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Below is a listing of the policy activity that we have posted to our website from January 26 – February 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 00.01.25t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services Medical Codes n/a February 1, 2014 00.03.07g Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of- Service (HMO-POS) Products Medical Codes n/a February 1, 2014 05.00.04c Food and Drug Administration (FDA) Approval of Medical Devices General Description, Guidelines, or Informational Update n/a February 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 05.00.21m Durable Medical Equipment (DME) Coverage and/or Reimbursement Position; Medical Codes; General Description, Guidelines, or Informational Update n/a February 5, 2014 05.00.35c Foot Orthotics and Other Podiatric Appliances Coverage and/or Reimbursement Position; Medical Codes February 13, 2014 March 12, 2014 05.00.42e Patient Lifts Medical Necessity Criteria; Medical Coding November 6, 2013 February 5, 2014 06.02.39a Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update January 3, 2014 February 3, 2014 07.00.02g Intravenous Chelation Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update November 7, 2013 February 5, 2014 07.02.03g Implantable Cardiac Loop Monitor Coverage and/or Reimbursement Position; Medical Necessity Criteria November 20, 2013 February 18, 2014 07.10.05b Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System Coverage and/or Reimbursement Position November 21, 2013 January 1, 2014 (Policy published on February 19, 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 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 (Revised February 12, 2014) May 1, 2014 09.00.49e Proton Beam Radiation Therapy Medical Necessity Criteria; Medical Coding January 2, 2014 April 2, 2014 11.02.12e Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery Medical Necessity Criteria; Medical Coding November 20, 2013 (Revised January 23, 2014) February 19, 2014 11.03.02n Bariatric Surgery Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Codes n/a January 1, 2014 (Published on February 4, 2014) 11.08.02f Reduction Mammoplasty Coverage and/or Reimbursement Position; Medical Coding November 6, 2013 (Revised December 2, 2013) February 4, 2014 11.08.06g Abdominoplasty and/or Panniculectomy Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding January 3, 2014 February 3, 2014 11.08.10f Excision of Redundant Skin Medical Necessity Criteria; Medical Coding January 3, 2014 February 3, 2014 11.08.25j Scar Revision Coverage and/or Reimbursement Position; Medical Coding January 2, 2014 April 2, 2014 11.11.01f Evaluation and Treatment of Erectile Dysfunction (ED) Medical Coding November 21, 2013 February 19, 2014 11.14.10k Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty Medical Coding November 6, 2013 February 5, 2014 11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty Medical Necessity Criteria; General Description, Guidelines, or Informational Update December 19, 2013 March 19, 2014 12.01.01v Experimental/Investigational Services Coverage and/or Reimbursement Position; Medical Codes n/a January 1, 2014 (Published on February 7, 2014)

Reissued policies

The following policies have been reviewed, and no substantive changes were made. Policy # Title Reissue effective date 00.01.18c Reimbursement for Associated Services Performed in Conjunction with Dental Care February 19, 2014 05.00.12e Manual Wheelchairs February 19, 2014 05.00.25f Cranial Remolding Orthoses (Helmets) February 19, 2014 05.00.72b Upper Limb Prostheses February 19, 2014 07.00.14d Cold Laser Therapy February 19, 2014 07.08.01e Non-Surgical Spinal Decompression Therapy February 19, 2014 07.10.04b Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor February 19, 2014 11.06.04h Uterine Artery Embolization February 19, 2014 11.06.05b Endometrial Ablation February 19, 2014 11.06.07b Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome February 19, 2014 11.08.12g Surgery for Gynecomastia February 19, 2014 11.14.11e Arthroscopic Electrothermal Joint Repair February 19, 2014

Archived policies

The following are policies that IBC has determined are no longer necessary to remain active. Policy # Title Notification date Archive effective date 07.03.16b Electrosleep Therapy using a Cranial Electrical Stimulation Device January 16, 2014 February 17, 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 00.01.49a Reporting Requirements for Drugs and Biologicals January 1, 2014 (Published on February 7, 2014) 00.03.02p Diagnostic Radiology Services Included in Capitation January 1, 2014 (Published on February 7, 2014) 00.10.20j Add-on Codes January 1, 2014 (Published on February 21, 2014) 00.10.36k Radiologic Guidance of a Procedure January 1, 2014 (Published on February 7, 2014) 03.00.06j Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service January 1, 2014 (Published on February 7, 2014) 03.00.15j Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period January 1, 2014 (Published on February 7, 2014) 03.00.16j Modifier 57: Decision for Surgery January 1, 2014 (Published on February 7, 2014) 07.10.05c Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System January 2, 2014 (Published on February 20, 2014) 09.00.32k Diagnostic and Therapeutic Radiopharmaceutical Agents January 1, 2014 (Published on February 7, 2014) 09.00.45f Magnetic Resonance Imaging (MRI) Contrast Agents January 1, 2014 (Published on February 7, 2014) 11.15.16i Vagus Nerve Stimulation (VNS) January 1, 2014 (Published on February 7, 2014)

To view policy activity, visit 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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