Below is a listing of the policy activity that we have posted to our website
from April 26 ? May 25, 2014.
New policy
The following policy has 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
00.01.56
National Correct Coding Initiative (NCCI) Modifier Indicator 0 (Zero)
Procedure Code Pairs
February 12, 2014
May 13, 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
08.00.34g
Infliximab (Remicade
®)
Coverage and/or Reimbursement
Position; Medical Necessity Criteria
Medical Coding; General Description,
Guidelines, or Informational Update
May 22, 2014
June 23, 2014
08.00.50l
Rituximab (Rituxan
®)
Medical Coding
March 5, 2014
June 3, 2014
08.00.62e
Abatacept (Orencia
®) for Injection for Intravenous Use
Coverage Position; Medical Necessity Criteria; General Description
March 5, 2014
June 3, 2014
08.00.81c
Bendamustine Hydrochloride (Treanda
®)
Medical Necessity Criteria
February 12, 2014
May 13, 2014
08.00.85d
Tocilizumab (Actemra
®) for Intravenous Infusion
Medical Necessity Criteria; General Description
March 5, 2014
June 3, 2014
08.00.94f
Denosumab (Prolia?,
Xgeva?)
Medically Necessary Criteria; Medical Coding; General Description, Guidelines,
or Informational Update
April 23, 2014
May 23, 2014
08.01.05b
Carfilzomib (Kyprolis?)
Medical Necessity Criteria
N/A
May 7, 2014
09.00.46l
High-Technology
Radiology Services
Coverage and/or Reimbursement
Position; Medical Coding
January 31, 2014
(notification revised
February 12, 2014)
May 1, 2014
11.00.06e
Treatment of Obstructive Sleep Apnea (OSA) and
Primary Snoring for Adults
Coverage and/or Reimbursement Position; Medical Coding; General Description,
Guidelines, or Informational Update
April 23, 2014
July 23, 2014
11.02.10j
Endovascular Grafts
for Abdominal Aortic
Aneurysms (AAA),
Aortic-Iliac Aneurysms,
and Infrarenal Aortic
Aneurysms
General Description; Coverage Position; Medically Necessary Criteria; Medical
Coding
March 26, 2014
June 24, 2014
11.15.19e
Nucleoplasty
General Description, Guidelines, or
Informational Update
N/A
May 7, 2014
12.01.01x
Experimental/ Investigational Services
Medical Coding; Coverage Position
April 10, 2014
July 9, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
05.00.45g
Repair or Replacement of an External Prosthetic Device
May 14, 2014 (published May 16, 2014)
05.00.69
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
May 14, 2014 (published May 16, 2014)
06.02.01e
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic
Treatment
May 14, 2014 (published May 15, 2014)
06.02.26b
In Vitro Allergy Testing
May 14, 2014 (published May 16, 2014)
08.01.00c
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of
Preterm Birth in High-Risk Pregnancies
May 14, 2014 (published May 15, 2014)
08.01.01c
Ipilimumab (Yervoy
®)
May 14, 2014 (published May 15, 2014)
08.01.08
Coverage of Prescription Oral Anticancer Drugs and Biologics as Provided Under
the Company's Medical Benefit
May 14, 2014 (published May 15, 2014)
09.00.04f
Bone Mineral Density (BMD) Testing
May 14, 2014 (published May 15, 2014)
09.00.40b
Screening for Vertebral Fracture with Dual-Energy X-ray
Absorptiometry (DEXA/DXA)
May 14, 2014 (published May 15, 2014)
09.00.42b
Computer-Aided Detection (CAD) System for use with Chest
Radiographs
May 14, 2014 (published May 15, 2014)
11.06.02f
Elective Abortion
May 14, 2014 (published May 15, 2014)
11.06.09a
Labiaplasty
May 14, 2014 (published May 15, 2014)
11.08.05g
Application and Removal of Tattoos
May 14, 2014 (published May 16, 2014)
11.14.03e
Meniscal Allograft Transplantation
May 14, 2014 (published May 15, 2014)
11.14.06f
Autologous Chondrocyte Implantation (ACI)/Carticel
® and Other
Cell-based Treatments of Focal Articular Cartilage Lesions
May 14, 2014 (published May 15, 2014)
11.14.09e
Osteochondral Autograft Transplantation (OAT) Procedure
May 14, 2014 (published May 15, 2014)
11.14.12c
Osteochondral Allograft Transplantation
May 14, 2014 (published May 15, 2014)
11.14.13e
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
May 14, 2014 (published May 16, 2014)
11.14.25a
Total Ankle Arthroplasty/Replacement
May 14, 2014 (published May 15, 2014)
11.15.22b
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis
May 14, 2014 (published May 15, 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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