website.
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Liberalized the meningioma criteria. Removed the 6-month life expectancy criteria from the policy. Recategorized into intracranial and extracranial indications.

Effective Date: March 1, 2018

Surgery, Policy No. 16 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Updated medical necessity criteria for lung tumors. Removed the requirement for surgical resection for non-small cell lung cancer.

Effective Date: March 1, 2018

Surgery, Policy No. 132 N/A N/A
Wearable Cardioverter-Defibrillators

Revised “low ejection” in criteria I.B. to state “left ventricular ejection fraction (LVEF) less than or equal to 35 percent” and expanded criteria I.C. to state: “As a bridge to definitive therapy (e.g., cardiac transplant), when criteria I.B. is met.”

Effective Date: February 1, 2018

Durable Medical Equipment, Policy No. 61 N/A N/A
IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia

New policy addresses IDH1 and IDH2 testing for indications other than myeloid neoplasms or leukemia.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 19 Add preauth to new codes 81120 and 81121. Add preauth to new codes 81120 and 81121.
Genetic Testing for Statin-Induced Myopathy

New policy for genetic testing for statin-induced myopathy.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 50 Add edit for new code 81328 to deny as not medically necessary. N/A
Genetic Testing for α-Thalassemia

New policy on genetic testing for alpha-thalassemia.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 52 Continue preauth on 81257 and 81404 (this policy is new to the list of policies that address these codes and require preauth). Add preauth to new codes 81258, 81259, and 81269. Add this policy to the preauth website for codes 81257, 81404, 81258, 81259, and 81269.
Genetic Testing for Myeloid Neoplasms and Leukemia

Updated the policy to include IDH1 testing when criteria are met. Removed review of JAK2 and MPL which may be considered medically necessary.

Effective Date: February 1, 2018

Genetic Testing, Policy No. 59

Add preauth to new codes 81120 and 81121. Remove preauth for codes 0017U, 0027U, and 81270.

Remove codes 0017U, 0027U, and 81270 from the preauth website.

NOTE: code 81270 is addressed in other medical policies still requiring preauth.

Laboratory and Genetic Testing for use of Thiopurines

New policy addressing genotypic and phenotypic analysis of the thiopurine methyltransferase (TPMT) enzyme and analysis of the metabolite markers azathioprine and mercaptopurine.

Effective Date: February 1, 2018

Laboratory, Policy No. 70 Continue preauth on 81401 (this policy is new to the list of policies that address this code and requires preauth). Add preauth to new code 81335. Add this policy to the preauth website for codes 81335, and 81401.
Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders

Removed fractional exhaled nitric oxide (FeNO) measurement (CPT 95012) as it may be considered medically necessary

Effective Date: February 1, 2018

Medicine, Policy No. 108 Removed investigational denial on CPT 95012. N/A
Ventricular Assist Devices and Total Artificial Hearts

Revised criteria as percutaneous ventricular assist devices (pVADs) may be considered medically necessary.

Effective Date: February 1, 2018

Surgery, Policy No. 52 Change edit on codes 33990, 33991, 33992, and 33993 from investigational to medically necessary. N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Added a note to policy specifying that the policy only applies to member contracts that are subject to preauthorization for Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder.

Effective Date: January 1, 2018

Behavioral Health, Policy No. 18

Retained existing edits on codes for the member contracts that are subject to preauthorization.

Termed edits for the member contracts that are no longer subject to preauthorization.

PreAuth lists updated as appropriate to align with the note in the policy that the policy only applies to member contracts that are subject to preauthorization for Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder.

Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Genetic testing for TP53 associated with Li-Fraumeni syndrome will now be addressed in a new policy, GT82.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 02 N/A N/A
Genetic Panel Testing (5-50 genes) for Hematolymphoid Neoplasms or Disorders

Added one genetic panel test that may be considered medically necessary and four that are considered investigational.

Effective Date: January 1, 2018

Genetic Testing; Policy No. 09 N/A Added codes 81170, 81218, 81219, 81245, 81246, 81270, 81272, 81275, 81276, 81273, 81310, 81311, to the preauth website for this policy.
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC)

Added testing for BRAF V600E variant to criteria.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 56 N/A N/A
Genetic Testing for Myeloid Neoplasms and Leukemia

Expanded scope of policy to include testing for ASXL1, IDH2, and RUNX1; clarified title and description. Updated policy criteria to include ASXL1, IDH2, and RUNX1 testing when criteria are met.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 59 Remove preauth for code 0016U. Remove code 0016U from the preauth website for this policy.
Evaluating the Utility of Genetic Panels

Added 18 new investigational panels and removed 61 panels. Added column to criteria to specify when a more specific medical policy applies.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 64 N/A N/A
Genetic Testing for Li-Fraumeni Syndrome

New policy which considers genetic testing for TP53 medically necessary when policy criteria are met.

Effective Date: January 1, 2018

Genetic Testing, Policy No. 82 Continue preath on code 81405, and continue to review unlisted code 81479. Add this new medical policy with code 81405 on the preauth website.
Vitamin D Testing

Added HIV/AIDS and transplant recipients as conditions for which vitamin D testing may be considered medically necessary.

Effective Date: January 1, 2018

Laboratory, Policy No. 52 Added additional diagnosis codes for code 82306. The coding toolkit will be updated with these additional diagnoses for code 82306. N/A
Protein Biomarkers for Screening, Detection, and/or Management of Prostate Cancer

Removed Prostarix™ from criteria as the test is no longer available. Moved the Apifiny® test from MED149 to this policy and it continutes to be investigational.

Effective Date: January 1, 2018

Laboratory, Policy No. 69 N/A N/A
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies and removed several in accordance with the annual code updates. Moved code 0021U and evidence to medical policy LAB69.

Effective Date: January 1, 2018

Medicine, Policy No. 149 N/A N/A
Transgender Services

Added clarification to the Policy Guidelines regarding mastectomy.

Effective Date: January 1, 2018

Medicine, Policy No. 153 N/A N/A
Cosmetic and Reconstructive Surgery

Revised blepharoplasty criteria to include eyelid taping measurements.

Effective Date: January 1, 2018

Surgery, Policy No. 12 N/A N/A
Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors

Added medical necessity criteria for lung tumors.

Effective Date: January 1, 2018

Surgery, Policy No. 132 N/A N/A
Femoroacetabular Impingement Surgery

Removed requirement of intra-articular injection, and clarified language for conservative therapy.

Effective Date: January 1, 2018

Surgery, Policy No. 160 N/A N/A
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast

Changed policy title.

Changed policy to address only adipose-derived stem cell enrichment in autologous fat grafting to the breast.

Effective Date: January 1, 2018

Surgery, Policy No 182 N/A Added codes 11950, 11951, 11952, and11954, to the preauth website for this policy

Change applies to the following IMRT policies:

Intensity Modulated Radiotherapy (IMRT) of the Thorax

Intensity Modulated Radiotherapy (IMRT) of the Prostate

Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

Intensity-Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis

Intensity Modulated Radiotherapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors

An optional table has been added that can be filled out to aid the provider in demonstrating that only through IMRT planning can published dose/volume constraints be met for organs at risk. The table conveys the information needed for review and summary analysis.

Effective Date: December 1, 2017

 

 

Medicine, Policy No. 136


Medicine, Policy No. 137


Medicine, Policy No. 138

 


Medicine, Policy No. 139

 

Medicine, Policy No. 147

N/A N/A
The following is a list of recently archived policies:
Gene Expression Analysis for Prostate Cancer Management

Archive Effective Date: April 1, 2018

NOTE: Now addressed in Medical Policy GT17.

Genetic Testing, Policy No. 71
Outpatient Cardiac Telemetry Archive Effective Date: March 1, 2018 Medicine, Policy No. 135
Genetic Panel Testing (5-50 genes) for Hematolymphoid Neoplasms or Disorders Archive Effective Date: February 1, 2018 Genetic Testing, Policy No. 09
Fecal Microbiota Transplantation Archive Effective Date: February 1, 2018 Medicine, Policy No. 154
Microwave Thermotherapy for Primary Breast Cancer Archive Effective Date: January 1, 2018 Medicine, Policy No. 111
Noninvasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease Archive Effective Date: December 1, 2017 Radiology, Policy No. 56