Medical policy

Regence medical policies are evidence-based and take into account the available scientific evidence published in peer-reviewed journals, as well as evidence-based clinical practice guidelines and specialty society statements. The process for Regence medical policy development is described in the Introduction to the Regence Medical Policy Manual.

In addition, Regence values the experience and opinions of practicing physicians and other health care providers. Your feedback on our policies is welcome and is an important part of our annual policy review process.

You may provide feedback to us on the following policies by:

• Responding to the email that directed you to this page. Please be sure to identify the policy you are providing comments on in your email response.

• Contacting Medical Policy Staff. Please be sure to identify the policy in the policy name field, as well as your name, specialty and contact information. (Note: contact information only needs to be included if you do not regularly receive medical policy email notification from Regence.)

Anesthesiology - (2)

• Interferential Current Stimulation, Durable Medical Equipment #83.07
• Auricular Electrostimulation, Medicine #146
  

Bariatric - (2)

• Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status, Laboratory #44
• Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders, Radiology #38
  

Behavioral Health - (3)

• Intensive In-Home Family Intervention, Behavioral Health #34
• Treatment of Depression in Adults, Clinical Practice Guideline
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders, Medicine #148
  

Cardiology - (1)

• Genetic Testing for Statin-Induced Myopathy, Genetic Testing #50
  

Chiropractic - (2)

• Interferential Current Stimulation, Durable Medical Equipment #83.07
• Auricular Electrostimulation, Medicine #146
  

Dermatology - (1)

• Genetic Testing for Cutaneous Malignant Melanoma, Genetic Testing #08
  

Electrodiagnostics - (1)

• Tumor Treating Fields Therapy, Durable Medical Equipment #85
  

Endocrinology - (1)

• Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status, Laboratory #44
  

Gastroenterology - (5)

• Genetic Testing for Lactase Insufficiency, Genetic Testing #67
• Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status, Laboratory #44
• Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders, Radiology #38
• Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD), Surgery #190
• Isolated Small Bowel Transplant, Transplant #09
  

General Surgery - (6)

• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Folate Testing, Laboratory #79
• Non-Contact Ultrasound Treatment for Wounds, Medicine #131
• Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products, Medicine #170
• Occipital Nerve Stimulation, Surgery #174
• Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD), Surgery #190
  

Genetics - (16)

• Genetic Testing for Alzheimer's Disease, Genetic Testing #01
• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Genetic Testing for Cutaneous Malignant Melanoma, Genetic Testing #08
• Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing, Genetic Testing #10
• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Genetic and Molecular Diagnostic Testing, Genetic Testing #20
• Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy, Genetic Testing #21
• Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes), Genetic Testing #43
• Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders and Twin Zygosity, Genetic Testing #44
• Genetic Testing for Statin-Induced Myopathy, Genetic Testing #50
• Diagnostic Genetic Testing for α-Thalassemia, Genetic Testing #52
• Genetic Testing for Myeloid Neoplasms and Leukemia, Genetic Testing #59
• Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies, Genetic Testing #66
• Genetic Testing for Lactase Insufficiency, Genetic Testing #67
• Genetic Testing for Duchenne and Becker Muscular Dystrophy, Genetic Testing #69
• Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification, Genetic Testing #70
  

Hematology Oncology - (9)

• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing, Genetic Testing #10
• Diagnostic Genetic Testing for α-Thalassemia, Genetic Testing #52
• Genetic Testing for Myeloid Neoplasms and Leukemia, Genetic Testing #59
• Folate Testing, Laboratory #79
• Placental and Umbilical Cord Blood as a Source of Stem Cells, Transplant #45.16
• Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias, Transplant #45.25
• Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults, Transplant #45.27
• Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, Transplant #45.28
  

Infectious Disease - (1)

• Folate Testing, Laboratory #79
  

Naturopath - (2)

• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Folate Testing, Laboratory #79
  

Nephrology - (1)

• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
  

Neurology - (11)

• Hippotherapy, Allied Health #34
• Tumor Treating Fields Therapy, Durable Medical Equipment #85
• Genetic Testing for Alzheimer's Disease, Genetic Testing #01
• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes), Genetic Testing #43
• Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies, Genetic Testing #66
• Genetic Testing for Duchenne and Becker Muscular Dystrophy, Genetic Testing #69
• Prolotherapy, Medicine #40
• Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders, Medicine #108
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders, Medicine #148
• Occipital Nerve Stimulation, Surgery #174
  

Neurosurgery - (10)

• Hippotherapy, Allied Health #34
• Tumor Treating Fields Therapy, Durable Medical Equipment #85
• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Prolotherapy, Medicine #40
• Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders, Medicine #108
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders, Medicine #148
• Positional Magnetic Resonance Imaging (MRI), Radiology #49
• Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty, Surgery #118
• Artificial Intervertebral Disc, Surgery #127
• Occipital Nerve Stimulation, Surgery #174
  

Obstetrics and Gynecology - (6)

• Perinatal Care, Clinical Practice Guideline
• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes), Genetic Testing #43
• Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders and Twin Zygosity, Genetic Testing #44
• Salivary Hormone Testing for Aging and Menopause, Laboratory #36
• Maternal Serum Analysis for Risk of Adverse Obstetric Outcomes, Laboratory #75
  

Oncology - (9)

• Tumor Treating Fields Therapy, Durable Medical Equipment #85
• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Genetic Testing for Cutaneous Malignant Melanoma, Genetic Testing #08
• Gene Expression-Based Assays for Cancers of Unknown Primary, Genetic Testing #15
• Genetic Testing for Myeloid Neoplasms and Leukemia, Genetic Testing #59
• Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification, Genetic Testing #70
• Folate Testing, Laboratory #79
• Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products, Medicine #170
• Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults, Transplant #45.27
  

Orthopedics - (6)

• Hippotherapy, Allied Health #34
• Prolotherapy, Medicine #40
• Positional Magnetic Resonance Imaging (MRI), Radiology #49
• Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty, Surgery #118
• Artificial Intervertebral Disc, Surgery #127
• Knee Surgeries, Surgery #229
  

Pathology - (6)

• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing, Genetic Testing #10
• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Genetic Testing for Myeloid Neoplasms and Leukemia, Genetic Testing #59
• Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status, Laboratory #44
• Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders, Medicine #108
  

Pediatric Surgery - (1)

• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
  

Pediatrics - (1)

• Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes), Genetic Testing #43
  

Physical Medicine - (3)

• Hippotherapy, Allied Health #34
• Interferential Current Stimulation, Durable Medical Equipment #83.07
• Auricular Electrostimulation, Medicine #146
  

Primary Care - (21)

• Hippotherapy, Allied Health #34
• Interferential Current Stimulation, Durable Medical Equipment #83.07
• Genetic Testing for Alzheimer's Disease, Genetic Testing #01
• Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome, Genetic Testing #02
• Genetic Testing for Cutaneous Malignant Melanoma, Genetic Testing #08
• Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing, Genetic Testing #10
• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
• Genetic Testing for Myeloid Neoplasms and Leukemia, Genetic Testing #59
• Salivary Hormone Testing for Aging and Menopause, Laboratory #36
• Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status, Laboratory #44
• Maternal Serum Analysis for Risk of Adverse Obstetric Outcomes, Laboratory #75
• Folate Testing, Laboratory #79
• Prolotherapy, Medicine #40
• Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders, Medicine #108
• Non-Contact Ultrasound Treatment for Wounds, Medicine #131
• Auricular Electrostimulation, Medicine #146
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders, Medicine #148
• Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products, Medicine #170
• Positional Magnetic Resonance Imaging (MRI), Radiology #49
• Occipital Nerve Stimulation, Surgery #174
• Air Ambulance Transport, Utilization Management #13
  

Psychiatry - (4)

• Intensive In-Home Family Intervention, Behavioral Health #34
• Treatment of Depression in Adults, Clinical Practice Guideline
• Auricular Electrostimulation, Medicine #146
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders, Medicine #148
  

Pulmonology - (1)

• Salivary Hormone Testing for Aging and Menopause, Laboratory #36
  

Radiation Oncology - (1)

• IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia, Genetic Testing #19
  

Radiology - (3)

• Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders, Radiology #38
• Positional Magnetic Resonance Imaging (MRI), Radiology #49
• Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty, Surgery #118
  

Solid Organ Transplants - (1)

• Isolated Small Bowel Transplant, Transplant #09
  

Urology - (1)

• Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products, Medicine #170