January 2020

January 2020

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies.

Pre-authorization for specialty medications

Effective January 1, 2020, the following specialty medications will be added to the pre-authorization list for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members: HCPCS C9038, J0129, J0289, J0567, J0599, J0640, J1428, J1442, J1626, J1628, J1746, J2502, J3397, J7170, J7321-J7324, J7326, J7327, J7503, J7699, J8499, J8520, J8700, J9000, J9015, J9042, J9057, J9190, J9201, J9312, J9370, Q2043, Q5103, Q5106, S0108 and S0190.

Effective January 1, 2020, the following specialty medications will require pre-authorization for Alsco Inc. (group #70000002) members: CPT 90371; HCPCS C9038, J0129, J0135, J0180, J0207, J0221, J0256, J0257, J0289, J0364, J0490, J0567, J0585, J0587, J0588, J0596-J0599, J0604, J0638, J0640, J0641, J0717, J0795, J0800, J0850, J0881, J0885, J0894, J0897, J1290, J1300, J1322, J1324, J1325, J1428, J1438, J1439, J1442, J1458-J1460, J1555-J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1595, J1602, J1626, J1628, J1645, J1726, J1729, J1743-J1746, J1786, J1826, J1830, J1930, J1931, J1950, J2170, J2182, J2323, J2350, J2353, J2354, J2357, J2430, J2502, J2505, J2507, J2778, J2786, J2788, J2790-J2793, J2796, J2840, J2941, J3060, J3110, J3240, J3262, J3285, J3315, J3357, J3380, J3385, J3397, J3485, J7170, J7179-J7183, J7185-J7187, J7189, J7190, J7192-J7195, J7197, J7198, J7200-J7202, J7205, J7207, J7209-J7211, J7321-J7327, J7503, J7527, J7639, J7682, J7686, J7699, J8499, J8520, J8521, J8565, J8700, J9000, J9015, J9020, J9025, J9035, J9040, J9041, J9042, J9047, J9050, J9055, J9057, J9065, J9130, J9150, J9171, J9185, J9190, J9201, J9202, J9213- J9217, J9225, J9226, J9250, J9262-J9267, J9299, J9305, J9312, J9315, J9340, J9351, J9355, J9357, J9370, Q2043, Q2050, Q3028, Q4074, Q5103, Q5104, Q5106, Q5108, S0090, S0108, S0148, S0190 and S9562.

View the complete specialty medication pre-authorization lists for CHG Healthcare Services, IEC Group and Alsco Inc. members are available on the Commercial Pre-authorization List. Submit pre-authorizations for these members to VIVIO Health Help Desk at 1 (925) 365-6600.

Medical reimbursement policy update

We review our reimbursement policies on an annual basis. Included below is an update to an existing policy that will be added to our Reimbursement Policy Manual.

To see how a claim will pay, access the Clear Claim Connection tool on the Availity Provider Portal.

Then following medical reimbursement policies were revised January 1, 2020:

  • Virtual Care (Administrative #132)
  • Urine Drig Testing (Medicine #106)

Read the December 2019 and February 2020 issues of our newsletter for details.

Dental reimbursement policy update

Effective January 1, 2020, we are adding a new dental reimbursement policy, Assessment of Salivary Flow by Measurement (Dental Diagnostic #72), to our Dental Policy Manual.

Read the December 2019 issue of our newsletter for details.

New employer group coming

Effective January 1, 2020, CTI Foods (group #70000011), a self-funded employer group headquartered in Idaho, will have access to our provider networks. Members will have access to the BlueCard PPO network nationally. AmeriBen, the third-party administrator, will provide claims administration, medical management and member services for these members.

Our Commercial Pre-authorization List will apply to these members.

HTCC decisions for 2020

The following Health Technology Clinical Committee (HTCC ) changes for UMP members are effective January 1, 2020:

  • Peripheral Nerve Ablation for Limb Pain
    • Will not be a covered benefit for adults or children using any technique to treat limb pain, including for knee, hip, foot or shoulder caused by osteoarthritis or other conditions
  • Proton Beam Therapy
    • Will be covered for children and adolescents
      21 and younger
    • Will be covered for individuals 22 and older for the following primary cancers:
      • Ocular
      • Skull-based
      • Esophageal
      • Head and neck
      • Brain and spinal
      • Primary hepatocellular carcinoma
      • Other primary cancers where all other treatment options are contraindicated after review by a multidisciplinary tumor board
    • Proton beam therapy is not covered for all other conditions
  • Sacroiliac Joint Fusion
    • Will not be covered for members 18 and older with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint disruption, minimally invasive and open sacroiliac joint fusion procedures
    • This decision does not apply to low back pain caused by:
      • Sacroiliitis associated with inflammatory arthropathies
      • Other etiology (e.g., radiculopathy, neurogenic claudication)
      • Sacroiliac joint pain related to recent major trauma or fracture, infection or cancer
  • Novocure (Tumor Treatment Fields Therapy for Glioblastoma)

    • Will not be a covered benefit

View the policy for all reimbursement determination criteria on the HTCC website.

Pre-authorization list updates

The following changes were made to our Commercial Pre-authorization List effective January 1, 2020:

  • Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (Surgery #182)
    • CPT 15769, 15771, 15772
  • Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (Genetic Testing #42)
    • CPT 81522
  • Bariatric Surgery (Surgery #58)
    • CPT 43820
  • Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies (Genetic Testing #58)
    • CPT 0156U
  • Cosmetic and Reconstructive Procedures (Surgery #12)
    • CPT 15769, 15771–15774
  • Gender Affirming Interventions for Gender Dysphoria (Medicine #153)
    • CPT 58150
  • Gene Expression Profiling for Melanoma (Genetic Testing #29)
    • CPT 81552
  • Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome (Genetic Testing #2)
    • CPT 81307, 81308
  • Insulin Infusion Pumps and Artificial Pancreas Device Systems (Durable Medical Equipment #77)
    • HCPCS E0787
  • Islet Transplantation (Transplants #13)
    • CPT 0584T-0586T
  • Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (Surgery #195)
    • CPT 33340
  • Physical Medicine—Physical therapy, occupational therapy, speech therapy
    • CPT 97219, 97130
  • Radiology—AIM Specialty Health
    • CPT 78429-78433
  • Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (Surgery #40)

    • CPT 15769, 15771, 15772

The following changes were made to our Uniform Medical Plan Pre-authorization List effective January 1, 2020:

  • Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (Surgery #182)
    • CPT 15769, 15771, 15772
  • Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (Genetic Testing #42)
    • CPT 81522
  • Bariatric Surgery (Surgery #58)
    • CPT 43820
  • Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies (Genetic Testing #58)
    • CPT 0156U
  • Cosmetic and Reconstructive Procedures (Surgery #12)
    • CPT 15769, 15771–15774
  • Gene Expression Profile Testing of Cancer Tissue
    • CPT 81542
  • Gene Expression Profiling for Melanoma (Genetic Testing #29)
    • CPT 81552
  • Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome (Genetic Testing #2)
    • CPT 81307, 81308
  • Insulin Infusion Pumps and Artificial Pancreas Device Systems (Durable Medical Equipment #77)
    • HCPCS E0787
  • Islet Transplantation (Transplants #13)
    • CPT 0584T-0586T
  • Joint management
    • CPT 23470, 23472-23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440-27443, 27445-27447, 27486-27488, 27580, 29805-29807, 29819-29828, 29860-29863, 29868, 29870, 29871, 29873-29877, 29879-29889, 29891-29895, 29897-29899, 29904-29907
  • Knee Arthroscopy for Osteoarthritis of the Knee
    • CPT 29874, 29877
  • Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (Surgery #195)
    • CPT 33340
  • Pain management
    • CPT 00640, 27096, 61790, 61791, 62320-62327, 62350, 62351, 62360-62362, 64405, 64479, 64480, 64483, 64484, 64490-64495, 64510, 64520, 72275; HCPCS G0259, G0260
  • Radiology—AIM Specialty Health
    • CPT 78429-78433
  • Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (Surgery #40)
    • CPT 15769, 15771, 15772
  • Sleep Apnea—Diagnosis and Equipment
    • CPT 95800, 95801, 95806-95808, 95810, 95811
    • HCPCS E0561, E0562, E0601, G0398-G0400
  • Sleep Medicine
    • CPT 95782, 95783, 95805; HCPCS E0470, E0471
  • Spinal Injections
    • CPT 62320-62323, 64479, 64480, 64483, 64484, 64490-64495
  • Spine
    • CPT 20931, 20937, 20938, 22100-22103, 22110, 22112, 22114, 22116, 22206-22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325-22328, 22532-22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632-22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842-22850, 22852-22855, 22859, 62380, 63001, 63003, 63005, 63011, 63012, 63015-63017, 63020, 63030, 63035, 63040, 63042-63048, 63050, 63051, 63055-63057, 63064, 63066, 63075-63078, 63081, 63082, 63085-63088, 63090, 63091, 63101-63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194-63200, 63250- 63252, 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290, 63295, 63300- 63308
    • HCPCS S2350, S2351
  • Total Knee Arthroplasty

    • CPT 27437, 27438, 27440, 27441, 27445-27447

Effective January 1, 2020, the following will be subject to Health Technology Clinical Committee (HTCC) decisions:

  • Breast MRI
    • 77046-77049
  • Cardiac Nuclear Imaging
    • 78451-78454, 78459, 78466, 78468, 78469, 78491, 78492
  • Computed Tomographic Angiography
    • 75574
  • Functional Neuroimaging for Primary Degenerative Dementia or Mild Cognitive Impairment
    • 70554, 70555, 78608, 78609
  • Imaging for Rhinosinusitis
    • 70450, 70460, 70486, 70487, 70470, 70488, 70542, 70540, 70543
  • Positron Emission Tomography (PET) Scans for Lymphoma

    • 78811-78816

Effective January 1, 2020, coordination of benefits (COB) and Medicare secondary claims will be subject to HTCC determination for UMP members. If a service or procedure is listed as requiring pre-authorization for UMP members because of HTCC determination, pre-authorization is also required for COB and Medicare secondary claims.

The following codes were added to our Medicare Pre-authorization List effective January 1, 2020:

  • Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (Medicare Surgery #182)
    • CPT 15769, 15771, 15772
  • Continuous Glucose Monitors (CGMs) and External Insulin Infusion Pumps (Medicare Durable Medical Equipment #86)
    • HCPCS E0787
  • Cosmetic and Reconstructive Procedures (Medicare Surgery #12)
    • CPT 15769, 15771-15774
  • Genetic and Molecular Diagnostics—Next Generation Sequencing and Genetic Panel Testing (Medicare Genetic Testing #64)
    • CPT 0140U-0142U, 0151U-0153U, 0157U-0162U, 81277, 81307-81309, 81522, 81542, 81552
  • Genetic and Molecular Diagnostics—Single Gene or Variant Testing (Medicare Genetic Testing #20)
    • CPT 0154U-0156U, 81277, 81307-81309
  • Measurement of Serum Antibodies to Infliximab, Adalimumab, Ustekinumab, and Vedolizumab (Medicare Laboratory #65)
    • CPT 80145, 80230, 80280
  • Powered Knee, Powered Ankle-Foot, Microprocessor-Controlled Ankle-Foot and Microprocessor-Controlled Knee Prostheses (Medicare Durable Medical Equipment #81)
    • HCPCS L2006
  • Physical Medicine—Physical therapy, occupational therapy, speech therapy
    • CPT 97219, 97130
  • Radiology—AIM Specialty Health
    • CPT 78429-78433
  • Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (Medicare Surgery #40)

    • CPT 15769, 15771, 15772

Please review our pre-authorization lists for all updates and pre-authorize services accordingly.

2020 changes to UMP benefits, networks and products

January 1, 2020, marks a new year and brings many changes for Washington public and state employees covered by the Washington Health Care Authority (HCA). During their open enrollment period, School Employees Benefits Board (SEBB) employees will join the Public Employees Benefits Board (PEBB) employees in having the option to select the Uniform Medical Plan (UMP) products offered through HCA. Regence is the third-party administrator for UMP claims processing, products and networks and will be working closely with the HCA to focus on improved care quality.

2020 changes

Included below are the medical management programs that will apply to UMP members effective January 1, 2020 (except as noted below).

  • Sleep Medicine
    • Services subject to the program's pre-authorization requirements
  • Physical Medicine
    • Pain management, spine and joint services subject to the program's pre-authorization requirements
      • Physical, speech and occupational therapy services subject to the program's pre-authorization requirements; Note: The effective date of this program is March 1, 2020
  • Radiology
    • Services subject to the Advanced Imaging Authorization program's pre-authorization requirements
  • Medication policies
    • Subject to Health Technology Clinical Committee (HTCC) decision
  • Medical drugs

    • Additional UMP-specific medical policies will require pre-authorization to determine whether they are medically necessary and meet clinical criteria; if a drug requires pre-authorization, please submit the request electronically

Preferred Drug List

Washington State Rx Services will continue to be the vendor administering the prescription drug benefit. The Preferred Drug List will be updated on January 1, 2020. View the current list.

Site of Care for infusion medication

UMP Classic and UMP Consumer-Directed Health Plans (CDHP) members will have the same infusion medication Site of Care program that other Regence members currently have. Pre-authorization is required for the site of care for specific medications as listed in our Site of Care Review (dru 408) medication policy. View our medication policies.

  • The program focuses on medical benefit drugs that are administered by a provider.
  • Site of Care will not apply to SEBB members.

The following programs are also available to UMP members January 1, 2019.

Diabetes prevention

  • Omada will be added to the SEBB products.
  • The program combines proven science with personalized support to help participants build healthy habits that last —whether that means improving eating habits, activity levels, sleep or stress management.

Virtual care

  • Telehealth services will be offered through in-network providers and Doctor on Demand 24/7, 365 days a year.

Tobacco cessation

  • Quit For Life helps tobacco users quit by using proven, evidence-based strategies.

Regence BabyWise

  • Our maternity support program is designed to improve the utilization of prenatal services and provide important support to members and families-to-be.

Regence Advice24

  • This will not be included on the UMP Plus UW Medicine Accountable Care Network (UW Medicine ACN) plan.
  • Our nurse advice line program offers members immediate toll-free access to registered nurses 24/7, 365 days a year.

Provider network changes

UMP members will continue to utilize the Regence Preferred Provider Organization (PPO) Network.

The following changes will be made to the UMP Plus networks on January 1, 2020:

Puget Sound High Value Network (PSHVN)

  • Adding Rainier Health Group and The Polyclinic
  • Removing MultiCare, Evergreen and Overlake

UW Medicine ACN

  • Removing Overlake and Island Hospital

Product changes

The following changes will be made to the UMP medical products on January 1, 2020.

Products for PEBB members

  • Nutritional visits will increase to 12 in a lifetime

Note: Vision will continue to be covered through the Regence vision benefit (not VSP).

Products for SEBB members - new for January 1, 2020

  • UMP Achieve 1, UMP Achieve 2 and UMP High-Deductible plans.
  • Chiropractic visits are limited to 16 per calendar year
  • Vision benefits will be administered by another health plan
  • The combined physical therapy, occupational therapy, speech therapy, and neurodevelopmental therapy visits are limited to 80 per calendar year

More information, including sample member ID cards, are available on our website.

Introducing Quartet: Improving the lives of people with mental health needs

In Washington, Regence BlueShield is partnering with Quartet, a healthcare technology and services company whose mission is to improve the lives of people with mental health needs. Together we are working to make it easier for these patients to get the care they need.

We are offering the Quartet program to both primary care providers (PCPs) and mental health providers in the Regence BlueShield service area at no cost.

Quartet’s HIPAA-compliant technology allows PCPs to identify their patients with underlying mental health conditions and easily refer them to a specialized network of mental health providers. Quartet’s technology further allows both mental health and PCPs to collaborate on patient care and measure treatment progress.

This model helps improve access to mental health care and, in turn, improves patient health outcomes. With your participation, patients, including those with mental health conditions that have historically been unaddressed, will receive an elevated level of care.

Quartet will be contacting providers when it’s time to sign up in your area.

If you are interested in learning more, please call Quartet Health at (347) 384-5950. Alternatively, mental health providers can learn more at quartethealth.com/mental-health-wa, and PCPs can learn more at quartethealth.com/primary-care-wa.

Diabetes prevention and management programs

We are committed to ensuring that our members who are living with diabetes receive the best care, treatment and information about how to manage their chronic condition. Included below are updates to our programs, effective January 1, 2020:

Medicare Advantage members have access to Livongo’s Virtual DPP, which is Centers for Disease Control and Prevention- (CDC-) recognized. It includes expert-led live and recorded classes, self-monitoring devices and technology, a suite of digital tools, unlimited one-on-one coaching and a supportive, interactive online community.

Additional employer groups have purchased Livongo Diabetes Management. View the list of participating employer groups. This program is for members with type 1 or type 2 diabetes. The program includes free testing strips and lancets—plus a new, free blood glucose meter; better diabetes monitoring; and answers to questions 24/7. It is available to Medicare Advantage members and employees of employer groups that have purchased the program.

Blue Distinction Specialty Care program updates

Blue Distinction® programs are updated periodically to provide meaningful quality and cost differentiation to consumers, employers and providers.

The Blue Distinction Specialty Care Program is a national designation program recognizing health care facilities for their proven expertise, high-quality care and patient results.

The following specialty care program will be added on January 1, 2020:

  • Substance Use Treatment and Recovery: This program will focus on identifying facilities delivering evidence-based, patient-focused care, resulting in improved quality outcomes and affordability for the treatment of substance use disorder, including opioid use disorder. At this time, facilities delivering one or more of the following levels of care will be considered for designation: residential, inpatient, intensive outpatient or partial hospitalization services.

The following specialty care programs will be refreshed:

  • Blue Distinction Centers for Knee and Hip Replacement: This program is being refreshed this year. On January 1, 2020, we’ll add providers who have achieved Blue Distinction Center (BDC) or Blue Distinction Center+ (BDC+) designations.
  • Blue Distinction Centers for Spine Surgery: This program is being refreshed this year. On
    January 1, 2020, we’ll add providers who have achieved BDC or BDC+ designations.
  • The Blue Distinction Centers for Transplants is expanding to include adult and pediatric kidney transplants. The Solid Organ Transplant program will consist of 10 transplant program designations.

Providers may apply for any of the following now:

  • Adult lung
  • Adult heart
  • Adult pancreas
  • Adult living donor liver
  • Adult deceased donor liver
  • Adult living donor kidney
  • Adult deceased donor kidney
  • Pediatric liver
  • Pediatric heart
  • Pediatric kidney

If you are interested in receiving a designation or have questions about the program, please contact John Irwin at John.Irwin@regence.com or by phone at (503) 220-6157.

Administrative Manual updates

The following updates will be made on January 1, 2020:

Regence BlueShield: Accountable Health Network Guidelines

  • Updated to reflect current process and format
  • Clarified who to contact for out-of-network referrals

Alternative Care

  • Adding section to the Idaho, Oregon and Utah
  • Updating the Washington section to reflect information for all Plans