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: April 1, 2025
Policy name	Summary of policy or change	Effective date	Section and policy number	Coding or implementation change	Pre-authorization change
Negative Pressure Wound Therapy in the Outpatient Setting	Adding indications for coverage, Clarifying criteria addressing nutritional status, and Adding criteria and required documentation for evaluation of arterial status for neuropathic ulcers.	July 1, 2025	Durable Medical Equipment #42	N/A	N/A
Electromagnetic Navigation Bronchoscopy	New policy created to address electromagnetic navigation bronchoscopy.	July 1, 2025	Surgery #179	Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 with preauth for this medical policy. Adding HCPCS code A4648 and continue no clinical edit on this code.	Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 to the preauth website for this medical policy.
Knee Surgeries	Clarifying criteria for soft tissue and bony procedures.	July 1, 2025	Surgery #229	Delete CPT code 27427 from this medical policy.	N/A
Air Ambulance Transport	Expanding post-service review of rotary air ambulance.	July 1, 2025	Utilization Management #13	N/A	N/A
Bariatric Surgery	Added criterion for revision of sleeve gastrectomy due to medication resistant gastroesophageal reflux disease.	June 1, 2025	Surgery #58	N/A	N/A
Mechanical Residual Limb Volume Management System for Upper Extremity Prostheses	New policy for mechanical residual limb volume management systems (e.g., RevoFit) for upper extremity prostheses.	April 1, 2025	Durable Medical Equipment #98	Added new Q2 HCPCS code L7406 as always not medically necessary for this policy.	N/A
Evaluating the Utility of Genetic Panels	Added 13 investigational panel tests Removed 101 tests from the policy.	April 1, 2025	Genetic Testing #64	Added new Q2 CPT 0533U with investigational denial for this policy.	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added the myOLARIS™-KTdx to the policy Changed the DetermaRx test to the new name, RiskReveal.	April 1, 2025	Laboratory #77	Added new Q2 CPT 0542U with investigational denial for this policy.	N/A
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
Orthognathic Surgery	Clarified policy criteria for functional impairments and documentation of orthodontic treatment.	April 1, 2025	Surgery #137	N/A	N/A
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)	Added NRG1 fusion testing to policy.	March 1, 2025	Genetic Testing #56	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
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	Updated policy to address continuation of ECMO.	March 1, 2025	Medicine #152	N/A	N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)	Updated policy to address the GERDX-System for transoral incisionless fundoplication for treatment of GERD.	March 1, 2025	Surgery #110	N/A	N/A
Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver	Added medical necessity criteria for cryoablation of certain desmoid tumors.	March 1, 2025	Surgery #132	N/A	N/A
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction	Clarified criteria without change to policy intent.	March 1, 2025	Surgery #134	Added HCPCS codes C1778, C1883 with no clinical edit.	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.
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Removed neurofilament light chain tests from the policy.	February 1, 2025	Laboratory #77	Removed CPT codes 0361U, 0443U from this medical policy with removal of investigational denial.	N/A
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

Recently archived policies
Policy name	Archive date	Policy number
Intensive In-Home Family Intervention	04/01/2025	Behavioral Health #34