Below is a listing of the policy activity that we have posted to our website from March 26 ? April 25, 2014.

New Policy

The following policy has 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

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 00.01.24e Obsolete or Unreliable Diagnostic Tests and Medical Services Medical Necessity Criteria; Medical Coding; Guidelines March 26, 2014 May 7, 2014 00.01.48a Marijuana for Medical Use General Description N/A March 26, 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 July 22, 2014 04.00.05d Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth General Description; Guidelines N/A March 26, 2014 05.00.08d Continuous Passive Motion (CPM) Devices in the Home Setting General Description, Guidelines, or Informational Update; Medical Necessity Criteria N/A April 23, 2014 05.00.31c Pulse Oximetry Device in the Home Setting General Description, Guidelines, or Informational Update N/A April 23, 2014 05.00.32e Speech- and Non-Speech-Generating Devices Medical Coding; General Description, Guidelines, or Informational Update N/A April 23, 2014 05.00.54f Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices Medical Necessity Criteria April 9, 2014 May 9, 2014 05.00.55h Wheelchair Cushions and Seating Medical Coding; Medical Necessity Criteria April 9, 2014 May 9, 2014 05.00.65d Home Uterine Activity Monitoring (HUAM) Devices General Description, Guidelines, or Informational Update N/A April 23, 2014 05.00.67k Wheelchair Options and Accessories Medical Coding; Medical Necessity Criteria April 21, 2014 May 21, 2014 07.03.18i Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies Medical Coding; General Description, Guidelines, or Informational Update N/A April 23, 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 08.00.50l Rituximab (Rituxan^®) Medical Coding March 5, 2014 June 3, 2014 08.00.62e Abatacept (Orencia^®) for injection for intravenous use Coverage Position; Medical Necessity Criteria; General Description March 5, 2014 June 3, 2014 08.00.70a Laronidase (Aldurazyme^®) Medical Necessity Criteria N/A March 26, 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 08.00.81c Bendamustine Hydrochloride (Treanda^®) Medical Necessity Criteria February 12, 2014 May 13, 2014 08.00.85d Tocilizumab (Actemra^®) for Intravenous Infusion Medical Necessity Criteria; General Description March 5, 2014 June 3, 2014 08.00.92g Coagulation Factors for Hemophilia General Description; Billing Requirements; Guidelines; Medical Coding N/A March 26, 2014 08.00.94f Denosumab (Prolia^TM, Xgeva^TM) Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update April 23, 2014 May 23, 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 10.04.01k Pulmonary Rehabilitation General Description, Guidelines, Medical Coding N/A April 23, 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 11.02.06j 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 11.02.10j Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms General Description; Coverage Position; Medical Necessity Criteria; Medical Coding March 26, 2014 June 24, 2014 11.04.01c Islet Cell Transplantation Guidelines; Medical Coding N/A March 26, 2014 11.08.25j Scar Revision Coverage and/or Reimbursement Position; Medical Coding January 2, 2014 April 2, 2014 11.14.21e Microprocessor-Controlled Prostheses for Lower-Extremity Amputees Coverage Position; Medical Necessity Criteria March 26, 2014 April 25, 2014 11.16.03f Lung Volume Reduction Surgery Medical Necessity Criteria; Medical Coding N/A April 23, 2014 12.01.01w Experimental/Investigational Services Medical Coding; Coverage Position N/A April 9, 2014 12.01.01x Experimental/Investigational Services Medical Coding; Coverage Position April 10, 2014 July 9, 2014

Reissued policies

The following policies have been reviewed, and no substantive changes were made. Policy # Title Reissue effective date 06.02.17c Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus^® IBD sgi Diagnostic^TM Test April 2, 2014 07.00.09c Topical Oxygenation April 2, 2014 07.03.14i Intraoperative Neurophysiological Monitoring (INM) March 19, 2014
(Published on March 27, 2014) 08.00.08e Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin^®) April 16, 2014
(Published on April 17, 2014) 08.00.72e Alglucosidase alfas, rhGAA (Myozyme^®, Lumizyme^®) April 2, 2014
(Published on April 3, 2014) 08.01.15a Golimumab (Simponi^® Aria^TM) Intravenous (IV) Injection April 2, 2014
(Published on April 4, 2014) 11.14.08c Orthognathic Surgery April 2, 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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