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Medical and claim payment policy activity posted from August 23 – September 25, 2014

October 1, 2014

Below is a listing of the policy activity that we have posted to our website from August 23 – September 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 Independence.

Policy # Title Notification date Effective date 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 11.16.07 Bronchial Thermoplasty N/A August 27, 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 00.06.02k Preventive Care Services Medical Necessity Criteria; Medical Coding June 5, 2014 September 3, 2014 02.02.01f Hospice and Respite Care Medical Coding N/A August 27, 2014 05.00.50j Ostomy Supplies Medical Necessity Criteria; Medical Coding September 19, 2014 October 20, 2014 05.00.58h Home Oxygen Therapy Medical Necessity Criteria August 27, 2014 September 26, 2014 05.00.60e Pressure-Reducing Support Surfaces Medical Necessity Criteria; General Description, Guidelines, or Informational Update August 13, 2014 September 15, 2014 05.00.61d Cervical Traction for In-home Use Medical Necessity Criteria August 11, 2014 September 10, 2014 05.00.73b Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding September 19, 2014 October 20, 2014 07.00.03l Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy Medical Coding; General Description, Guidelines, or Informational Update N/A September 10, 2014 07.00.21f Allergy Immunotherapy Medical Necessity Criteria; Coverage and/or Reimbursement Position August 27, 2014 November 25, 2014 07.03.05q Sleep Disorder Testing Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update September 8, 2014 October 8, 2014 07.03.07k Evaluation and Management of Autism Spectrum Disorders (ASD) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update July 28, 2014 August 27, 2014 07.10.05d Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System General Description, Guidelines, or Informational Update N/A September 3, 2014 07.12.01d Pelvic Floor Stimulation as a Treatment of Incontinence Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update August 11, 2014 September 10, 2014 08.00.15c Off-label Coverage for Prescription Drugs and Biologics Medical Necessity Criteria; General Description, Guidelines, or Informational Update N/A August 27, 2014 08.00.17d Total Parenteral Nutrition (TPN)/Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Parenteral Nutrition (IPN) Medical Necessity Criteria; General Description, Guidelines, or Informational Update September 12, 2014 October 13, 2014 08.00.18j Medical Foods (i.e., Enteral Nutrition and Nutritional Formulas) and Low-Protein Modified Food Products Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A September 10, 2014 08.00.47f Nesiritide (Natrecor®) Medical Necessity Criteria; General Description, Guidelines, or Informational Update September 10, 2014 October 10, 2014 08.00.55e Omalizumab (Xolair®) Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A August 27, 2014 08.00.67h Cetuximab (Erbitux®) Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A August 27, 2014 08.00.76d Oxaliplatin (Eloxatin®) Medical Necessity Criteria; Medical Coding N/A August 27, 2014 08.00.83d Pralatrexate (Folotyn®) for Injection Medical Necessity Criteria; General Description, Guidelines, or Informational Update N/A September 24, 2014 08.00.87b Pemetrexed (Alimta®) Medical Necessity Criteria; Medical Coding N/A August 27, 2014 08.00.88b Ofatumumab (Arzerra?) Medical Necessity Criteria N/A September 24, 2014 08.00.95c Personalized Vaccines (e.g., Provenge®) Medical Necessity Criteria September 24, 2014 October 24, 2014 08.00.97d Romidepsin (Istodax®) Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A September 24, 2014 08.01.07c Pertuzumab (Perjeta®) Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update July 30, 2014 August 29, 2014 08.01.09c Omacetaxine mepesuccinate (Synribo®) Medical Necessity Criteria; General Description, Guidelines, or Informational Update N/A August 27, 2014 08.01.11c Ado-Trastuzumab Emtansine (Kadcyla®) Medical Necessity Criteria; General Description, Guidelines, or Informational Update; Medical Coding July 30, 2014 August 29, 2014 08.01.12a Repository Corticotropin (H.P. Acthar® Gel Injection) Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update 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 Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update August 27, 2014 September 26, 2014 11.02.17e Endovascular Stent- Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions Medical Necessity Criteria; General Description, Guidelines, or Informational Update N/A August 27, 2014 11.03.11k Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) General Description, Guidelines, or Informational Update N/A August 27, 2014 11.08.15r Reconstructive Breast Surgery Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update; Medical Coding August 27, 2014 September 26, 2014 11.14.07k Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update N/A September 10, 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 Necessity Criteria; Medical Coding August 29, 2014 October 1, 2014 11.15.20j Deep Brain Stimulation (DBS) Medical Coding August 29, 2014 October 1, 2014

Reissued policies

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

Policy # Title Reissue effective date 00.10.35f Remote Patient Management: Telemedicine and Telehealth September 3, 2014 (Published September 3, 2014) 02.01.02b Private Duty Nursing September 3, 2014 (Published September 3, 2014) 05.00.24k Interstitial Continuous Glucose Monitoring Systems (CGMSs) September 3, 2014 (Published September 3, 2014) 06.02.04c Fetal Fibronectin Enzyme (fFN) Immunoassay September 3, 2014 (Published September 3, 2014) 06.02.06m Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations September 17, 2014 (Published September 19, 2014) 06.02.10l Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) September 17, 2014 (Published September 19, 2014) 06.02.27e Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis September 17, 2014 (Published September 19, 2014) 06.02.30c Pharmacogenetic Testing to Determine Drug Sensitivity September 17, 2014 (Published September 19, 2014) 06.02.31c Genetic Testing for Congenital Long QT Syndrome September 17, 2014 (Published September 22, 2014) 06.02.35g Genetic Testing September 17, 2014 (Published September 19, 2014) 07.00.05f In Vivo Allergy Sensitivity Testing September 17, 2014 (Published September 19, 2014) 07.00.10g Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin®) September 17, 2014 (Published September 19, 2014) 07.05.06e Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies September 17, 2014 (Published September 19, 2014) 07.05.07b Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies September 17, 2014 (Published September 19, 2014) 07.07.03i Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL]) September 17, 2014 (Published September 19, 2014) 07.07.09e Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions September 17, 2014 (Published September 19, 2014) 07.08.03a Medical and Surgical Treatment of Temporomandibular Joint Disorder September 3, 2014 (Published September 3, 2014) 07.11.02d Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders September 3, 2014 (Published September 3, 2014) 07.13.05g Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®) September 17, 2014 (Published September 22, 2014) 07.13.07e Corneal Pachymetry Using Ultrasound September 17, 2014 (Published September 23, 2014) 08.00.13o Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG) September 3, 2014 (Published September 3, 2014) 08.00.25g Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use September 3, 2014 (Published September 4, 2014) 08.00.26r Botulinum Toxin Agents September 3, 2014 (Published September 4, 2014) 08.00.50l Rituximab (Rituxan®) September 17, 2014 (Published September 19, 2014) 08.00.51g Enzyme Replacement for the Treatment of Gaucher?s Disease September 3, 2014 (Published September 4, 2014) 08.00.66h Bevacizumab (Avastin®) September 3, 2014 (Published September 4, 2014) 08.00.84a Eculizumab (Soliris®) September 3, 2014 (Published September 4, 2014) 08.00.99a Belimumab (Benlysta®) August 20, 2014 (Published September 18, 2014) 08.01.13 Brentuximab Vedotin (Adcetris®) September 3, 2014 (Published September 4, 2014) 09.00.48c Radioembolization for Primary and Metastatic Tumors of the Liver September 17, 2014 (Published September 19, 2014) 09.00.51a Positron Emission Mammography (PEM) September 17, 2014 (Published September 18, 2014) 09.00.52a Digital Breast Tomosynthesis September 3, 2014 (Published September 3, 2014) 10.00.02a Day Rehabilitation September 3, 2014 (Published September 4, 2014) 10.02.02e Chiropractic Spinal and Extraspinal Manipulation Therapy September 17, 2014 (Published September 18, 2014) 10.06.01h Speech Therapy September 3, 2014 (Published September 4, 2014) 11.00.09d Solid Organ Transplants September 3, 2014 (Published September 4, 2014) 11.00.13d Hyperthermic Intraperitoneal Chemotherapy (HIPEC) September 17, 2014 (Published September 19, 2014) 11.01.01i Otoplasty September 3, 2014 (Published September 3, 2014) 11.01.02j Cochlear Implant September 3, 2014 (Published September 4, 2014) 11.01.06a Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids September 3, 2014 (Published September 4, 2014) 11.01.07b Cataract Surgery September 17, 2014 (Published September 19, 2014) 11.02.06j Catheter Ablation of Cardiac Arrhythmias September 3, 2014 (Published September 3, 2014) 11.02.12e Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery September 17, 2014 (Published September 19, 2014) 11.02.16o Ventricular Assist Devices (VADs) September 3, 2014 (Published September 4, 2014) 11.02.19c Total Artificial Hearts (TAHs) September 17, 2014 (Published September 19, 2014) 11.03.01d Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate September 3, 2014 (Published September 4, 2014) 11.05.16a Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma September 17, 2014 (Published September 19, 2014) 11.07.01l Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) September 17, 2014 (Published September 19, 2014) 11.07.02f Sentinel Lymph Node Biopsy September 3, 2014 (Published September 3, 2014) 11.08.01e Hair Transplants and Cranial Prostheses (Wigs) September 3, 2014 (Published September 4, 2014) 11.08.02f Reduction Mammoplasty September 3, 2014 (Published September 4, 2014) 11.08.03i Lipectomy and Liposuction September 3, 2014 (Published September 4, 2014) 11.08.06g Abdominoplasty and/or Panniculectomy September 3, 2014 (Published September 4, 2014) 11.08.10f Excision of Redundant Skin September 3, 2014 (Published September 4, 2014) 11.08.13f Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty September 3, 2014 (Published September 4, 2014) 11.08.19j Prophylactic Mastectomy September 17, 2014 (Published September 19, 2014) 11.08.25j Scar Revision September 17, 2014 (Published September 22, 2014) 11.09.02a Sex Reassignment Surgery (SRS) for Gender Identity Disorder (GID) September 3, 2014 (Published September 4, 2014) 11.11.01f Evaluation and Treatment of Erectile Dysfunction (ED) September 17, 2014 (Published September 19, 2014) 11.14.10k Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty September 3, 2014 (Published September 3, 2014) 11.14.22b Lumbar Interspinous Process Decompression September 17, 2014 (Published September 19, 2014) 11.14.26 Surgical Treatments of Athletic Pubalgia September 3, 2014 (Published September 3, 2014) 11.15.11b Treatment for Hyperhidrosis (Nonpharmacologic) September 3, 2014 (Published September 3, 2014) 11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty September 3, 2014 (Published September 4, 2014) 11.16.06e Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis September 17, 2014 (Published September 19, 2014) 11.17.07f Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence September 3, 2014 (Published September 4, 2014) 12.05.01g Outpatient Diabetes Education and Self-Management Training September 17, 2014 (Published September 19, 2014)

Archived policy

The following policy is deemed no longer necessary by Independence.

Policy # Title Notification date Effective date 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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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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