Medical Policy

Policy updates

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 regence.com. We have included the section and policy number for your convenience.

Last updated: January 1, 2025
Policy name	Summary of policy or change	Effective date	Section and policy number	Coding or implementation change	Pre-authorization change
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities	Clarified criteria regarding pancreatic cancer and prostate cancer.	April 1, 2025	Medicine #165	N/A	N/A
Screening Laboratory Testing	New policy addressing screening laboratory testing in asymptomatic individuals.	March 1, 2025	Laboratory #80	Adding CPT codes: 82310, 82330, 82340, 82670, 82681, 82728, 82977, 83540, 83550, 83735, 83970, 83993, 84100, 84105, 84402, 84403, 84410, 84443, 84466, 85651, 85652, 86038, 86039, 86140, 86225, 86235 to the policy with no edit. This will be implemented as an automatic denial for the CPT codes listed when billed with the diagnosis code Z00.00 as a sole diagnosis code.	N/A
Surgical Site of Care – Hospital Outpatient	Added joint procedure codes that were formerly reviewed by eviCore.	March 1, 2025	Utilization Management #19	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 which are moving from eviCore joint Site of Care to this policy, (UM19) with preauth edit	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 to the preauth website for this policy.
Ablation of Peripheral Nerves to Treat Pain	New investigational policy for the use of ablation of peripheral nerves to treat pain.	February 1, 2025	Surgery #236	Adding CPT codes: 0440T, 0441T, 0442T and continue investigational denial. Adding CPT codes 64624, 64640 and add investigational denial for this policy. Adding CPT code 64999 and continue unlisted review.	N/A
Lumbar Spinal Fusion	Clarifying documentation requirements for: Conservative therapy, and Documenting tobacco use status.	February 1, 2025	Surgery #187	N/A	N/A
Administrative Guidelines to Determine Dental vs Medical Services	Updated criteria to remove age limits and provide guidance for use of general anesthesia services.	January 1, 2025	Allied Health #35	N/A	N/A
Electromagnetic Therapy	Updated policy to address concurrent optical and electromagnetic stimulation for wound healing.	January 1, 2025	Durable Medical Equipment #83.13	Added two new CPT codes 0906T, 0907T as always investigational. Removed deleted CPT codes 0768T, 0769T	N/A
Laboratory Tests for Organ Transplant Rejection	Updated policy to address urinary measurement of CXCL10. Clarified criteria for gene expression tests for organs other than the heart.	January 1, 2025	Laboratory #51	Added two new CPT code 0526U as always investigational.	N/A
Hyperbaric Oxygen Therapy	Added criteria for continuation of treatment.	January 1, 2025	Medicine #14	N/A	N/A
New and Emerging Medical Technologies and Procedures	Updated the policy in alignment with the 2025 Q1 annual code update.	January 1, 2025	Medicine #149	Added new CPT codes 0901T, 0902T, 0903T, 0904T, 0905T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T, 0930T, 0931T, 0932T, 0933T, 0934T, 0936T, 0937T, 0938T, 0939T, 0940T, 0946T as always investigational. Added new HCPCS codes C8001, C8003 as always investigational. Revised CPT code 0615T.	N/A
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS), and High Intensity Focused Ultrasound (HIFU) Ablation, and Transurethral Ultrasound Ablation (TULSA)	Changed policy title; policy was previously titled Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation. Added criteria related to transurethral ultrasound ablation (TULSA).	January 1, 2025	Surgery #139	Added new CPT codes 0947T, 51721, 55881, 55882 as always investigational. Added new CPT code 61715 with preauth edit.	Added new CPT code 61715 to the preauth website for this policy.
Ablation of Primary and Metastatic Liver Tumors	Added criteria to address 3D Ablation confirmation software.	January 1, 2025	Surgery #204	Added new CPT code 0944T as always investigational.	N/A
Dual Chamber Leadless Cardiac Pacemakers	Changed policy title; policy was previously titled Leadless Cardiac Pacemakers. Updated policy to remove reference to single chamber leadless pacemakers. Only addresses dual chamber leadless pacemakers as investigational.	January 1, 2025	Surgery #217	Removed CPT codes 0823T, 0824T, 0825T, 0826T, 33274, 33275 from this policy. Removed HCPCS codes C1605 from this policy.	Removed codes 0823T, 0825T, 33274 from the preauth website for this policy.
Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis	Added criteria to address prostatic urethral scaffold device.	January 1, 2025	Surgery #230	Added new CPT codes 0941T, 0942T, 0943T, 53865, 53866 as always investigational. Removed deleted HCPCS code C9769 from this policy.	N/A
Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension	Changed policy title; policy was previously titled Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension. Updated policy to address ultrasound renal denervation for the treatment of hypertension.	January 1, 2025	Surgery #235	Added new HCPCS codes C1735, C1736 as always investigational.	N/A
Gender Affirming Interventions for Gender Dysphoria	Clarified criteria and documentation requirements.	December 11, 2024	Medicine #153	Added CPT codes 15769, 15772 and continue preauth requirement. Added HCPCS codes C1789 with no edit.	Added CPT codes 15769, 15772 to the preauth website for this policy.
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder	Clarified policy criteria with no change to intent.	December 1, 2024	Behavioral Health #18	N/A	N/A
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.	December 1, 2024	Genetic Testing #88	N/A	N/A
Molecular Testing in the Management of Pulmonary Nodules	Updated policy to address the REVEAL Lung Nodule Characterization test.	December 1, 2024	Laboratory #73	N/A	N/A
Rhinoplasty	Adding not medically necessary criteria. Requiring documenation of prior trauma, such as imaging.	December 1, 2024	Surgery #12.28	N/A	N/A
Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome	Added clarifying language to the Policy Guidelines section regarding stem cell collection prior to treatment.	December 1, 2024	Transplant #45.22	N/A	N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder	Clarifying provider type and added context for continuation treatment.	November 1, 2024	Behavioral Health #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.	November 1, 2024	Behavioral Health #33	N/A	N/A
Electrical Bone Growth Stimulators (Osteogenic Stimulation)	Edited policy for clarity	November 1, 2024	Durable Medical Equipment #83.11	N/A	N/A
Noninvasive Ventilators in the Home Setting	Edited policy for clarity	November 1, 2024	Durable Medical Equipment #87	N/A	N/A
Reduction Mammaplasty	Revised policy to consider mammaplasty in individuals between 16-18 years of age to be potentially medically necessary when there is clinical reason for the earlier surgery. Simplified the criteria related to the indications for the surgery. Removed shoulder grooving.	November 1, 2024	Surgery #60	N/A	N/A
Lower Extremity Sensory Prostheses	New policy to address lower extremity sensory prostheses.	October 1, 2024	Durable Medical Equipment #95	Added new Q4 HCPCS codes L8720, L8721 with investigational denial for this new policy.	N/A
Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment	New policy to address amplitude-modulated radiofrequency electromagnetic fields (AM RF-EMF) for cancer treatment.	October 1, 2024	Durable Medical Equipment #96	Added new Q4 HCPCS code E0767 with investigational edit for this new policy	N/A
Evaluating the Utility of Genetic Panels	Added nine investigational panel tests Removed eight tests from the policy.	October 1, 2024	Genetic Testing #64	Added new Q4 CPT codes 0476U, 0477U, 0516U with investigational denial.	N/A
Fetal Red Blood Cell Antigen Genotyping Using Maternal Plasma	Changed policy title; policy was previously titled Fetal RHD Genotyping Using Maternal Plasma Policy now addresses all cell-free fetal red blood cell antigen genotyping.	October 1, 2024	Genetic Testing #74	Added new Q4 CPT codes 0488U, 0494U with investigational denial.	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added four new investigational tests to policy.	October 1, 2024	Laboratory #77	Added new Q4 CPT codes 0506U, 0510U, 0512U, 0513U with investigational denial.	N/A
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products	Added C9354 to policy as investigational.	October 1, 2024	Medicine #170	Adding HCPCS: C9354 with always investigational denial	N/A
Digital Therapeutic Products for Gait Training	New policy to address digital therapeutic products for gait training.	October 1, 2024	Medicine #175.06	Added new Q4 HCPCS code E3200 with investigational edit for this new policy	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.	October 1, 2024	Surgery #12.03	N/A	N/A
Hysterectomy	Clarified pelvic inflammatory disease criteria.	October 1, 2024	Surgery #218	N/A	N/A
Serologic Genetic and Molecular Screening for Colorectal Cancer	Clarified that the policy addresses Guardant Shield test and continue investigational determination.	September 1, 2024	Genetic Testing #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.	September 1, 2024	Medicine #49	N/A	N/A
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders	Added clarifying language for provider type and Transcranial Magnetic Stimulation (TMS) protocols. Added investigational criteria for accelerated protocols.	September 1, 2024	Medicine #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.	September 1, 2024	Radiology #48	Add CPT codes 77089, 77090, 77091, 77092 to the policy with always investigational edit.	N/A
Shoulder Surgeries	Liberalized selected documentation requirements and streamlined criteria.	September 1, 2024	Surgery #228	N/A	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.	September 1, 2024	Utilization Management #19	N/A	Updated the policy title on the preauth website for this policy.
Substance Use Disorder	Clarified use of ASAM criteria to determine medical necessity.	August 1, 2024	Behavioral Health #35	N/A	N/A
Knee Surgeries	Clarified language in criterion to specify patellofemoral pain.	August 1, 2024	Surgery # 229	N/A	N/A
Panniculectomy	Clarified policy criteria with no change to intent.	August 1, 2024	Surgery #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.	August 1, 2024	Surgery #221	Add CPT codes 0483T, 0484T and remove always investigational edit and add PA for this policy. Add CPT codes 0543T, 0544T, 0569T, 0570T, 0646T, 0805T, 0806T and keep always investigational edits for this policy.	Add 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.	August 1, 2024	Surgery #235	Add CPT codes 0338T, 0339T with investigational edit for this policy.	N/A
Folate Testing	New policy will address folate testing.	June 1, 2024	Laboratory #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.	May 1, 2024	Laboratory #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.	May 1, 2024	Surgery #01	N/A	N/A
Orthognathic Surgery	Clarified policy criteria reference to adult and pediatric patients.	May 1, 2024	Surgery #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).	May 1, 2024	Transplant #45.16	Added HCPCS codes C9399, J3490 with no change to the unlisted code workflow	N/A

Recently archived policies
Policy name	Archive date	Policy number
No policies archived in past six months	N/A	N/A