Below is a listing of the policy activity that we have posted to our website from September 26 ? October 24, 2014.

New policies

The following policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with Independence.

Policy # Title Notification date Effective date 00.01.60 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services October 1, 2014 January 1, 2015 05.00.75 Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) August 29, 2014 September 30, 2014 06.02.38 Nerve Fiber Density Testing August 27, 2014 September 26, 2014 08.01.18 Vedolizumab (Entyvio^®) September 24, 2014 October 24, 2014

Updated policies

The following policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with Independence.

Policy # Title Type of policy change Notification date Effective date 00.01.56a National Correct Coding Initiative (NCCI) code pair edits Coverage and/or Reimbursement Position October 1, 2014 January 1, 2015 00.06.02l Preventive Care Services Medical Coding N/A October 1, 2014 05.00.01i Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency Medical Necessity Criteria October 20, 2014 November 19, 2014 05.00.39k Ankle-Foot/Knee-Ankle- Foot Orthoses General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria October 20, 2014 November 19, 2014 05.00.50j Ostomy Supplies Medical Coding; Medical Necessity Criteria September 19, 2014 October 20, 2014 05.00.58h Home Oxygen Therapy Medical Necessity Criteria August 27, 2014 September 26, 2014 05.00.73b Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES) Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity Criteria September 19, 2014 October 20, 2014 07.00.21f Allergy Immunotherapy Coverage and/or Reimbursement Position; Medical Necessity Criteria August 27, 2014 November 25, 2014 07.02.03h Implantable Cardiac Loop Monitor Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding October 3, 2014 January 1, 2015 07.02.12g Cardiac Event Detection Monitoring (External Loop Monitoring) Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014 07.03.05q Sleep Disorder Testing Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria September 8, 2014 October 8, 2014 07.05.02l Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria October 20, 2014 November 19, 2014 07.07.07c Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update October 20, 2014 November 19, 2014 08.00.17d Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN) General Description, Guidelines, or Informational Update; Medical Necessity Criteria September 12, 2014 October 13, 2014 08.00.47f Nesiritide (Natrecor^®) General Description, Guidelines, or Informational Update; Medical Necessity Criteria September 10, 2014 October 10, 2014 08.00.57g Complex Regional Pain Syndrome (CRPS) Parenteral Treatments Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014 08.00.73f Bortezomib (Velcade^®) General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014 08.00.75h Erythropoiesis-Stimulating Agents (ESAs) General Description, Guidelines, or Informational Update; Medical Necessity Criteria N/A October 1, 2014 08.00.90d Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane^® for Injectable Suspension) Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014 08.00.91c Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C^®, Aralast NP?, Glassia?, Zemaira?) General Description, Guidelines, or Informational Update N/A October 8, 2014 08.00.95c Personalized Vaccines (e.g., Provenge^®) Medical Necessity Criteria September 24, 2014 October 24, 2014 08.01.04h Preventive Immunization Medical Coding; Medical Necessity Criteria October 20, 2014 November 19, 2014 08.01.12a Repository Corticotropin (H.P. Acthar^® Gel Injection) Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Necessity Criteria August 27, 2014 November 25, 2014 09.00.36h First-Trimester Prenatal Screening for Fetal Aneuploidy Medical Coding August 13, 2014 November 11, 2014 10.01.01k Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria August 27, 2014 September 26, 2014 10.03.01e Physical Medicine, Rehabilitation, and Habilitation Services Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding October 20, 2014 November 19, 2014 11.00.16e Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors Coverage and/or Reimbursement Position; Medical Necessity Criteria October 3, 2014 January 1, 2015 11.08.15r Reconstructive Breast Surgery Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria August 27, 2014 September 26, 2014 11.15.01l Spinal Cord Stimulation (Dorsal Column Stimulation) Medical Coding; Medical Necessity Criteria August 29, 2014 October 1, 2014 11.15.16j Vagus Nerve Stimulation (VNS) Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity Criteria August 29, 2014 October 1, 2014 11.15.20j Deep Brain Stimulation (DBS) Medical Coding August 29, 2014 October 1, 2014 11.15.23c Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity Criteria October 3, 2014 January 1, 2015 12.01.01z Experimental/ Investigational Services Coverage and/or Reimbursement Position N/A October 1, 2014

Reissued policies

The following policies have been reviewed, and no substantive changes were made.

Policy # Title Reissue effective date Reissue published date 06.02.14e In Vitro Chemosensitivity and Chemoresistance Assays October 1, 2014 October 2, 2014 06.02.18g Pharmacogenetics and Metabolite Monitoring Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy October 1, 2014 October 2, 2014 06.02.24f Preimplantation Genetic Testing October 1, 2014 October 2, 2014 06.02.37 Immune Cell Function Assay October 1, 2014 October 2, 2014 06.03.04i Apheresis Therapy October 1, 2014 October 2, 2014 07.00.01f Biofeedback Therapy October 1, 2014 October 2, 2014 07.00.02g Intravenous Chelation Therapy October 1, 2014 October 2, 2014 07.03.10d Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI) October 1, 2014 October 2, 2014 07.13.01f Orthoptic/Pleoptic Training October 1, 2014 October 2, 2014 07.13.06g Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) October 1, 2014 October 2, 2014 07.13.08c Partial Coherence Interferometry October 1, 2014 October 2, 2014 07.13.11e Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects October 1, 2014 October 2, 2014 07.13.14a The Argus^® II Retinal Prosthesis October 1, 2014 October 2, 2014 08.00.50l Rituximab (Rituxan^®) October 1, 2014 October 1, 2014 11.02.01j Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence October 1, 2014 October 2, 2014 11.02.10j Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms October 1, 2014 October 2, 2014 11.02.12e Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery October 1, 2014 October 2, 2014 11.02.19c Total Artificial Hearts (TAHs) October 1, 2014 October 2, 2014 11.02.25c Transcatheter Aortic-Valve Replacement (TAVR) October 1, 2014 October 2, 2014 11.03.02n Bariatric Surgery October 1, 2014 October 2, 2014 11.05.02g Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy October 1, 2014 October 2, 2014 11.05.11a Implantation of Intrastromal Corneal Ring Segments (INTACS) October 1, 2014 October 2, 2014 11.07.01l Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) October 1, 2014 October 2, 2014 11.08.04g Selective Photothermolysis Using Pulsed-Dye Lasers (PDL) October 1, 2014 October 2, 2014 11.08.29c Procedures for the Treatment of Acne October 1, 2014 October 2, 2014 11.11.06e Saturation Needle Biopsy of the Prostate October 1, 2014 October 2, 2014 11.14.02i Trigger Point Injections October 1, 2014 October 2, 2014 11.14.20d Hip Resurfacing October 1, 2014 October 2, 2014 11.15.03g Insertion of Implantable Infusion Pumps October 1, 2014 October 2, 2014 11.15.09e Denervation of the Spinal Nerves for Chronic Facet Pain October 1, 2014 October 2, 2014 11.17.04m Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence October 1, 2014 October 2, 2014 11.17.06h Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) October 1, 2014 October 2, 2014 11.17.07f Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence October 1, 2014 October 2, 2014

Coding updates

The following policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT^® and HCPCS codes; revenue codes) and/or remove terminated medical codes.

Policy # Title Effective date Published date 00.01.25v PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services October 1, 2014 October 17, 2014 00.03.02r Diagnostic Radiology Services Included in Capitation October 1, 2014 October 17, 2014 05.00.47k Knee Braces October 1, 2014 October 1, 2014 08.00.92j Coagulation Factors for Hemophilia October 1, 2014 October 3, 2014 09.00.46m High-Technology Radiology Services October 1, 2014 October 1, 2014

Archived policies

The following are policies that Independence has determined are no longer necessary to remain active.

Policy # Title Notification date Effective date 08.00.06g Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E. 45^®) October 8, 2014 January 6, 2015 08.00.80c Temozolomide (Temodar^®) for Injection August 27, 2014 September 26, 2014

To view policy activity, go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet^® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.

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