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Medical and claim payment policy activity posted as of January 25, 2014

January 31, 2014

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Below is a listing of the policy activity that we have posted to our website as of January 25, 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 IBC.

Policy # Title Notification date Effective date 08.01.10 Octreotide acetate (Sandostatin® LAR Depot) December 4, 2013 March 4, 2014 11.00.18 Robotic-Assisted Surgery n/a January 6, 2014 11.14.24 Manipulation Under Anesthesia October 3, 2013 January 1, 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 IBC.

Policy # Title Type of policy change Notification date Effective date 00.06.02i Preventive Care Services Coverage and/or Reimbursement Position; Medical Coding n/a January 1, 2014 05.00.24j Interstitial Continuous Glucose Monitoring Systems (CGMSs) Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 (Revised: November 25, 2013) October 3, 2013 (Revised: November 25, 2013) 05.00.37e Compression Garments Medical Necessity Criteria; Medical Coding December 2, 2013 January 1, 2014 05.00.39i Ankle-Foot/Knee-Ankle-Foot Orthoses Coverage and/or Reimbursement Position; Medical Coding October 3, 2013 January 1, 2014 05.00.42e Patient Lifts Medical Necessity Criteria; Medical Coding November 6, 2013 February 5, 2014 06.02.39a Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update January 3, 2014 February 3, 2014 07.00.02g Intravenous Chelation Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update November 7, 2013 February 5, 2014 07.00.03k Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 (Revised: November 20, 2013) January 1, 2014 07.00.20e Routine Costs Associated with Qualifying Clinical Trials Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 January 1, 2014 07.02.03g Implantable Cardiac Loop Monitor Coverage and/or Reimbursement Position; Medical Necessity Criteria November 20, 2013 February 18, 2014 07.02.05i External Counterpulsation (ECP) Medical Coding; General Description, Guidelines, or Informational Update December 4, 2013 January 3, 2014 07.03.05p Sleep Disorder Testing Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 January 1, 2014 07.03.08d Neuropsychological Evaluation/Testing Medical Necessity Criteria October 9, 2013 January 7, 2014 07.05.02j Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 January 1, 2014 07.06.01b Complete Decongestive Therapy (CDT) Coverage and/or Reimbursement Position n/a January 1, 2014 07.10.05b Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System Coverage and/or Reimbursement Position November 21, 2013 January 1, 2014 (policy will be published on February 19, 2014) 07.13.01f Orthoptic/Pleoptic Training Coverage and/or Reimbursement Position n/a January 1, 2014 07.13.05g Photodynamic Therapy (PDT) Using Verteporfin (Visudyne?) General Description, Guidelines, or Informational Update; Medical Coding n/a January 2, 2014 07.13.11e Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects Medical Necessity Criteria; Medical Coding n/a January 8, 2014 08.00.13o Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding October 3, 2013 January 1, 2014 08.00.57e Complex Regional Pain Syndrome (CRPS) Parenteral Treatments Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update December 11, 2013 January 10, 2014 08.00.73e Bortezomib (Velcade?) Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014 08.00.74g Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis?], pegaptanib sodium [Macugen?], aflibercept [Eylea?]) Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update January 2, 2014 April 2, 2014 08.00.78j Self-Administered Drugs Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 (Revised: October 11, November 8, and December 20, 2013) January 1, 2014 08.00.92e Coagulation Factors for Hemophilia Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update October 3, 2013 January 1, 2014 09.00.10p Brachytherapy Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update December 19, 2013 March 19, 2014 09.00.17j Intensity Modulated Radiation Therapy (IMRT) Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update January 3, 2014 April 2, 2014 09.00.49e Proton Beam Radiation Therapy Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014 10.03.01c Physical Medicine, Rehabilitation, and Habilitation Services General Description, Guidelines, or Informational Update October 3, 2013 January 1, 2014 11.01.07b Cataract Surgery Medical Necessity Criteria n/a January 2, 2014 11.02.01j Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence Medical Necessity Criteria n/a January 2, 2014 11.02.12e Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery Medical Necessity Criteria; Medical Coding November 20, 2013 (Revised: January 23, 2014) February 19, 2014 11.03.01d Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate Medical Necessity Criteria; Medical Coding n/a January 1, 2014 11.07.01l Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding October 3, 2013 January 1, 2014 11.08.02f Reduction Mammaplasty Coverage and/or Reimbursement Position; Medical Coding November 6, 2013 (Revised: December 2, 2013) February 4, 2014 11.08.06g Abdominoplasty and/or Panniculectomy Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding January 3, 2014 February 3, 2014 11.08.10f Excision of Redundant Skin Medical Necessity Criteria; Medical Coding January 3, 2014 February 3, 2014 11.08.25j Scar Revision Coverage and/or Reimbursement Position; Medical Coding January 2, 2014 April 2, 2014 11.11.01f Evaluation and Treatment of Erectile Dysfunction (ED) Medical Coding November 21, 2013 February 19, 2014 11.14.10k Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty Medical Coding November 6, 2013 February 5, 2014 11.16.01g Septoplasty, Rhinoplasty,and Septorhinoplasty Medical Necessity Criteria; General Description, Guidelines, or Informational Update December 19, 2013 March 19, 2014 11.17.04m Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence Coverage and/or Reimbursement Position; Medical Coding December 9, 2013 January 8, 2014 12.04.03a Air or Sea Ambulance Transport Services Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update December 2, 2013 January 1, 2014

Reissued policies

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

Policy # Title Reissue effective date 07.00.10f Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin?) December 26, 2013 07.13.07e Corneal Pachymetry Using Ultrasound December 26, 2013 11.00.13d Hyperthermic Intraperitoneal Chemotherapy (HIPEC) December 26, 2013 11.05.16 Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma December 26, 2013 11.07.02f Sentinel Lymph Node Biopsy December 26, 2013

Archived policies

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

Policy # Title Notification date Archive effective date 07.03.16b Electrosleep Therapy using a Cranial Electrical Stimulation Device January 16, 2014 February 17, 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 00.06.02j Preventive Care Services January 2, 2014 00.10.35f Remote Patient Management: Telemedicine and Telehealth January 1, 2014 05.00.21l Durable Medical Equipment (DME) January 1, 2014 05.00.30h Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-level Devices January 1, 2014 05.00.38g Negative-Pressure Wound Therapy (NPWT) Systems January 1, 2014 05.00.39j Ankle-Foot/Knee-Ankle-Foot Orthoses January 2, 2014 05.00.47i Knee Braces January 1, 2014 05.00.50i Ostomy Supplies January 1, 2014 05.00.58g Home Oxygen Therapy January 1, 2014 05.00.62f Injectable Dermal Fillers January 1, 2014 05.00.67j Wheelchair Options and Accessories January 1, 2014 06.02.10l Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) January 1, 2014 06.02.35f Genetic Testing January 1, 2014 06.03.04i Apheresis Therapy January 1, 2014 07.00.10g Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin?) January 1, 2014 07.03.07j Evaluation and Management of Autism Spectrum Disorders (ASD) January 1, 2014 07.05.06e Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies January 1, 2014 07.05.07b Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies January 1, 2014 08.00.44n Zoledronic Acid (Zometa?, Reclast?) January 1, 2014 08.00.51g Enzyme Replacement for the Treatment of Gaucher's Disease January 1, 2014 08.00.57d Complex Regional Pain Syndrome (CRPS) Parenteral Treatments January 1, 2014 08.00.78k Self-Administered Drugs January 2, 2014 08.00.92f Coagulation Factors for Hemophilia January 2, 2014 08.01.04f Preventive Immunization January 1, 2014 08.01.05a Carfilzomib (KyprolisTM) January 1, 2014 08.01.07b Pertuzumab (Perjeta?) January 1, 2014 08.01.09b Omacetaxine mepesuccinate (Synribo?) January 1, 2014 08.01.11b Ado-trastuzumab emtansine (Kadcyla?) January 1, 2014 08.01.15a Golimumab (Simponi? AriaTM) Intravenous (IV) Injection January 1, 2014 08.09.11r Medicare Part B vs. Part D Crossover Drugs January 1, 2014 09.00.10o Brachytherapy January 1, 2014 09.00.17i Intensity Modulated Radiation Therapy (IMRT) January 1, 2014 09.00.48c Radioembolization for Primary and Metastatic Tumors of the Liver January 1, 2014 09.00.49d Proton Beam Radiation Therapy January 1, 2014 10.06.01g Speech Therapy January 1, 2014 11.00.16d Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors January 1, 2014 11.01.01i Otoplasty January 1, 2014 11.02.06i Catheter Ablation of Cardiac Arrhythmias January 1, 2014 11.02.10i Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms January 1, 2014 11.02.13e Transcoronary Ablation of Septal Hypertrophy (TASH) January 1, 2014 11.02.25c Transcatheter Aortic-Valve Replacement (TAVR) January 1, 2014 11.03.11i Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) January 1, 2014 11.03.11j Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) January 2, 2014 11.05.16a Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma January 1, 2014 11.06.04h Uterine Artery Embolization January 1, 2014 11.06.07b Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome January 1, 2014 11.08.15p Reconstructive Breast Surgery January 1, 2014 11.08.15q Reconstructive Breast Surgery January 2, 2014 11.08.20l Wound Care: Bioengineered Skin Substitutes January 1, 2014 11.08.23g Mohs' Micrographic Surgery January 1, 2014 11.08.25i Scar Revision January 1, 2014 11.11.06e Saturation Needle Biopsy of the Prostate January 1, 2014 11.14.21d Microprocessor-Controlled Prostheses for Lower-Extremity Amputees January 1, 2014 11.15.01k Spinal Cord Stimulation (Dorsal Column Stimulation) January 1, 2014 11.15.20i Deep Brain Stimulation (DBS) January 1, 2014 11.17.04l Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence January 1, 2014 12.04.02e Nonemergency Ambulance Transport Services January 1, 2014 12.04.03b Air or Sea Ambulance Transport Services January 2, 2014

To view policy activity, go to our Medical Policy site, select Accept and Go to Medical Policy Online. You can also view policy notifications 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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This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
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