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Beginning with the February 2014 edition of Partners in Health Update,
the policy notifications article will include new
policies, re-issued policies, policy updates, and coding updates. This
additional information is intended to give providers
greater detail regarding our medical policy activity.
Below is a listing of the policy notifications that we have posted to our
website as of December 30, 2013.
Policy effective date
Policy #
Notification title
Notification issue date
December 26, 2013
06.03.04h
Apheresis Therapy
September 27, 2013
December 26, 2013
11.01.02j
Cochlear Implant
September 27, 2013
January 1, 2014
05.00.24j
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
October 3, 2013
(Revised Nov. 25, 2013)
January 1, 2014
05.00.37e
Compression Garments
December 2, 2013
January 1, 2014
05.00.39i
Ankle-Foot/Knee-Ankle-Foot Orthosis
October 3, 2013
January 1, 2014
07.00.03k
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
October 3, 2013
(Revised Nov. 22, 2013)
January 1, 2014
07.00.20e
Routine Costs Associated with Qualifying Clinical Trials
October 3, 2013
January 1, 2014
07.03.05p
Sleep Disorder Testing
October 3, 2013
January 1, 2014
07.05.02j
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the
Small Bowel, Esophagus, and Colon
October 3, 2013
January 1, 2014
07.10.05b
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
November 20, 2013
January 1, 2014
08.00.13o
Immune Globulin Intravenous (IVIG),
Subcutaneous (SCIG)
October 3, 2013
(Revised Dec. 16, 2013)
January 1, 2014
08.00.78j
Self-Administered Drugs
October 3, 2013
January 1, 2014
08.00.92e
Coagulation Factors for Hemophilia
October 3, 2013
January 1, 2014
10.03.01c
Physical Medicine, Rehabilitation, and Habilitation Services
October 3, 2013
January 1, 2014
11.07.01l
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
October 3, 2013
January 1, 2014
11.14.24
Manipulation under Anesthesia
October 3, 2013
January 1, 2014
12.04.03a
Air or Sea Ambulance Transport Services
December 2, 2013
January 3, 2014
07.02.05i
External Counterpulsation (ECP)
December 4, 2013
January 7, 2014
07.03.08d
Neuropsychological Evaluation/Testing
October 9, 2013
January 8, 2014
11.17.04l
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS)
for the Control of Incontinence
January 8, 2013
January 10, 2014
08.00.57e
Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
December 11, 2013
(Revised Dec. 16, 2013)
February 4, 2014
11.08.02f
Reduction Mammoplasty
November 6, 2013
February 5, 2014
05.00.42e
Patient Lifts
November 6, 2013
February 5, 2014
07.00.02g
Intravenous Chelation Therapy
November 7, 2013
February 5, 2014
11.14.10k
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
November 6, 2013
February 18, 2014
07.02.03g
Implantable Cardiac Loop Monitor
November 20, 2013
February 18, 2014
11.02.12e
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting
of the Extracranial Carotid Artery or Intracranial Artery
November 20, 2013
February 19, 2014
11.11.01f
Evaluation and Treatment of Erectile Dysfunction (ED)
November 21, 2013
March 4, 2014
08.01.10
Octreotide acetate (Sandostatin® LAR Depot)
December 4, 2013
March 19, 2014
09.00.10p
Brachytherapy
December 19, 2013
March 19, 2014
11.16.01g
Septoplasty, Rhinoplasty, and Septorhinoplasty
December 19, 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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