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Medical Policy
Regence Medical Policy Update, August 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

Gender Affirming Interventions for Gender Dysphoria

Adding revision to a previous gender affirming surgery because of dissatisfaction with the appearance to the list of not medically necessary interventions.

Effective Date: October 1, 2020

Medicine, Policy No. 153 N/A N/A
Drug Testing for Substance Use and Pain Management

Changed policy title.

Added oral fluid and hair drug testing to policy as investigational.

Effective Date: October 1, 2020

Laboratory, Policy No. 68 Adding CPT codes 0011U, 0116U, P2031 to this policy as investigational. N/A
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Effective Date: October 1, 2020

Surgery, Policy No. 12.05 N/A N/A
Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

Discontinuing use of MCG criteria for ultrasound bone growth stimulation, which will now be reviewed using the plan’s medical policy.

Ultrasonic bone growth stimulators are considered medically necessary for the treatment of fracture nonunion/delayed union when policy criteria are met. Two serial imaging studies during the most recent three-month period showing evidence of nonunion or nonhealing is required.

Ultrasound bone growth stimulation is considered not medically necessary for the treatment of fresh or stress fractures, consistent with previous criteria.

Ultrasound bone growth stimulation is considered investigational for all other conditions, including osteotomy, which had previously been covered under MCG criteria.

Effective Date: September 1, 2020

Durable Medical Equipment, Policy No. 83.12 Continue the preauth requirement on CPT code 20979 and HCPCS code E0760. Add new policy to the preauth website with CPT code 20979 and HCPCS code E0760 requiring preauth.
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
Measurement of Serum Antibodies to Selected Biologic Agents

Changed policy title.

Testing for serum antibodies to infliximab and adalimumab and biosimilars, either alone or in combination tests including serum drug levels, may be considered medically necessary in patients with inflammatory bowel disease when there is evidence of loss of response. Testing is not medically necessary when there has not been a loss of response to the medication.

Effective Date: August 1, 2020

Laboratory, Policy No. 65 Adding unlisted CPT code 80299 to this policy and continue to review. N/A
New and Emerging Medical Technologies and Procedures

Added CPT code 0465T as always investigational.

Removed CPT 38999, which will be addressed by the new policy SUR220.

Effective Date: August 1, 2020

Medicine, Policy No. 149

Adding investigational denial to CPT code 0465T

Moved CPT code 38999 from this medical policy to new policy SUR220, and continue to review.

N/A
Surgical Treatments for Lymphedema and Lipedema

New policy addressing the surgical treatment of lymphedema and lipedema which includes investigational statements for both microsurgery techniques and liposuction techniques.

Effective Date: August 1, 2020

Surgery, Policy No. 220 Add CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 38999 to this new medical policy with an investigational denial when a specific lymphedema or lipedema ICD-10 diagnosis is found on the claim. N/A
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Added testing criteria related to family history for individuals without cancer and clarified that providers should document if they use a USPSTF-endorsed risk tool and document the name of the tool used for prior authorization requests.

Effective Date: July 1, 2020

Genetic Testing, Policy No. 02 N/A N/A
Evaluating the Utility of Genetic Panels

Added 18 panel tests to policy.

Effective Date: July 1, 2020

Genetic Testing, Policy No. 64 Added new quarterly code update CPT codes 0173U and 0175U to this investigational policy. N/A
Analysis of Proteomic and Metabolomic Patterns for Cancer Detection, Risk, Prognosis, or Treatment Selection

Changed policy title.

Added proteomic/metabolomic testing for cancer prognosis and treatment to policy.

Effective Date: July 1, 2020

Laboratory, Policy No. 41 Added new quarterly code update CPT 0174U and CPT code 81538 (previously in MED149) to this policy with investigational edits. N/A
New and Emerging Medical Technologies and Procedures

Added new investigational medical technologies in accordance with the 2020 3rd quarter code updates.

Moved code 81538 to medical policy LAB41.

Effective Date: July 1, 2020

Medicine, Policy No. 149

Add new quarterly code update CPT 0600T, 0601T, 0602T, 0603T, 0604T, 0605T, 0606T, 0613T, 0615T, 0619T to this investigational policy, and removed CPT code 81538 (moved to LAB41). N/A
Gender Affirming Interventions for Gender Dysphoria

Removed voice lessons/therapy from the list of not medically necessary interventions.

Updated the general Criteria (I.A.4) addressing hormone therapy to state the following: twelve continuous months of hormone therapy as appropriate to the patient’s gender goals unless hormones are not clinically indicated for the individual.

Effective Date: July 1, 2020

Medicine, Policy No. 153 N/A N/A
Cochlear Implant

In line with the expanded indication in the recent FDA approval, lowering the minimum age required for implantation with the Cochlear® Nucleus 24 cochlear implant system to 9 months.

Effective Date: July 1, 2020

Surgery, Policy No. 08 N/A N/A
Implantable Cardioverter Defibrillators

Moved ICD implantation in pediatric patients from note to criteria which may be considered medically necessary.

Effective Date: July 1, 2020

Surgery, Policy No. 17

Remove CPT codes 93260, 93261, and 93644 from this policy.

Add new quarterly code update CPT 0614T to this policy.
N/A
Bariatric Surgery

Added medical necessity criteria for adolescent populations who have attained Tanner 4 or 5 pubertal development when criteria are met.

Effective Date: July 1, 2020

Surgery, Policy No. 58 N/A N/A
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Added SpineJack as an approved mechanical augmentation device to policy criteria.

Effective Date: July 1, 2020

Surgery, Policy No. 107 N/A N/A
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)

Added MET variant and RET fusion testing to policy, which may be considered medically necessary when criteria are met.

Effective Date: June 1, 2020

Genetic Testing, Policy No. 56 N/A N/A
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders

Edited criteria to emphasize the importance of document submission. Documentation is required of the depression rating scale used and the resulting score, the psychopharmacologic regimen history with documented response, and the duration and cadence of psychotherapy.

Effective Date: June 1, 2020

Medicine, Policy No. 148 N/A 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.
Ventral Hernia Repair

Added medically necessary statement for Component Separation Technique (CST) for the repair of a large (≥ 10 cm in width) abdominal wall defect that cannot be closed primarily.

Added Policy Guidelines to define loss of abdominal domain as 50% of the abdominal viscera reside outside of the abdominal cavity.

Effective Date: June 1, 2020

Surgery, Policy No. 12.03 N/A N/A
Hysterectomy

New policy to replace MCG for review of hysterectomy.

This policy requires review for these diagnoses: abnormal uterine bleeding, pelvic pain, chronic pelvic inflammatory disease, pelvic adhesive disease, pelvic venous congestion, adenomyosis, cervical intraepithelial neoplasia, and leiomyoma.

Additionally, policy will be available in eAuth/auto-auth for auto-approval when criteria are met for indications requiring review.

Effective Date: June 1, 2020

Surgery, Policy No. 218 Continue the preauth requirements on CPT codes 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573

Remove the MCG hysterectomy guidelines from the preauth website.

Add new policy to the preauth website for CPT codes 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, with a note clarifying the diagnoses that require preauth related to this policy.
COVID-19 Antibody Testing

New policy that will states we will cover one antibody test per year, per member with no cost share.

Additional antibody tests will be covered to identify COVID-19 antibodies when medical necessity criteria have been met.

Effective Date: June 1, 2020

Laboratory, Policy No. 74 Added CPT codes 86769 and 86328 to this medical policy. N/A
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.
COVID-19 Testing

Changed policy title.

Added COVID-19 molecular and antigen testing to the policy and simplified criteria, removing requirements for clinical documentation and restriction on number of tests.

Effective Date: March 1, 2020

Laboratory, Policy No. 74 N/A N/A
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
The following is a list of recently archived policies:
Suprachoroidal Delivery of Pharmacological Agents Archive Effective Date: May 1, 2020 Medicine, Policy No. 132