Below is a listing of the policy activity that we have posted to our website from April 26 ? May 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 AmeriHealth.

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 AmeriHealth.

Policy # Title Type of policy change Notification date Effective date 08.00.34g Infliximab (Remicade^®) Coverage and/or Reimbursement Position; Medical Necessity Criteria Medical Coding; General Description, Guidelines, or Informational Update May 22, 2014 June 23, 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 08.00.81c 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 08.00.94f Denosumab (Prolia?, Xgeva?) Medically Necessary Criteria; Medical Coding; General Description, Guidelines, or Informational Update April 23, 2014 May 23, 2014 08.01.05b Carfilzomib (Kyprolis?) Medical Necessity Criteria N/A May 7, 2014 09.00.46l High-Technology Radiology Services Coverage and/or Reimbursement Position; Medical Coding January 31, 2014 (notification revised February 12, 2014) May 1, 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 11.02.10j Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms General Description; Coverage Position; Medically Necessary Criteria; Medical Coding March 26, 2014 June 24, 2014 11.15.19e Nucleoplasty General Description, Guidelines, or Informational Update N/A May 7, 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 05.00.45g Repair or Replacement of an External Prosthetic Device May 14, 2014 (published May 16, 2014) 05.00.69 Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD) May 14, 2014 (published May 16, 2014) 06.02.01e Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment May 14, 2014 (published May 15, 2014) 06.02.26b In Vitro Allergy Testing May 14, 2014 (published May 16, 2014) 08.01.00c Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies May 14, 2014 (published May 15, 2014) 08.01.01c Ipilimumab (Yervoy^®) May 14, 2014 (published May 15, 2014) 08.01.08 Coverage of Prescription Oral Anticancer Drugs and Biologics as Provided Under the Company's Medical Benefit May 14, 2014 (published May 15, 2014) 09.00.04f Bone Mineral Density (BMD) Testing May 14, 2014 (published May 15, 2014) 09.00.40b Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA) May 14, 2014 (published May 15, 2014) 09.00.42b Computer-Aided Detection (CAD) System for use with Chest Radiographs May 14, 2014 (published May 15, 2014) 11.06.02f Elective Abortion May 14, 2014 (published May 15, 2014) 11.06.09a Labiaplasty May 14, 2014 (published May 15, 2014) 11.08.05g Application and Removal of Tattoos May 14, 2014 (published May 16, 2014) 11.14.03e Meniscal Allograft Transplantation May 14, 2014 (published May 15, 2014) 11.14.06f Autologous Chondrocyte Implantation (ACI)/Carticel^® and Other Cell-based Treatments of Focal Articular Cartilage Lesions May 14, 2014 (published May 15, 2014) 11.14.09e Osteochondral Autograft Transplantation (OAT) Procedure May 14, 2014 (published May 15, 2014) 11.14.12c Osteochondral Allograft Transplantation May 14, 2014 (published May 15, 2014) 11.14.13e Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions May 14, 2014 (published May 16, 2014) 11.14.25a Total Ankle Arthroplasty/Replacement May 14, 2014 (published May 15, 2014) 11.15.22b Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis May 14, 2014 (published May 15, 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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