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Policy notifications posted as of August 31, 2012

August 31, 2012

All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of August 31, 2012. Policy effective date Policy No. Notification title Notification issue date August 29, 2012 11.08.04g Selective Photothermolysis Using Pulsed-Dye Lasers July 30, 2012 September 1, 2012 00.03.02m Diagnostic Radiology Services Included in Capitation June 1, 2012 September 15, 2012 00.03.07c Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products August 15, 2012 September 15, 2012 00.01.25p PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services August 15, 2012 September 18, 2012 11.03.01c Repair of Cleft Lip and/or Cleft Palate June 21, 2012 September 28, 2012 06.02.17c Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus? IBD sgi DiagnosticTM Test August 29, 2012 September 28, 2012 11.01.07a Cataract Surgery August 29, 2012 September 28, 2012 08.01.04b Preventive Immunization August 29, 2012 September 28, 2012 08.00.08e Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin?) August 29, 2012 September 28, 2012 08.00.44k Zoledronic Acid (Zometa?, Reclast?) August 29, 2012 October 1, 2012 09.00.28b Magnetic Resonance Spectroscopy (MRS) August 31, 2012 October 1, 2012 12.01.01o Experimental/Investigational Services June 29, 2012 October 3, 2012 07.13.05f Photodynamic Therapy (PDT) Using Verteporfin (Visudyne?) July 3, 2012 October 30, 2012 11.14.07i Intra-articular Injection of Hyaluronan for the Treatment of Osteoarthritis August 1, 2012 To view the policy notifications, visit our Medical Policy website, 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., an independent company.

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