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Medical and claim payment policy activity posted from June 25 – July 25, 2014

July 31, 2014

Below is a listing of the policy activity that we have posted to our website from June 25 ? July 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 08.01.17 Elosulfase alfa (Vimizim?) June 18, 2014 July 18, 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 00.01.25u PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services Coverage and/or Reimbursement Position; Medical Coding N/A July 16, 2014 00.06.02k Preventive Care Services Medical Necessity Criteria; Medical Coding June 5, 2014 September 3, 2014 02.01.01c Home Health Care Services Medical Necessity Criteria; Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update April 23, 2014, Revised
June 19, 2014 July 22, 2014 05.00.14g High-Frequency Chest Wall Oscillation Devices Medical Necessity Criteria June 18, 2014 July 18, 2014 05.00.38h Negative-Pressure Wound Therapy (NPWT) Systems Medical Coding; Medical Necessity Criteria June 30, 2014 July 30, 2014 05.00.42f Patient Lifts Medical Necessity Criteria; Medical Coding; N/A July 2, 2014 05.00.43e Seat Lift Mechanisms Medical Necessity Criteria N/A July 2, 2014 05.00.47j Knee Braces Medical Coding; Medical Necessity Criteria; Coverage and/or Reimbursement Position June 30, 2014 July 30, 2014 05.00.56f Hospital Beds and Accessories Medical Necessity Criteria; General Description, Guidelines, or Informational Update July 3, 2014 August 4, 2014 05.00.59g Lower Limb Prostheses General Description, Guidelines, or Informational Update; Medical Necessity Criteria N/A July 16, 2014 07.03.21g Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding June 30, 2014 July 30, 2014 07.07.02g Ultraviolet Light Therapy for the Treatment of Dermatological Conditions General Description, Guidelines, or Informational Update; Medical Necessity Criteria; Medical Coding N/A July 2, 2014 07.10.06a Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update June 30, 2014 July 30, 2014 08.00.33j Trastuzumab (Herceptin®) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update April 23, 2014 July 22, 2014 09.00.17j Intensity Modulated Radiation Therapy (IMRT) Medical Coding January 3, 2014 April 2, 2014,
Revised
July 15, 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 11.00.14d Treatment of Twin-Twin Transfusion Syndrome (TTTS) Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A July 2, 2014 12.01.01x Experimental/ Investigational Services Medical Coding; Coverage and/or Reimbursement Position April 10, 2014 July 9, 2014 12.01.01y Experimental/Investigational Services Coverage and/or Reimbursement Position; Medical Coding N/A July 10, 2014

Reissued policies

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

Policy # Title Reissue effective date 01.00.09b Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump July 23, 2014 (Published July 24, 2014) 05.00.70a Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures June 25, 2014 (Published June 25, 2014) 07.02.09b Ambulatory Blood Pressure Monitoring (ABPM) July 23, 2014 (Published July 24, 2014) 07.06.01b Complete Decongestive Therapy (CDT) July 9, 2014 (Published July 11, 2014) 07.06.03a Bioimpedance for the Detection of Lymphedema July 9, 2014 (Published July 11, 2014) 08.00.62e Abatacept (Orencia®) for Injection for Intravenous Use July 9, 2014 (Published July 11, 2014) 08.01.03c Belatacept (Nulojix®) July 9, 2014 (Published July 11, 2014) 09.00.02d Electron Beam Computed Tomography (EBCT) for Screening Evaluations June 25, 2014 (Published June 25, 2014) 09.00.24b Full-Body Computerized Tomography (CT) Scan Screening June 25, 2014 (Published June 26, 2014) 11.03.12j Colorectal Cancer Screening July 23, 2014 (Published July 24, 2014) 11.05.01c Refractive Keratoplasty July 9, 2014 (Published July 11, 2014) 11.05.07c Surgical Correction of Strabismus July 9, 2014 (Published July 11, 2014) 11.05.08c Photocoagulation of Macular Drusen July 9, 2014 (Published July 11, 2014) 11.08.14f Removal of Breast Implants June 25, 2014 (Published June 25, 2014) 11.11.05e Circumcision July 23, 2014 (Published July 24, 2014) 11.14.01f Mentoplasty or Genioplasty June 25, 2014 (Published June 25, 2014) 11.14.17b Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure July 9, 2014 (Published July 11, 2014) 11.14.19g Artificial Intervertebral Disc Insertion June 25, 2014 (Published June 25, 2014) 11.14.23c Surgical Treatment of Femoroacetabular Impingement July 9, 2014 (Published July 11, 2014) 11.14.24 Manipulation Under Anesthesia June 25, 2014 (Published June 25, 2014) 12.04.03b Air or Sea Ambulance Transport Services July 23, 2014 (Published July 24, 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 00.03.02q Diagnostic Radiology Services Included in Capitation July 1, 2014 (Published July 25, 2014) 00.03.07h Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of- Service (HMO-POS) Products July 1, 2014 (Published July 25, 2014) 03.00.06k Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service July 1, 2014 (Published July 11, 2014) 03.00.10k Modifiers LT/RT: left Side/Right Side Procedures July 11, 2014 (Published July 11, 2014) 03.00.15k Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period July 1, 2014 (Published July 11, 2014) 03.00.16k Modifier 57: Decision for Surgery July 1, 2014 (Published July 11, 2014) 05.00.24k Interstitial Continuous Glucose Monitoring Systems (CGMSs) July 1, 2014 (Published July 1, 2014) 05.00.32f Speech- and Non-Speech-Generating Devices July 1, 2014 (Published July 1, 2014) 06.02.35g Genetic Testing July 1, 2014 (Published July 1, 2014) 07.05.02k Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon July 1, 2014 (Published July 10, 2014) 08.00.57f Complex Regional Pain Syndrome (CRPS) Parenteral Treatments July 1, 2014 (Published July 1, 2014) 08.00.92h Coagulation Factors for Hemophilia July 1, 2014 (Published July 1, 2014) 09.00.10q Brachytherapy July 1, 2014 (Published July 10, 2014) 10.03.01d Physical Medicine, Rehabilitation, and Habilitation Services July 1, 2014 (Published July 2, 2014) 10.06.01h Speech Therapy July 1, 2014 (Published July 2, 2014)

Archived policy

The following policy is deemed no longer necessary by IBC.

Policy # Title Notification date Effective date 08.00.54d Radioimmunotherapy with Tositumomab and Iodine I-131 Tositumomab (the Bexxar® Therapeutic Regimen) July 14, 2014 August 13, 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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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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