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Medical and claim payment policy activity postedOctober 25 – November 20, 2014

December 1, 2014

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Below is a listing of the policy activity that we have posted to our website from October 25 – November 20, 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 Independence.

Policy # Title Notification date Effective date
00.01.60 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services October 1, 2014 January 1, 2015

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 #TitleType of policy change Notification dateEffective date
00.01.56a National Correct Coding Initiative (NCCI) Code Pair Edits Coverage and/or Reimbursement Position October 1, 2014 January 1, 2015
05.00.01iPneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency Medical Necessity CriteriaOctober 20, 2014November 19, 2014
05.00.39kAnkle-Foot/Knee-Ankle-Foot OrthosesGeneral Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 20, 2014November 19, 2014
07.00.21fAllergy ImmunotherapyCoverage and/or Reimbursement Position; Medical Necessity Criteria August 27, 2014November 25, 2014
07.02.03hImplantable Cardiac Loop MonitorCoverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical CodingOctober 3, 2014January 1, 2015
07.02.12gCardiac Event Detection Monitoring (External Loop Monitoring) Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 8, 2014 November 7, 2014
07.05.02lWireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and ColonGeneral Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 20, 2014November 19, 2014
07.07.07cElectrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsCoverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update October 20, 2014November 19, 2014
08.00.57gComplex Regional Pain Syndrome (CRPS) Parenteral Treatments Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 8, 2014 November 7, 2014
08.00.73fBortezomib (Velcade®)General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 8, 2014November 7, 2014
08.00.78nSelf-Administered DrugsMedical CodingOctober 31, 2014 December 1, 2014
08.00.90dPaclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/ (Abraxane® for Injectable Suspension)Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014
08.00.93bC1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest®Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity CriteriaOctober 27, 2014November 26, 2014
08.01.04hPreventive ImmunizationMedical Coding; Medical Necessity Criteria October 20, 2014November 19, 2014
08.01.12aRepository Corticotropin (H.P. Acthar® Gel Injection)Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Necessity Criteria August 27, 2014 November 25, 2014
09.00.36hFirst-Trimester Prenatal Screening for Fetal AneuploidyMedical Coding August 13, 2014 Published November 11, 2014;
Retroactively effective August 13, 2014
10.03.01ePhysical Medicine, Rehabilitation, and Habilitation ServicesCoverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update; Medical Coding October 20, 2014November 19, 2014
11.00.16eRadiofrequency Ablation and Cryosurgical Ablation of Lung TumorsCoverage and/or Reimbursement Position; Medical Necessity CriteriaOctober 3, 2014January 1, 2015
11.15.23cEpidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity CriteriaOctober 3, 2014 January 1, 2015

Archived policy

The following is a policy that Independence has determined is no longer necessary to remain active.

Policy # Title Notification date Archive effective date
08.00.06gInpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E.45®)October 8, 2014 January 6, 2015

To view policy activity, go to 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 the Reference Tools transaction, 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.

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