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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 October 30, 2013.
Policy effective date
Policy No.
Notification title
Notification issue date
November 1, 2013
11.00.10o
Multiple Surgical Reduction Guidelines
August 2, 2013
November 27, 2013
07.10.05a
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
August 28, 2013
December 10, 2013
05.00.73a
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical
Stimulators (FES)
September 11, 2013
December 10, 2013
11.01.06a
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing
Aids
September 11, 2013
December 26, 2013
06.03.04h
Apheresis Therapy
September 27, 2013
December 26, 2013
11.01.02j
Cochlear Implant
September 27, 2013
January 1, 2014
05.00.24j
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
October 3, 2013
January 1, 2014
05.00.39i
Ankle-Foot/Knee-Ankle-Foot Orthosis
October 3, 2013
January 1, 2014
07.00.03k
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
October 3, 2013
January 1, 2014
07.00.20e
Routine Costs Associated with Qualifying Clinical Trials
October 3, 2013
January 1, 2014
07.03.05p
Sleep Disorder Testing
October 3, 2013
January 1, 2014
07.05.02j
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the
Small Bowel, Esophagus, and Colon
October 3, 2013
January 1, 2014
08.00.13o
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
October 3, 2013
January 1, 2014
08.00.78j
Self-Administered Drugs
October 3, 2013
January 1, 2014
08.00.92e
Coagulation Factors for Hemophilia
October 3, 2013
January 1, 2014
10.03.01c
Physical Medicine, Rehabilitation, and Habilitation Services
October 3, 2013
January 1, 2014
11.07.01l
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
October 3, 2013
January 1, 2014
11.14.24
Manipulation under Anesthesia
October 3, 2013
January 7, 2014
07.03.08d
Neuropsychological Evaluation/Testing
October 9, 2013
To view the policy notifications, visit our Medical Policy portal, 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.
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