Below is a listing of the policy activity that we have posted to our website
from September 26 ? October 24, 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 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
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous
Neuromodulation Therapy (PNT)
August 29, 2014
September 30, 2014
06.02.38
Nerve Fiber Density Testing
August 27, 2014
September 26, 2014
08.01.18
Vedolizumab (Entyvio
®)
September 24, 2014
October 24, 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 Independence.
Policy #
Title
Type of policy change
Notification date
Effective date
00.01.56a
National Correct Coding Initiative (NCCI) code pair edits
Coverage and/or Reimbursement Position
October 1, 2014
January 1, 2015
00.06.02l
Preventive Care Services
Medical Coding
N/A
October 1, 2014
05.00.01i
Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous
Insufficiency
Medical Necessity Criteria
October 20, 2014
November 19, 2014
05.00.39k
Ankle-Foot/Knee-Ankle- Foot Orthoses
General Description, Guidelines, or Informational Update; Medical Coding;
Medical Necessity Criteria
October 20, 2014
November 19, 2014
05.00.50j
Ostomy Supplies
Medical Coding; Medical Necessity Criteria
September 19, 2014
October 20, 2014
05.00.58h
Home Oxygen Therapy
Medical Necessity Criteria
August 27, 2014
September 26, 2014
05.00.73b
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical
Stimulators (FES)
Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity
Criteria
September 19, 2014
October 20, 2014
07.00.21f
Allergy Immunotherapy
Coverage and/or Reimbursement Position; Medical Necessity Criteria
August 27, 2014
November 25, 2014
07.02.03h
Implantable Cardiac Loop Monitor
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding
October 3, 2014
January 1, 2015
07.02.12g
Cardiac Event Detection Monitoring (External Loop Monitoring)
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding; Medical Necessity Criteria
October 8, 2014
November 7, 2014
07.03.05q
Sleep Disorder Testing
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding; Medical Necessity Criteria
September 8, 2014
October 8, 2014
07.05.02l
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the
Small Bowel, Esophagus, and Colon
General Description, Guidelines, or Informational Update; Medical Coding;
Medical Necessity Criteria
October 20, 2014
November 19, 2014
07.07.07c
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of
Wounds
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update
October 20, 2014
November 19, 2014
08.00.17d
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) /
Intraperitoneal Parenteral Nutrition (IPN)
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria
September 12, 2014
October 13, 2014
08.00.47f
Nesiritide (Natrecor
®)
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria
September 10, 2014
October 10, 2014
08.00.57g
Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding; Medical Necessity Criteria
October 8, 2014
November 7, 2014
08.00.73f
Bortezomib (Velcade
®)
General Description, Guidelines, or Informational Update; Medical Coding;
Medical Necessity Criteria
October 8, 2014
November 7, 2014
08.00.75h
Erythropoiesis-Stimulating Agents (ESAs)
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria
N/A
October 1, 2014
08.00.90d
Paclitaxel Protein-bound Particles for Injectable Suspension
(Albumin-bound)/(Abraxane
® for Injectable Suspension)
Medical Coding; Medical Necessity Criteria
October 8, 2014
November 7, 2014
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C
®, Aralast NP?,
Glassia?, Zemaira?)
General Description, Guidelines, or Informational Update
N/A
October 8, 2014
08.00.95c
Personalized Vaccines (e.g., Provenge
®)
Medical Necessity Criteria
September 24, 2014
October 24, 2014
08.01.04h
Preventive Immunization
Medical Coding; Medical Necessity Criteria
October 20, 2014
November 19, 2014
08.01.12a
Repository 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
09.00.36h
First-Trimester Prenatal Screening for Fetal Aneuploidy
Medical Coding
August 13, 2014
November 11, 2014
10.01.01k
Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs
General Description, Guidelines, or Informational Update; Medical Coding;
Medical Necessity Criteria
August 27, 2014
September 26, 2014
10.03.01e
Physical Medicine, Rehabilitation, and Habilitation Services
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding
October 20, 2014
November 19, 2014
11.00.16e
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
Coverage and/or Reimbursement Position; Medical Necessity Criteria
October 3, 2014
January 1, 2015
11.08.15r
Reconstructive Breast Surgery
Coverage and/or Reimbursement Position; General Description, Guidelines, or
Informational Update; Medical Coding; Medical Necessity Criteria
August 27, 2014
September 26, 2014
11.15.01l
Spinal Cord Stimulation (Dorsal Column Stimulation)
Medical Coding; Medical Necessity Criteria
August 29, 2014
October 1, 2014
11.15.16j
Vagus Nerve Stimulation (VNS)
Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity
Criteria
August 29, 2014
October 1, 2014
11.15.20j
Deep Brain Stimulation (DBS)
Medical Coding
August 29, 2014
October 1, 2014
11.15.23c
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain
Management
Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity
Criteria
October 3, 2014
January 1, 2015
12.01.01z
Experimental/ Investigational Services
Coverage and/or Reimbursement Position
N/A
October 1, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
Reissue published date
06.02.14e
In Vitro Chemosensitivity and Chemoresistance Assays
October 1, 2014
October 2, 2014
06.02.18g
Pharmacogenetics and Metabolite Monitoring Using Azathioprine
(AZA)/6-Mercaptopurine (6-MP) Therapy
October 1, 2014
October 2, 2014
06.02.24f
Preimplantation Genetic Testing
October 1, 2014
October 2, 2014
06.02.37
Immune Cell Function Assay
October 1, 2014
October 2, 2014
06.03.04i
Apheresis Therapy
October 1, 2014
October 2, 2014
07.00.01f
Biofeedback Therapy
October 1, 2014
October 2, 2014
07.00.02g
Intravenous Chelation Therapy
October 1, 2014
October 2, 2014
07.03.10d
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
October 1, 2014
October 2, 2014
07.13.01f
Orthoptic/Pleoptic Training
October 1, 2014
October 2, 2014
07.13.06g
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
October 1, 2014
October 2, 2014
07.13.08c
Partial Coherence Interferometry
October 1, 2014
October 2, 2014
07.13.11e
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
October 1, 2014
October 2, 2014
07.13.14a
The Argus
® II Retinal Prosthesis
October 1, 2014
October 2, 2014
08.00.50l
Rituximab (Rituxan
®)
October 1, 2014
October 1, 2014
11.02.01j
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein
Incompetence
October 1, 2014
October 2, 2014
11.02.10j
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac
Aneurysms, and Infrarenal Aortic Aneurysms
October 1, 2014
October 2, 2014
11.02.12e
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting
of the Extracranial Carotid Artery or Intracranial Artery
October 1, 2014
October 2, 2014
11.02.19c
Total Artificial Hearts (TAHs)
October 1, 2014
October 2, 2014
11.02.25c
Transcatheter Aortic-Valve Replacement (TAVR)
October 1, 2014
October 2, 2014
11.03.02n
Bariatric Surgery
October 1, 2014
October 2, 2014
11.05.02g
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and
Canthoplasty/Canthopexy
October 1, 2014
October 2, 2014
11.05.11a
Implantation of Intrastromal Corneal Ring Segments (INTACS)
October 1, 2014
October 2, 2014
11.07.01l
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
October 1, 2014
October 2, 2014
11.08.04g
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
October 1, 2014
October 2, 2014
11.08.29c
Procedures for the Treatment of Acne
October 1, 2014
October 2, 2014
11.11.06e
Saturation Needle Biopsy of the Prostate
October 1, 2014
October 2, 2014
11.14.02i
Trigger Point Injections
October 1, 2014
October 2, 2014
11.14.20d
Hip Resurfacing
October 1, 2014
October 2, 2014
11.15.03g
Insertion of Implantable Infusion Pumps
October 1, 2014
October 2, 2014
11.15.09e
Denervation of the Spinal Nerves for Chronic Facet Pain
October 1, 2014
October 2, 2014
11.17.04m
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS)
for the Control of Incontinence
October 1, 2014
October 2, 2014
11.17.06h
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due
to Benign Prostatic Hyperplasia (BPH)
October 1, 2014
October 2, 2014
11.17.07f
Radiofrequency Micro-remodeling (by transurethral, transvaginal, or
paraurethral approach) for Urinary Stress Incontinence
October 1, 2014
October 2, 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
Published date
00.01.25v
PPO Network Rules for Provision of Specialty Services for Durable Medical
Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative
Services
October 1, 2014
October 17, 2014
00.03.02r
Diagnostic Radiology Services Included in Capitation
October 1, 2014
October 17, 2014
05.00.47k
Knee Braces
October 1, 2014
October 1, 2014
08.00.92j
Coagulation Factors for Hemophilia
October 1, 2014
October 3, 2014
09.00.46m
High-Technology Radiology Services
October 1, 2014
October 1, 2014
Archived policies
The following are policies that Independence has determined are no longer
necessary to remain active.
Policy #
Title
Notification date
Effective date
08.00.06g
Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E.
45
®)
October 8, 2014
January 6, 2015
08.00.80c
Temozolomide (Temodar
®) for Injection
August 27, 2014
September 26, 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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CPT copyright 2013 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association.