Regence
Medical Policy Update, November 1, 2023 |
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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 |
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Coding / Implementation Change
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| 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 |
| 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 |
| 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 |
| 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 |
| Identification of Microorganisms Using Nucleic Acid Probes |
Added pathogen panel testing for urinary tract infections and for surgical or chronic wounds to the policy as investigational.
Effective Date: August 1, 2023 |
Genetic Testing, Policy No. 85 |
Adding CPT code 0321U and new Q2 CPT codes 0370U, 0371U, 0372U, 0374U as always investigational |
N/A |
| Temporary Implanted Nitinol Device (e.g., iTind) for Benign Prostatic Hyperplasia |
New investigational medical policy.
Effective Date: August 1, 2023 |
Surgery, Policy No. 230 |
Adding CPT code 53855, and HCPCS code C9769 to this policy as investigational. |
N/A |
| Negative Pressure Wound Therapy in the Outpatient Setting |
Clarified policy criteria.
Effective Date: July 1, 2023 |
Durable Medical Equipment, Policy No. 42 |
N/A |
N/A |
| Topographic Genotyping to Classify Cancer Risk |
Changed policy title; policy was previously titled Pathfinder TG® Molecular Testing.
Updated policy description.
Added solid pancreatic lesions to criteria.
Effective Date: July 1, 2023 |
Genetic Testing, Policy No. 16 |
N/A |
N/A |
| Genotyping for Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm |
Changed title from: Genotyping for 9p21 Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm.
Updated policy to now address all single nucleotide variant tests for cardiovascular risks.
Effective Date: July 1, 2023 |
Genetic Testing, Policy No. 62 |
Added new 7/1/23 effective CPT code 0401U to this medical policy with always investigational edit. |
N/A |
| Investigational Gene Expression, Biomarker, and Multianalyte Testing |
Adding six new investigational tests to the policy.
Effective Date: July 1, 2023 |
Laboratory, Policy No. 77 |
Adding CPT codes 0041U, 0042U with investigational denial for this medical policy. Adding new 7/1/23 effective CPT codes 0389U, 0393U, 0398U, 0399U to this medical policy with always investigational edit. |
N/A |
| New and Emerging Medical Technologies and Procedures |
Updated the policy in alignment with the Q3 2023 quarterly code update to address new investigational medical technologies.
Effective Date: July 1, 2023 |
Medicine, Policy No. 149 |
Added new 7/1/2023 effective CPT codes 0793T, 0794T, 0805T, 0806T, 0807T, 0808T, and HCPCS code C9787 to this medical policy with investigational denial edit. |
N/A |
| Deep Brain Stimulation |
Modified policy language related to contraindications due to new devices with enhanced compatibility.
Effective Date: July 1, 2023 |
Surgery, Policy No. 84 |
Added HCPCS code L8678 to this policy with no change to current review edit. |
N/A |
| Leadless Cardiac Pacemakers |
Revised criteria to include an investigational criterion for dual chamber leadless pacemakers.
Effective Date: July 1, 2023 |
Surgery, Policy No. 217 |
Added new 7/1/2023 effective CPT codes 0795T, 0796T, 0797T, 0801T, 0802T, 0803T to this medical policy with investigational denial edit.
Added new 7/1/2023 effective CPT codes 0798T, 0799T, 0800T, 0804T to this medical policy with no clinical edits. |
N/A |
| Substance Use Disorders |
New policy that uses American Society of Addiction Medicine (ASAM) Criteria, 3rd edition for review of inpatient detoxification, residential or subacute detoxification, residential rehabilitation, partial hospitalization, and intensive outpatient treatment for substance use disorders.
Effective Date: June 1, 2023 |
Behavioral Health, Policy No. 35 |
N/A |
N/A |
| Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome |
Reorganized criteria for testing breast cancer-related genes, and added indications for testing based on family history.
Effective Date: June 1, 2023 |
Genetic Testing, Policy No. 02 |
N/A |
N/A |
| Heart Transplants |
Updated criteria for increased clarity.
Effective Date: June 1, 2023 |
Transplant, Policy No. 02 |
N/A |
N/A |
| The following
is a list of recently archived policies: |
| None |
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