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Medical Policy
Regence Medical Policy Update, February 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.
         
Policy Name
Summary of Policy or Change

Section and
Policy #

Coding / Implementation Change

PreAuthorization Change

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
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
Functional Neuromuscular Electrical Stimulation

Clarified Criteria with no change to intent.

Effective Date: February 1, 2024

Durable Medical Equipment, Policy No. 83.04 N/A N/A
Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder

New policy addresses digital therapeutic products for post-traumatic stress disorder and panic disorder.

Effective Date: February 1, 2024

Medicine, Policy No. 175.05 Added HCPCS code A9291 to this new policy with preauth edit. Added HCPCS code A9291 to the preauth website for this policy.
Bariatric Surgery

Clarified definitions and reorganized criteria with no change to intent.

Effective Date: February 1, 2024

Surgery, Policy No. 58 Added CPT code 0813T to this policy with investigational denial. N/A
Identification of Microorganisms Using Nucleic Acid Probes

Added oral HPV testing to policy as investigational.

Effective Date: January 1, 2024

Genetic Testing, Policy No. 85 Added new Q1 CPT codes 0429U, 87523 to this policy with investigational denial. N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing

Added one new investigational test to the policy.

Effective Date: January 1, 2024

Laboratory, Policy No. 77 Added new Q1 CPT code 0437U to this policy with investigational denial N/A
Extracorporeal Shock Wave Therapy (ESWT)

Changed policy title from: Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Expanded scope of the policy to include Extracorporeal Shock Wave Treatment for all indications.

Effective Date: January 1, 2024

Medicine, Policy No. 90

Added new Q1 CPT code 0864T and CPT codes 0512T, 0513T to this policy with investigational denial.

Added unlisted code 55899.
N/A
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the 2024 Q1 annual code update.

Effective Date: January 1, 2024

Medicine, Policy No. 149

Added new Q1 CPT codes 0811T, 0812T, 0814T, 0859T, 0860T, 0861T, 0862T, 0863T, 0865T, 0866T
Added codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T from SUR17 that will be archived 1/1/2024 to this medical policy and continue investigational edit.
Deleted: 0499T, 0533T, 0534T, 0535T, 0536T, 0641T, 0642T, 0715T
Revise: 0517T, 0518T, 0519T, 0520T, 0640T

Non-code update deleted: 0619T, 0656T, 0657T, C1761
N/A
Gender Affirming Interventions for Gender Dysphoria

Updated criteria to address the OR HB2002 law, added criteria to address facial gender affirming surgery, and clarified existing criteria.

Effective Date: January 1, 2024

Medicine, Policy No. 153

Adding CPT codes 11920, 11921, 15774, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208 to this policy and continue preauth edit.

Adding unlisted code 21299.

Adding codes 21137, 21139 that will require preauth for gender affirming diagnoses.

Adding CPT codes 11920, 11921, 15774, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, to the preauth website for this policy.

Adding codes 21137, 21139 to the preauth website for this policy with instruction that these codes will require preauth for gender affirming diagnoses.
Subcutaneous Tibial Nerve Stimulation

New policy addressing implantable subcutaneous tibial nerve stimulation devices.

Effective Date: January 1, 2024

Surgery, Policy No. 154 Added new Q1 CPT codes 0816T, 0817T, 0818T, 0819T to this policy with investigational denial. N/A
Hypoglossal Nerve Stimulation

Updating criteria to align with recent FDA approval for the inspireII.

Clarified CPAP intolerance.

Effective Date: January 1, 2024

Surgery, Policy No. 215 Age requirement changing from 22 to 18. N/A
Radiofrequency Ablation and Injection of Sacroiliac Joint Nerves

New policy with always investigational criteria for radio frequency ablation and injections for the nerves of the sacroiliac joint.

Effective Date: January 1, 2024

Surgery, Policy No. 231 Adding CPT codes 64451, 64625 with investigational denial. N/A
Ablation for the Treatment of Chronic Rhinitis

Changed policy title from: Cryoablation for Chronic Rhinitis

Expanded policy scope to include radiofrequency and laser ablation as always investigational treatments for chronic rhinitis.

Effective Date: January 1, 2024

Surgery, Policy No. 224 Added new Q1 CPT codes 31242, 31243 to this policy with investigational denial. N/A
Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis

Changed policy title from: Temporary Implanted Nitinol Device (e.g., iTind) for Benign Prostatic Hyperplasia

Policy updated to include drug-coated balloon catheters for benign prostatic hyperplasia and urethral stricture.

Effective Date: January 1, 2024

Surgery, Policy No. 230

Added new Q1 CPT codes 52284 to this policy with investigational denial.

Moved CPT 0619T from MED149 to this policy with no change to investigational denial.
N/A
Vertebral Body Tethering and Stapling

New policy addressing vertebral body tethering and stapling as investigational treatments for scoliosis.

Effective Date: January 1, 2024

Surgery, Policy No. 232

Added new Q1 CPT codes 0790T, 22836, 22837, 22838 to this policy with investigational denial.

Moved CPT codes 0656T, 0657T to this policy from MED149 with no change to investigational denial.

Added unlisted code 22899 with unlisted code review edit.
N/A
Coronary Intravascular Lithotripsy

New policy addressing coronary intravascular lithotripsy as investigational for all indications.

Effective Date: January 1, 2024

Surgery, Policy No. 233

Added new Q1 CPT code 92972.

Moved HCPCS code C1761 with no change to investigational denial.
N/A
Surgical Site of Service – Hospital Outpatient

Updated and clarified policy criteria.

Effective Date: January 1, 2024

Utilization Management, Policy No. 19 N/A N/A
Negative Pressure Wound Therapy in the Outpatient Setting

Clarified criteria for associated clinical care and supplies for effective use of a negative pressure wound therapy (NPWT) system (e.g., wound care services).

Effective Date: December 1, 2023

Durable Medical Equipment, Policy No. 42 N/A N/A
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults

Simplified the criteria for end stage lung failure. Added language for patients unable to wean from Extracorporeal Membrane Oxygenation (ECMO).

Effective Date: December 1, 2023

Medicine, Policy No. 152 N/A N/A
Cochlear Implants

Added Criteria for Single Sided Deafness.

Effective Date: December 1, 2023

Surgery, Policy No. 08 Removing CPT codes 92630, 92633 (associated with auditory rehabilitation) from this policy. N/A for this policy, but continue the eviCore preauth for CPT codes 92630, 92633.
Ventral (including incisional) Hernia Repair

Updating medical policy criteria notes to reflect new coding rules.

Clarified documentation in the list of information needed for review.

Effective Date: December 1, 2023

Surgery, Policy No. 12.03 N/A N/A
Leadless Cardiac Pacemakers

Expanded criteria to include U.S. Food and Drug Administration (FDA) approved devices.

Effective Date: December 1, 2023

Surgery, Policy No. 217 N/A N/A
Heart Transplant

Clarified criteria related to VAD prior to heart transplant.

Effective Date: December 1, 2023

Transplant, Policy No. 02 N/A N/A
Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome

Clarified criteria without change to intent.

Effective Date: December 1, 2023

Transplant, Policy No. 45.22 N/A N/A
Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

Updated criteria in order to enable stem cell collection.

Effective Date: December 1, 2023

Transplant, Policy No. 45.33 N/A N/A
Air Ambulance Transport

Clarified not medically necessary criteria.

Effective Date: December 1, 2023

Utilization Management, Policy No. 13 N/A N/A
Enteral and Oral Nutrition in the Home Setting

New commercial medical policy applies only to select individual members

Effective Date: November 1, 2023

Allied Health, Policy No. 05

Adding Not Medically Necessary edit for this policy to the following codes: A9152 A9153 B4100 B4102 B4103 B4104 B4149 B4154 S9432 S9434.

Add preauth requirement for this policy to the following codes: B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4105 B4150 B4152 B4153 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9998 S9433 S9435.

Add the following codes with preauth requirement to the preauth website: B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4105 B4150 B4152 B4153 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9998 S9433 S9435.
Power Wheelchairs: Group 3

Updated the criteria for clarity with no change to the intent of the policy.

Effective Date: November 1, 2023

Durable Medical Equipment, Policy No. 37 N/A N/A
Identification of Microorganisms Using Nucleic Acid Probes

Updating policy to consider respiratory pathogen panel testing with 12 or more targets to be investigational

Effective Date: November 1, 2023

Genetic Testing, Policy No. 85 Add CPT codes: 0115U, 0202U, 0223U, 0225U, 0373U, 87492, 87633 with investigational denial. N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

Update the criteria for clarity with no change to the intent of the policy.

Effective Date: November 1, 2023

Surgery, Policy No. 213 Add Q4 new HCPCS code C9788 with investigational edit. N/A
Hysterectomy

New commercial medical policy applies only to select individual members and will include pre-authorization requirements for select diagnosis codes

Effective Date: November 1, 2023

Surgery, Policy No. 218

Add preauth requirement for this policy to the following codes: 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.

If one of the following diagnosis is not billed in the primary position a Workflow will bypass the preauth: A18.17 A54.24 A54.85 A56.11 A74.81 D06.0 D06.1 D06.7 D06.9 D21.9 D25.0 D25.1 D25.2 D25.9 G89.29 K66.0 N70.01 N70.02 N70.03 N70.11 N70.12 N70.13 N70.91 N70.92 N70.93 N71.01 N71.1 N71.9 N72 N73.0 N73.1 N73.2 N73.3 N73.4 N73.5 N73.6 N73.8 N73.9 N74 N80.0 N80.1 N80.2 N80.3 N80.4 N80.5 N80.8 N80.9 N83.6 N83.7 N87.0 N87.1 N87.9 N92.0 N92.1 N92.3 N92.4 N92.5 N92.6 N93.0 N93.8 N93.9 N94.0 N94.10 N94.11 N94.12 N94.19 N94.4 N94.5 N94.6 N94.89 N94.9 N95.0 N99.4 R10.2 R87.610 R87.611 R87.612 R87.613 R87.619 R87.810

Add the following codes with preauth requirement to the preauth website: 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.

If one of the following diagnosis is not billed in the primary position a Workflow will bypass the preauth: A18.17 A54.24 A54.85 A56.11 A74.81 D06.0 D06.1 D06.7 D06.9 D21.9 D25.0 D25.1 D25.2 D25.9 G89.29 K66.0 N70.01 N70.02 N70.03 N70.11 N70.12 N70.13 N70.91 N70.92 N70.93 N71.01 N71.1 N71.9 N72 N73.0 N73.1 N73.2 N73.3 N73.4 N73.5 N73.6 N73.8 N73.9 N74 N80.0 N80.1 N80.2 N80.3 N80.4 N80.5 N80.8 N80.9 N83.6 N83.7 N87.0 N87.1 N87.9 N92.0 N92.1 N92.3 N92.4 N92.5 N92.6 N93.0 N93.8 N93.9 N94.0 N94.10 N94.11 N94.12 N94.19 N94.4 N94.5 N94.6 N94.89 N94.9 N95.0 N99.4 R10.2 R87.610 R87.611 R87.612 R87.613 R87.619 R87.810

Air Ambulance Transport

Updating commercial medical policy to add post-service review for select individual members.

Effective Date: November 1, 2023

Utilization Management, Policy No. 13 Adding HCPCS code S9961 with post service review. N/A
Definitive Lower Limb Prostheses

Adding codes to the criteria section of the policy.

Effective Date: October 1, 2023

Durable Medical Equipment, Policy No. 18 Adding HCPCS codes L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5968 to this medical policy with preauth requirement. Adding HCPCS codes L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5968 to the preauth website for this medical policy.
BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy

Updated criteria for BRAF testing for targeted treatment for all glioma as it now may be considered medically necessary.

Effective Date: October 1, 2023

Genetic Testing, Policy No. 41 N/A N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing

Added six new investigational tests and removed two tests that are no longer availabe.

Effective Date: October 1, 2023

Laboratory, Policy No. 77

Added new CPT codes 0019M, 0404U, 0407U, 0414U, 0415U, 0418U to the policy as investigational.

Removed deleted CPT codes 0357U, 0386U from this policy and termed the investigational denial.

N/A
New and Emerging Medical Technologies and Procedures

Updated the policy in alignment with the 2023 Q4 quarterly code update.

Effective Date: October 1, 2023

Medicine, Policy No. 149

Added new HCPCS code C9790 with investigational edit.

Removed CPT codes 0687T, 0688T, 0704T, 0705T, 0706T from this medical policy and move into new medical policy MED175.04

N/A
Digital Therapeutic Products for Amblyopia

New policy with investigational criteria.

Effective Date: October 1, 2023

Medicine, Policy No.175.04

Added new HCPCS code A9292 with investigational edit.

Added CPT codes 0687T, 0688T, 0704T, 0705T, 0706T which were removed from MED149 and moved to this new policy with existing investigational edit.

N/A
Opto-acoustic Imaging of the Breast

New investigational policy for opto-acoustic imaging of the breast.

Effective Date: October 1, 2023

Radiology, Policy No. 60 Added new HCPCS code C9788 with investigational edit. N/A
Negative Pressure Wound Therapy in the Outpatient Setting

Updating the policy criteria for clarity, including:

  • Updated documentation requirements.
  • Policy now addresses single-use negative pressure wound therapy systems.

Effective Date: September 1, 2023

Durable Medical Equipment, Policy No. 42 Changing edits on codes 97607, 97608 to remove PreAuth and add investigational denial edit for this policy. Removing codes 97607, 97608 from the PreAuth website for this policy.
Tumor Treatment Field Therapy (TTFT)

New policy will have medically necessary and investigational criteria for TTFT.

Effective Date: September 1, 2023

Durable Medical Equipment, Policy No. 85 Adding CPT 77261, and HCPCS A4555 with no edit, CPT 77299 with unlisted code review, and E0766 with PreAuth to this policy. Adding the policy and code E0766 to the PreAuth website.
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome

Removing criteria that were related to testing for specific single-gene syndromes (e.g., PTEN) that are addressed in other policies and/or are no longer recommended by clinical practice guidelines.

Effective Date: September 1, 2023

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

Added 16 investigational panels and removed 19 tests.

Effective Date: September 1, 2023

Genetic Testing, Policy No. 64 Deleted CPT code 0242U from this policy as it is addressed in LAB46 where it has a preauth edit. Removed CPT 0242U from the preauth list for this policy (NOTE: will continue preauth for LAB46 as it is currently on the preauth list for that policy).
Laboratory Tests for Organ Transplant Rejection

Added medical necessary criteria for AlloMap test and investigational criterion for gene expression profiling tests on biopsy tissue (e.g., Molecular Microscope® Diagnostic System).

Effective Date: September 1, 2023

Laboratory, Policy No. 51 Changed edit on CPT code 81595 from investigational denial to PreAuth with the addition of medical necessity criteria. Add CPT code 81595 to the PreAuth website for this policy.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders

Updating policy criteria regarding:

  • anti-depressant use,
  • failure of psychotherapy, and
  • extension of transcranial magnetic stimulation (TMS).

Effective Date: September 1, 2023

Medicine, Policy No. 148 N/A N/A
Rhinoplasty

Added criteria for rhinophyma.

Effective Date: September 1, 2023

Surgery, Policy No. 12.28 N/A N/A
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Simplified the policy criteria without change to the intent of the policy.

Effective Date: September 1, 2023

Surgery, Policy No. 214 N/A N/A
The following is a list of recently archived policies:
Eating Disorder Inpatient Treatment Policy Archived: February 1, 2024 Behavioral Health, Policy No. 25
Eating Disorder Intensive Outpatient Policy Archived: February 1, 2024 Behavioral Health, Policy No. 26
Eating Disorder Partial Hospitalization Policy Archived: February 1, 2024 Behavioral Health, Policy No. 27
Eating Disorder Residential Treatment Policy Archived: February 1, 2024 Behavioral Health, Policy No. 28
Psychiatric Inpatient Hospitalization Policy Archived: February 1, 2024 Behavioral Health, Policy No. 29
Psychiatric Intensive Outpatient Policy Archived: February 1, 2024 Behavioral Health, Policy No. 30
Psychiatric Partial Hospitalization Policy Archived: February 1, 2024 Behavioral Health, Policy No. 31
Psychiatric Residential Treatment Policy Archived: February 1, 2024 Behavioral Health, Policy No. 32
Implantable Cardioverter Defibrillator Policy Archived: January 1, 2024 Surgery, Policy No. 17
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer Policy Archived: December 1, 2023 Transplant, Policy No. 45.26