Regence
Medical Policy Update, September 1, 2024 |
|
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. |
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|
Policy Name |
Summary
of Policy or Change |
|
Coding / Implementation Change
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| ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD) |
Clarifying that the clonoSEQ B-cell test, but not the T-cell test, may be considered medically necessary.
Effective Date: December 1, 2024 |
Genetic Testing, Policy No. 88 |
N/A |
N/A |
| Rhinoplasty |
Adding not medically necessary criteria.
Requiring documenation of prior trauma, such as imaging.
Effective Date: December 1, 2024 |
Surgery, Policy No. 12.28 |
N/A |
N/A |
| Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder |
Clarifying provider type and added context for continuation treatment.
Effective Date: November 1, 2024 |
Behavioral Health, Policy No. 18 |
N/A |
N/A |
| Applied Behavior Analysis Initial Assessment for the Treatment of Autism Spectrum Disorder |
Clarifying provider type with no change to intent.
Effective Date: November 1, 2024 |
Behavioral Health, Policy No. 33 |
N/A |
N/A |
| Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products |
Added C9354 to policy as investigational.
Effective Date: October 1, 2024 |
Medicine, Policy No. 170 |
Adding HCPCS: C9354 with always investigational denial |
N/A |
| Anterior Abdominal Wall (Including Incisional) Hernia Repair |
Changed policy title from: Ventral (Including Incisional) Hernia Repair
Deletd Criterion I.B (Bowel obstruction or strangulation) because all ICD-10 codes that require review are for hernias “without obstruction or gangrene.”
Updated “ventral” hernia to “anterior abdominal hernia.”
Effective Date: October 1, 2024 |
Surgery, Policy No. 12.03 |
N/A |
N/A |
| Serologic Genetic and Molecular Screening for Colorectal Cancer |
Clarified that the policy addresses Guardant Shield test and continue investigational determination.
Effective Date: September 1, 2024 |
Genetic Testing, Policy No. 86 |
N/A |
N/A |
| Charged Particle (Proton) Radiotherapy |
Adding requirement of professional attestation related to cost to list of required documentation with no change to current criteria.
Effective Date: September 1, 2024 |
Medicine, Policy No. 49 |
N/A |
N/A |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders |
Adding clarifying language for provider type and Transcranial Magnetic Stimulation (TMS) protocols.
Adding investigational criteria for accelerated protocols.
Adding clarifying language for provider type and allowed age that is consistent with device-specific FDA indication.
Effective Date: September 1, 2024 |
Medicine, Policy No. 148 |
N/A |
N/A |
| Screening for Vertebral Fracture or Fracture Risk with Dual X-ray Absorptiometry (DXA) |
Updated to include trabecular bone score for vertebral fracture risk as investigational.
Effective Date: September 1, 2024 |
Radiology, Policy No. 48 |
Add CPT codes 77089, 77090, 77091, 77092 to the policy with always investigational edit. |
N/A |
| Surgical Site of Care-Hospital Outpatient |
Changed policy title; policy was previously titled Surgical Site of Service- Hospital Outpatient
Updated terminology throughout the policy.
Effective Date: September 1, 2024 |
Utilization Management, Policy No. 19 |
N/A |
Update the policy title on the preauth website for this policy. |
| Substance Use Disorder |
Clarified use of ASAM criteria to determine medical necessity.
Effective Date: August 1, 2024 |
Behavioral Health, Policy No. 35 |
N/A |
N/A |
| Knee Surgeries |
Clarified language in criterion to specify patellofemoral pain.
Effective Date: August 1, 2024 |
Surgery, Policy No. 229 |
N/A |
N/A |
| Panniculectomy |
Clarified policy criteria with no change to intent.
Effective Date: August 1, 2024 |
Surgery, Policy No. 12.01 |
N/A |
N/A |
| Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders excluding Transcatheter Edge-to-Edge Repair (TEER) |
New medical policy.
Effective Date: August 1, 2024 |
Surgery, Policy No. 221 |
Added CPT codes 0483T, 0484T and remove always investigational edit and add PA for this policy.
Added CPT codes 0543T, 0544T, 0569T, 0570T, 0646T, 0805T, 0806T and keep always investigational edits for this policy.
|
Added CPT codes 0483T, 0484T to the preauth website for this policy. |
| Radiofrequency Ablation of the Renal Sympathetic Nerves for the Treatment of Uncontrolled Hypertension |
New medical policy.
Effective Date: August 1, 2024 |
Surgery, Policy No. 235 |
Added CPT codes 0338T, 0339T with investigational edit. |
N/A |
| Identification, Evaluation, and Treatment of Overweight and Obesity in Adults |
Continue to recommend the VA/DOD guidelines.
Effective Date: July 1, 2024 |
Clinical Practice Guideline |
N/A |
N/A |
| Management of Chronic Noncancer Pain with Opioids in Adults |
Continue to recommend the Substance Abuse and Mental Health Services Administration TIPS publication.
Effective Date: July 1, 2024 |
Clinical Practice Guideline |
N/A |
N/A |
| Preventive Services Guideline for Adults |
Continue to recommend the USPSTF screening recommendations.
Effective Date: July 1, 2024 |
Clinical Practice Guideline |
N/A |
N/A |
| Screening and Management of Substance Use Disorders in Adults |
Continue to recommend the VA/DoD guidelines.
Effective Date: July 1, 2024 |
Clinical Practice Guideline |
N/A |
N/A |
| Electrical Stimulation for the Treatment of Wounds |
Clarified that criteria include stimulation for nerve regeneration.
Effective Date: July 1, 2024 |
Durable Medical Equipment, Policy No. 83.09 |
Added CPT codes 0882T, 0883T to this policy with investigational edit. |
N/A |
| Evaluating the Utility of Genetic Panels |
Added 15 investigational panel tests and removed three tests from the policy.
Effective Date: July 1, 2024 |
Genetic Testing, Policy No. 64 |
Added CPT codes 0460U, 0461U, 0474U, 0475U to this policy with investigational edit. |
N/A |
| Expanded Molecular Testing of Cancers to Select Targeted Therapies |
Expanded to allow molecular profiling panel testing for any advanced or metastatic solid tumor cancer, when criteria are met.
Effective Date: July 1, 2024 |
Genetic Testing, Policy No. 83 |
Added CPT code 0473U to this policy with potentially investigational edit. |
N/A |
| Investigational Gene Expression, Biomarker, and Multianalyte Testing |
Added four investigational tests to policy.
Effective Date: July 1, 2024 |
Laboratory, Policy No. 77 |
Added CPT codes 0450U, 0451U, 0456U, 0458U, 0462U, 0020M to this policy with investigational edit. |
N/A |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders |
Added new codes for accelerated protocols.
Effective Date: July 1, 2024 |
Medicine, Policy No. 148 |
Added CPT codes 0889T, 0890T, 0891T, 0892T to this policy with investigational edit. |
N/A |
| Transcatheter Aortic Valve Implantation for Aortic Stenosis |
Removed requirement for left ventricular ejection fraction greater than 20%.
Effective Date: July 1, 2024 |
Surgery, Policy No. 201 |
N/A |
N/A |
| Benign Prostatic Hyperplasia Surgical Treatments |
Changed policy title from: Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate
Update policy criteria in alignment with Q3 code updates.
Effective Date: July 1, 2024 |
Surgery, Policy No. 210 |
Moved CPT code 0714T to this policy from MED149 and keep investigational edit.
Added CPT code 0867T to this policy with investigational edit. |
N/A |
| Hematopoietic Cell Transplantation Policies |
Removed CPT 38221 and 38222 from these Hematopoietic Cell Transplantation policies, as they require preauthorization for Surgical Site of Service – Hospital Outpatient, Utilization Management, Policy No. 19 (UM19).
Removed CPT 38220 from these policies. Removed 38243 from these policies and remove preauthorization requirement.
Effective Date: July 1, 2024 |
Transplant, Policy Nos. 45.22, 45.23, 45.24, 45.25, 45.27, 45.28, 45.30, 45.31, 45.32, 45.33, 45.35, 45.36, 45.37, 45.38, 45.40 |
Deleted CPT codes 38220, 38221, 38222,
38243 from this policy.
Remove preauth from 38243 for this policy. |
Remove preauth from CPT code 38243 and from the preauth website for this policy. |
| Surgical Site of Service – Hospital Outpatient |
Removed CPT codes for medicine administration from UM19.
Effective Date: July 1, 2024 |
Utilization Management, Policy No. 19 |
Deleted CPT codes 46505, 50430, 64418, 64425, 64530, 64610, 64642, 64644, 64646, 20526, 20600, 20604, 20605, 20606, 20610, 20611, 27093, 27095 from this policy. |
Removed CPT codes 46505, 50430, 64418, 64425, 64530, 64610, 64642, 64644, 64646, 20526, 20600, 20604, 20605, 20606, 20610, 20611, 27093, 27095 from the preauth website for this policy. |
| Folate Testing |
New policy will address folate testing.
Effective Date: June 1, 2024 |
Laboratory, Policy No. 79 |
Adding CPT codes 82746, 82747 to this medical policy.
Code 82746 will deny as always not medically necessary unless billed with specific diagnosis codes.
Code 82747 will deny as always not medically necessary. |
N/A |
| Biomarkers for Cardiovascular Disease |
New policy addresses measurement or quantitation of lipoprotein subclasses for cardiovascular disease.
Effective Date: May 1, 2024 |
Laboratory, Policy No. 78 |
Adding CPT codes 0052U, 83700, 83701, 83704, 83722 to this policy with investigational denial |
N/A |
| Endometrial Ablation |
Updated criteria to allow documentation requirements to be met using clinical documentation, without requirement for pathology/procedure reports.
Effective Date: May 1, 2024 |
Surgery, Policy No. 01 |
N/A |
N/A |
| Orthognathic Surgery |
Clarified policy criteria reference to adult and pediatric patients.
Effective Date: May 1, 2024 |
Surgery, Policy No. 137 |
N/A |
N/A |
| Placental and Umbilical Cord Blood as a Source of Stem Cells |
Policy updated to include medical necessity criteria for omisirge (omidubicel).
Effective Date: May 1, 2024 |
Transplant, Policy No. 45.16 |
Added HCPCS codes C9399, J3490 with no change to the unlisted code workflow |
N/A |
| Definitive Lower Limb Prostheses |
Policy updated to include new HCPCS codes for a pneumatic prosthetic knee (L5841) and the RevoFit System for socket volume adjustment (L5783).
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 18 |
Adding HCPCS: L5783 with always not medically necessary denial, and L5841 with potentially investigational edit. |
N/A |
| Powered Exoskeleton for Ambulation and Rehabilitation |
Policy title changed from: Powered Exoskeleton for Ambulation.
Expanded policy scope to include powered exoskeleton devices for robot-assisted physical therapy.
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 89 |
Adding HCPCS: E0739
with always investigational edit |
N/A |
| Upper Extremity Rehabilitation System with Brain-Computer Interface |
New Policy with investigational criteria.
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 94 |
Adding HCPCS: E0738 with always investigational edit |
N/A |
| Evaluating the Utility of Genetic Panels |
Added 16 new investigational tests and removed 41 tests from the policy.
Effective Date: April 1, 2024 |
Genetic Testing, Policy No. 64 |
Deleting CPT: 0170U |
N/A |
| Investigational Gene Expression, Biomarker, and Multianalyte Testing |
Added six investigational tests to the policy.
Effective Date: April 1, 2024 |
Laboratory, Policy No. 77 |
Adding CPT: 0170U, 0441U, 0442U, 0443U, 0446U, 0447U
Continue investigational denial on code 0170U
New codes 0441U 0442U 0443U 0446U 0447U have an investigational denial. |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
Updating criteria with additional documentation requirements.
Effective Date: April 1, 2024 |
Medicine, Policy No. 153 |
N/A |
N/A |
| Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid |
Updating criteria to require clinical documentation of expected survival.
Effective Date: April 1, 2024 |
Medicine, Policy No. 164 |
N/A |
N/A |
| Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities |
Updating criteria related to pulmonary function.
Effective Date: April 1, 2024 |
Medicine, Policy No. 165 |
N/A |
N/A |
| Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products |
Added three products that may have medical necessity to criteria for non-healing diabetic lower-extremity ulcers.
Effective Date: April 1, 2024 |
Medicine, Policy No. 170 |
Add Q2 HCPCS: A2026, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310
Delete Q2 HCPCS: Q4244
Also removed 2023 deleted HCPCS code: C1849 and
remove Revised and New notes from codes
Code Q4121, remove investigational denial and add preauth.
New 4/1/2024 codes, A2026 Q4305 Q4306 Q4307 Q4308 Q4309 Q4310, adding investigational denial via the Annual Code Set Update PIRF on the 4/11/2024 RPG agenda.
Code Q4244 being deleted via the Annual Code Set Update PIRF on the 4/11/2024 RPG agenda. |
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| Pectus Excavatum and Carinatum Treatment |
Policy title changed from: Pectus Excavatum and Carinatum Treatment.
Added non-coverage criteria for the use of orthotics in the treatment of pectus carinatum.
Effective Date: April 1, 2024 |
Surgery, Policy No. 12.02 |
Adding:
HCPCS: L1320 with always not medically necessary denial, and
Unlisted HCPCS: L1499 with no change to unlised code review |
N/A |
| Gastroesophageal Reflux Surgery |
Clarified criteria.
Effective Date: April 1, 2024 |
Surgery, Policy No. 186 |
N/A |
N/A |
| Transurethral Water Vapor Thermal Therapy and Transurethral Waterjet Ablation (Aquablation) of the Prostate |
Liberalized to consider Aquablation medically necessary when criteria are met.
Effective Date: April 1, 2024 |
Surgery, Policy No. 210 |
CPT: 0421T, and HCPCS: C2596 changing from investigational denial to require PreAuth. |
Adding CPT: 0421T, and HCPCS: C2596 to the PreAuth website for this policy. |
| Small Bowel, Small Bowel/Liver, and Multivisceral Transplant |
Changed policy title from:
Isolated Small Bowel Transplant.
Added criteria regarding multivisceral transplant previously addressed in TRA18.
Effective Date: April 1, 2024 |
Transplant, Policy No. 09 |
Adding CPT: 43999, 44799, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 47399, 48550, 48551, 48552, 48554, 48999 and
Adding HCPCS: S2053, S2054, S2055, S2152 with no change to edits. |
Adding CPT: 43999, 44135, 44136, 44799, 47135, 47399, 48554, 48999 to the PreAuth webiste for this policy. |
| The following
is a list of recently archived policies: |
| Small Bowel/Liver and Multivisceral Transplant |
Policy Archived: April 1, 2024 |
Transplant, Policy No. 18 |
| Autologous Hematopoietic Cell Transplantation for Malignant Astrocytomas and Gliomas |
Policy Archived: April 1, 2024 |
Transplant, Policy No. 45.34 |
