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: October 1, 2025
Policy name	Summary of policy or change	Effective date	Section and policy number	Coding or implementation change	Pre-authorization change
Surgical Treatments for Lymphedema and Lipedema	Clarified clinical examination and diagnostic documentation requirements.	January 1, 2026	Surgery #220	N/A	N/A
Surgical Site of Care - Colonoscopy	New policy. Surgical Site of Care - Hospital Outpatient (#19) will be updated 1/1/2026 to align with implementation of this new policy.	January 1, 2026	Utilization Management #20	Adding CPT codes 44388, 44389, 44391, 44392, 44394, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398 to the policy with preauth edit. Adding HCPCS codes G0105, G0121 to the policy with preauth edit.	Adding CPT codes 44388, 44389, 44391, 44392, 44394, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398 to the preauth website for this policy. Adding HCPCS codes G0105, G0121 to the preauth website for this policy.
Definitive Lower Limb Prostheses	Clarified when prior prosthesis use is applicable, define ordering practitioner, and include examples of validated functional level assessment tools.	October, 1, 2025	Durable Medical Equipment #18	Added new Q4 HCPCS code L5657 to this policy with no edit. Revised Q4 HCPCS code L5783 to match new description	N/A
Negative Pressure Wound Therapy in the Outpatient Setting	Clarified policy Criteria	October, 1, 2025	Durable Medical Equipment #42	N/A	N/A
Evaluating the Utility of Genetic Panels	Added seven panel tests, and Removed four tests from policy.	October, 1, 2025	Genetic Testing #64	Added Q4 CPT code 0592U with investigational edit for this policy.	N/A
Laboratory Tests for Organ Transplant Rejection	Updated policy to address Donor-derived cell-free DNA testing and gene expression profiling for liver transplant, and Non-HLA antibody testing for organ transplant.	October, 1, 2025	Laboratory #51	Added Q4 CPT codes 0575U, 0576U, 0581U to the policy with investigational denial.	N/A
Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer	Updated criteria to address testing more generally.	October, 1, 2025	Laboratory #60	Added Q4 CPT code 0577U to this policy with investigational denial.	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added the following tests to the policy: PromarkerD, iDart™ Lyme IgG ImmunoBlot Kit, and PancreaSure tests.	October, 1, 2025	Laboratory #77	Added Q4 CPT codes 0579U, 0580U, 0599U to the policy with always investigational edit. Deleted Q4 CPT codes 0450U, 0451U and remove investigational edit.	N/A
Circulating Tumor-Tissue Modified Viral DNA Testing for Cancer Management	New policy. Moved codes with no change to existing edit from Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers, Laboratory #46.	October, 1, 2025	Laboratory #82	Added CPT codes 0356U, 0470U to this new policy with no change to investigational edit.	N/A
Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension	Added criteria for ablation of renal sympathetic nerves.	October, 1, 2025	Surgery #235	Removed investigational denial and added preauth to CPT codes 0338T, 0339T, 0935T, and HCPCS codes C1735, C1736 for this policy.	Added CPT codes 0338T, 0339T, 0935T, and HCPCS codes C1735, C1736 to the preauth website for this policy.
Patient Lifts and Seat Lifts	New policy addressing patient lifts and seat lifts will apply only to Individual members.	September 1, 2025	Durable Medical Equipment #23	Added HCPCS codes E0625, E0627, E0629, E0630, E0635, E0636, E0639, E0640, E1035, E1036 with preauth requirement for this policy for Individual Line of Business only.	Added codes E0625, E0627, E0629, E0630, E0635, E0636, E0639, E0640, E1035, E1036 to the preauth website for Individual Line of Business only.
Identification of Microorganisms Using Nucleic Acid Probes	Updating criteria for large respiratory panel tests (>12 targets) to be considered not medically necessary.	September 1, 2025	Genetic Testing #85	Changed edit on CPT codes 0115U, 0202U, 0223U, 0225U 0373U, 87633 from investigational to not medically necessary for this medical policy.	N/A
New and Emerging Medical Technologies and Procedures	Removed two codes that have been moved into new medical policy SUR237 - Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma.	September 1, 2025	Medicine #149	Removed CPT codes 0660T, 0661T from this medical policy, effective 9/1/2025 and moving to new policy SUR237.	N/A
Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers)	Updated criteria related to the Coflex device.	September 1, 2025	Surgery #155	Changed edit for CPT codes 22867, 22868 from always investigational to add preauth.	Added CPT codes 22867, 22868 to the preauth website for this policy.
Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders	Updated criteria for transcatheter tricuspid valve repair and replacement.	September 1, 2025	Surgery #221	Changed edit for CPT codes 0569T, 0570T, 0646T from always investigational to add preauth.	Added CPT codes 0569T, 0570T, 0646T to the preauth website for this policy.
Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma	New policy addressing Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma.	September 1, 2025	Surgery #237	Added CPT codes 0660T, 0661T to this policy and continue investigational denial. Added HCPCS code J7355 to this policy and add investigational denial.	N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder	Clarified policy criteria.	August 1, 2025	Behavioral Health #18	N/A	N/A
Power Wheelchairs: Group 2 and Group 3	Changed policy title; policy was previously titled Power Wheelchairs: Group 3 Added group 2 criteria and codes to the policy with this update	August 1, 2025	Durable Medical Equipment #37	Added HCPCS codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 with preauth requirement for this policy for Individual Line of Business only.	Added codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 to the preauth website for Individual Line of Business only.
Augmentative Communication Devices and Systems	New medical policy with medical necessity criteria will apply only to Individual members.	August 1, 2025	Durable Medical Equipment #52	Added HCPCS codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 with preauth requirement for this policy for Individual Line of Business only. Continue unlisted review on code E2599.	Added codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 to the preauth website for Individual Line of Business only.
Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar	New medical policy with medical necessity criteria will apply only to Individual members.	August 1, 2025	Durable Medical Equipment #97	Added HCPCS codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 with preauth requirement for this policy for Individual Line of Business only.	Added codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 to the preauth website for Individual Line of Business only.
Testosterone Testing	New lab policy for testosterone testing.	August 1, 2025	Laboratory #81	Added CPT codes 84402, 84410 as not medically necessary when frequency values are exceeded over a rolling 365 days. Added CPT code 84403 with no clinical edit.	N/A
New and Emerging Medical Technologies and Procedures	Moved 12 codes from this policy: 11 codes to new policy SUR17, and One code to MED105.	August 1, 2025	Medicine #149	Remove CPT codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T from this policy and move to new policy SUR17 with no change to investigational denial. Remove CPT code 0936T from this policy and move to MED105 with no change to investigational denial.	N/A
Extravascular (Substernal) Implantable Cardioverter-Defibrillator	New policy.	August 1, 2025	Surgery #17	Add codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T with no change to investigational denial with move from MED149 to this new policy.	N/A
Varicose Vein Treatment	Clarified required documentation for conservative therapy.	August 1, 2025	Surgery #104	N/A	N/A
Mental Health and Eating Disorders	New policy establishes the intensity of service (IOS) standards.	July 1, 2025	Behavioral Health #36	Policy uses revenue codes only: 0124, 1001, 0905, 0912, 0913 with no edit.	N/A
Negative Pressure Wound Therapy in the Outpatient Setting	Added indications for coverage, Clarifying criteria addressing nutritional status, and Added criteria and required documentation for evaluation of arterial status for neuropathic ulcers.	July 1, 2025	Durable Medical Equipment #42	N/A	N/A
Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities	Removed fetal tissue testing for ultrasound anomalies, which will be addressed in GT79 - Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss.	July 1, 2025	Genetic Testing #78	N/A	N/A
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss	Added a phrase to criterion I to clarify fetal testing after pregnancy termination is addressed in this policy, not GT78 - Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities.	July 1, 2025	Genetic Testing #79	N/A	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added the IGoCheck and MammoCheck tests from Milagen, Inc. to the policy.	July 1, 2025	Laboratory #77	Added new Q3 CPT codes 0558U, 0559U to this policy with always investigational edit.	N/A
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting	Added new investigational technology.	July 1, 2025	Medicine #33	Added new Q3 CPT codes 0981T, 0982T, 0983T to this policy with always investigational edit.	N/A
New and Emerging Medical Technologies and Procedures	Updated the policy in alignment with the 2025 Q3 annual code update.	July 1, 2025	Medicine #149	Added new Q3 CPT codes 0948T, 0949T, 0951T, 0952T, 0953T, 0954T, 0955T, 0961T, 0962T, 0963T, 0967T, 0972T, 0978T, 0979T, 0980T, 0984T, 0985T, 0986T, 0987T to this policy with always investigational edit.	N/A
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	Policy updated to address upper gastrointestinal optical sensor capsule.	July 1, 2025	Radiology #38	Added new Q3 CPT code 0977T to this policy with always investigational edit.	N/A
Electromagnetic Navigation Bronchoscopy	New policy created to address electromagnetic navigation bronchoscopy.	July 1, 2025	Surgery #179	Added CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 with preauth for this medical policy. Added HCPCS code A4648 and continue no clinical edit on this code.	Added CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 to the preauth website for this medical policy.
Responsive Neurostimulation	Added criterion to address the use of epicranial neurostimulation (e.g., EASEE)	July 1, 2025	Surgery #216	Added new Q3 CPT codes 0968T, 0969T to this policy with always investigational edit.	N/A
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
Long-Term Sub-Scalp Electroencephalography Monitoring Systems	New policy.	July 1, 2025	Surgery #239	Added new Q3 CPT codes 0956T, 0957T, 0958T, 0959T, 0960T to this policy with always investigational edit.	N/A
Percutaneous Laser Ablation of Benign and Malignant Breast Tumors	New policy.	July 1, 2025	Surgery #240	Added new Q3 CPT codes 0970T, 0971T to this policy with always investigational edit.	N/A
Air Ambulance Transport	Expanding post-service review of rotary air ambulance.	July 1, 2025	Utilization Management #13	N/A	N/A
New and Emerging Medical Technologies and Procedures	Removed two codes that have been moved into new medical policy MED178 - Histotripsy for Hepatic or Renal Tumor Treatment, and Removed one code that is addressed in SUR221 - Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders excluding Transcatheter Edge to Edge Repair TEER.	June 1, 2025	Medicine #149	Removed CPT codes 0686T, 0888T from this policy and moved to MED178, with no change to the edit. Removed CPT 0545T from this policy that was left in error when it was moved to SUR221 with Q3 code updates effective 7/1/2024.	N/A
Histotripsy for Hepatic or Renal Tumor Treatment	New policy addressing Histotripsy for Hepatic or Renal Tumor Treatment.	June 1, 2025	Medicine #178	Moved CPT codes 0686T, 0888T to this medical policy from MED149 and continue investigational denial.	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
Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids	Clarified criteria. Updated minimum age for Osia system.	June 1, 2025	Surgery #121	N/A	N/A
Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity	Combined investigational criteria in the policy.	May 1, 2025	Genetic Testing #44	N/A	N/A

Recently archived policies
Policy name	Archive date	Policy number
Treatment of Adult Sepsis	07/01/2025	Medicine #172
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	06/01/2025	Medicine #152
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)	05/01/2025	Medicine #140
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy	05/01/2025	Surgery #147