Below is a listing of the policy activity that we have posted to our website from February 26 ? March 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 00.01.56 National Correct Coding Initiative (NCCI) Modifier Indicator 0 (Zero) Procedure Code Pairs February 12, 2014 May 13, 2014 08.01.10 Octreotide acetate (Sandostatin^® LAR Depot) December 4, 2013 March 4, 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 00.10.37a Humanitarian Use Devices (HUD) and the Humanitarian Device Exemption (HDE) Process Description, Guidelines, or Informational Update N/A March 12, 2014 05.00.09g Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System Medical Necessity Criteria; Medical Codes; General Description, Guidelines, or Informational Update February 14, 2014 March 14, 2014 05.00.11e Therapeutic Shoes and Orthopedic Shoes Description, Guidelines, or Informational Update N/A March 12, 2014 05.00.15n Nebulizers Medical Coding N/A March 12, 2014 05.00.16d Blood Pressure Devices for Home Use Description, Guidelines, or Informational Update N/A March 12, 2014 05.00.29h Automatic External and Wearable Cardioverter Defibrillators Description, Guidelines, or Informational Update N/A March 12, 2014 05.00.35c Foot Orthotics and Other Podiatric Appliances Coverage and/or Reimbursement Position; Medical Coding February 14, 2014 March 12, 2014 08.00.50l Rituximab (Rituxan^®) Medical Necessity Criteria; Medical Coding March 5, 2014 June 3, 2014 08.00.62e Abatacept (Orencia^®) for Injection for Intravenous Use Description, Guidelines, or Informational Update; Medical Necessity Criteria March 5, 2014 June 3, 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 08.00.78l Self-Administered Drugs Coverage and/or Reimbursement Position; Medical Coding N/A February 26, 2014 08.00.81c Bendamustine Hydrochloride (Treanda^®) Medical Necessity Criteria February 12, 2014 May 13, 2014 08.00.85d Tocilizumab (Actemra^®) for Intravenous Infusion Description, Guidelines, or Informational Update; Medical Necessity Criteria March 5, 2014 June 3, 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 09.00.46l High-Technology Radiology Services Coverage and/or Reimbursement Position; Medical Codes January 31, 2014 (notification revised on February 12, 2014) May 1, 2014 09.00.49e Proton Beam Radiation Therapy Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014 11.02.06j Catheter Ablation of Cardiac Arrhythmias Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Codes; General Description, Guidelines, or Informational Update February 26, 2014 March 26, 2014 11.08.25j Scar Revision Coverage and/or Reimbursement Position; Medical Coding January 2, 2014 April 2, 2014 11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty Medical Necessity Criteria; General Description, Guidelines, or Informational Update December 19, 2013 March 19, 2014

Reissued policies

The following policies have been reviewed, and no substantive changes were made. Policy # Title Reissue effective date 00.01.44e Never Events and Preventable Adverse Events March 5, 2014 05.00.71b Standing Frames March 19, 2014 07.02.07g Ambulatory, Real-Time Cardiac Surveillance System March 5, 2014 07.03.08d Neuropsychological Evaluation/Testing March 19, 2014 07.03.22 Repetitive Transcranial Magnetic Stimulation (rTMS) March 19, 2014 08.00.93a C1 Esterase Inhibitors (Human): Cinryze^® and Berinert^® March 19, 2014 11.15.13c Lysis of Epidural Adhesions March 19, 2014 11.15.24 Migraine Deactivation Surgery March 19, 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 00.03.03e Outpatient Short-Term Rehabilitation Services Included in Capitation January 1, 2014 (published on March 7, 2014) 03.00.07n Modifer 51: Multiple Procedures January 1, 2014 (published on March 24, 2014) 03.00.29h Modifier 51 Exempt March 7, 2014 (published on March 24, 2014) 08.01.04g Preventive Immunization January 2, 2014 (published on March 10, 2014) 08.09.11s Medicare Part B vs. Part D Crossover Drugs January 2, 2014 (published on March 7, 2014) 11.00.10p Multiple Surgical Reduction Guidelines January 1, 2014 (published on March 21, 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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