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Policy notifications posted as of March 28, 2013

March 28, 2013

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All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of March 28, 2013.

Policy effective date

Policy No.

Notification title

Notification issue date

March 29, 2013

08.01.05

Carfilzomib (Kyprolis?)

February 27, 2013

March 29, 2013

08.01.09

Omacetaxine mepesuccinate (Synribo?)

February 27, 2013

April 1, 2013

05.00.58f

Home Oxygen Therapy

February 28, 2013

April 1, 2013

09.00.53

Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone-Gel-Filled Breast Implants
in Asymptomatic Individuals

March 1, 2013

April 2, 2013

11.14.08c

Orthognathic Surgery

January 2, 2013

April 2, 2013

08.00.81b

Bendamustine Hydrochloride (Treanda?)

January 2, 2013

April 2, 2013

11.14.03e

Meniscal Allograft Transplantation

January 2, 2013

April 4, 2013

08.00.25g

Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use

January 4, 2013

April 16, 2013

07.02.07g

Ambulatory, Real-Time Cardiac Surveillance System

January 16, 2013

April 16, 2013

11.05.02g

Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy

January 16, 2013

April 17, 2013

11.15.09d

Denervation of the Spinal Nerves for Chronic Facet Pain

January 17, 2013

May 11, 2013

11.14.25a

Total Ankle Arthroplasty/Replacement

March 13, 2013

To view the policy notifications, visit our Medical Policy portal, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.

NaviNet® is a registered trademark of NaviNet, Inc.

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