Regence
Medical Policy Update, March 1, 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 |
|
| Genetic Cancer Susceptibility Panels Using Next Generation Sequencing |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 73 |
| Genetic Testing for Macular Degeneration |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 75 |
| Whole Exome Sequencing |
New policy.
Effective Date: October 1, 2014 |
Genetic Testing, Policy No. 76 |
| Confocal Laser Endomicroscopy |
New investigational policy.
Effective Date: October 1, 2014 |
Medicine, Policy No. 151 |
| Reduction Mammaplasty |
Added criteria indicating reduction mammaplasty is not medically necessary when criteria are not met.
Effective Date: October 1, 2014 |
Surgery, Policy No. 60 |
| Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) |
Added clarification that investigational criteria applies to all indications.
Effective Date: October 1, 2014 |
Surgery, Policy No. 131 |
| Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) |
Clarified definition of advanced NSCLC.
Effective Date: November 1, 2014 |
Genetic Testing, Policy No. 56 |
| Evaluating the Utility of Genetic Panels |
Addition of new panel tests.
Effective Date: November 1, 2014 |
Genetic Testing, Policy No. 64 |
| Intensity Modulated Radiation Therapy (IMRT) of the Thorax |
Added general criteria for thoracic tumors.
Effective Date: November 1, 2014 |
Medicine, Policy No. 136 |
| Cosmetic and Reconstructive Surgery |
Liberalization of blepharoplasty and brow ptosis criteria.
Effective Date: November 1, 2014 |
Surgery, Policy No. 12 |
| Varicose Vein Treatment |
Added criteria for minimum vein diameter in mm and incompetence in seconds on venous imaging studies. Added microwave and steam injection ablation, and endovenous glue as investigational treatments.
Effective Date: November 1, 2014 |
Surgery, Policy No. 104 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| The following
is a list of recently archived policies: |
| Wheelchairs |
Archive Effective Date:
December 1, 2014 |
Durable Medical Equipment, Policy No. 37 |
| 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 add to GT56 |
Genetic Testing, Policy No. 14 |
