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Medical and claim payment policy activity posted from July 26 – August 22, 2014

August 28, 2014

Below is a listing of the policy activity that we have posted to our website from July 26 ? August 22, 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 00.06.02k Preventive Care Services Medical Necessity Criteria; Medical Coding June 5, 2014 September 3, 2014 05.00.38h Negative-Pressure Wound Therapy (NPWT) Systems Medical Necessity Criteria; Medical Coding June 30, 2014 July 30, 2014 05.00.47j Knee Braces Medical Necessity Criteria; Medical Coding; 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 05.00.60e 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 05.00.62g Injectable Dermal Fillers General Description, Guidelines, or Informational Update; Medical Necessity Criteria; Medical Coding Not available August 6, 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 07.03.21g 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 07.10.06a 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 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 08.00.22l Immune Prophylaxis for Respiratory Syncytial Virus (RSV) Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update Not available August 19, 2014 08.00.78m Self-Administered Drugs Coverage and/or Reimbursement Position Not available July 30, 2014 08.00.86a Ecallantide (Kalbitor®) Medical Necessity Criteria Not available July 30, 2014 08.00.92i Coagulation Factors for Hemophilia Medical Coding; General Description, Guidelines, or Informational Update Not available July 30, 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 08.01.11c Ado-trastuzumab emtansine (Kadcyla®) Medical Necessity Criteria; General Description, Guidelines, or Informational Update; Medical Coding July 30, 2014 August 29, 2014 09.00.36h First-Trimester Prenatal Screening for Fetal Aneuploidy Medical Coding August 13, 2014 November 11, 2014 12.04.02f Nonemergency Ambulance Transport Services Medical Necessity Criteria Not available July 30, 2014

Reissued policies

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

Policy # Title Reissue effective date 05.00.37e Compression Garments August 6, 2014 (Published August 6, 2014) 06.02.09e Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping August 20, 2014 (Published August 21, 2014) 06.02.29 AlloMap? Molecular Expression Testing for Heart Transplant Rejection August 20, 2014 (Published August 21, 2014) 06.02.32a Multigene Expression Assays for Predicting Recurrence in Colon Cancer August 6, 2014 (Published August 6, 2014) 06.02.36 PathFinderTG® August 20, 2014 (Published August 21, 2014) 06.02.39a Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab August 20, 2014 (Published August 21, 2014) 06.02.43 Proteomic (protein)-based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA?) August 6, 2014 (Published August 6, 2014) 06.03.05d Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage) August 6, 2014 (Published August 6, 2014) 07.02.05 External Counterpulsation (ECP) August 6, 2014 (Published August 6, 2014) 07.13.12c Instrument-based Vision Screening August 6, 2014 (Published August 6, 2014) 08.00.44n Zoledronic Acid (Zometa®, Reclast®) August 20, 2014 (Published August 21, 2014) 08.00.64 Natalizumab (Tysabri®) August 20, 2014 (Published August 21, 2014) 08.00.65h Pamidronate Disodium (Aredia®) for Intravenous Infusion August 20, 2014 (Published August 21, 2014) 08.00.68e Ibandronate Sodium (Boniva®) for Intravenous Injection August 20, 2014 (Published August 21, 2014) 08.00.69 Agalsidase beta (Fabrazyme®) August 6, 2014 (Published August 7, 2014) 08.00.71c Idursulfase (Elaprase?) August 6, 2014 (Published August 7, 2014) 08.00.74g Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®]) August 20, 2014 (Published August 21, 2014) 08.00.79 Plerixafor Injection (Mozobil?) August 20, 2014 (Published August 21, 2014) 08.00.82c Ustekinumab (Stelara?) for Subcutaneous Injection August 6, 2014 (Published August 7, 2014) 08.00.96b Cabazitaxel (Jevtana®) August 20, 2014 (Published August 21, 2014) 08.00.99a Belimumab (Benlysta®) August 20, 2014 (Published August 21, 2014) 08.01.02a Pegloticase (Krystexxa®) August 6, 2014 (Published August 7, 2014) 08.01.10 Octreotide acetate (Sandostatin® LAR Depot) August 20, 2014 (Published August 21, 2014) 08.01.14 radium Ra 223 dichloride (Xofigo®) August 6, 2014 (Published August 7, 2014) 08.01.16 galsulfase (Naglazyme®) August 6, 2014 (Published August 7, 2014) 09.00.10q Brachytherapy August 6, 2014 (Published August 7, 2014) 09.00.17j Intensity Modulated Radiation Therapy (IMRT) August 6, 2014 (Published August 7, 2014) 09.00.49e Proton Beam Radiation Therapy August 6, 2014 (Published August 7, 2014) 11.00.01d Revision of a Previous Cosmetic Procedure August 20, 2014 (Published August 20, 2014) 11.00.03h Fetal Surgery August 20, 2014 (Published August 20, 2014) 11.02.11e Transcatheter Closure of Cardiac Septal Defects August 20, 2014 (Published August 20, 2014) 11.02.13e Transcoronary Ablation of Septal Hypertrophy (TASH) August 6, 2014 (Published August 6, 2014) 11.03.15f Gastric Electrical Stimulation (Enterra®), Gastric Pacing August 20, 2014 (Published August 20, 2014) 11.05.17 Implantable Miniature Telescope (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD) August 6, 2014 (Published August 6, 2014) 11.08.08 Chemical Peels August 20, 2014 (Published August 21, 2014) 11.11.03c Cryosurgical Ablation of the Prostate Gland August 20, 2014 (Published August 20, 2014) 11.14.14e Percutaneous Intradiscal Annuloplasty (IDET/PIRFT) August 20, 2014 (Published August 20, 2014) 11.15.15e Percutaneous Discectomy August 20, 2014 (Published August 20, 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 00.10.20k Add-on Codes July 1, 2014 (Publish July 29, 2014) 03.00.07o Modifier 51: Multiple Procedures July 1, 2014 (Publish August 1, 2014) 03.00.28j Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period July 1, 2014 (Publish July 29, 2014) 11.00.10q Multiple Surgical Reduction Guidelines July 1, 2014 (Publish July 29, 2014)

Archived policies

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.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

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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