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Below is a listing of the policy activity that we have posted to our
website as of January 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
08.01.10
Octreotide acetate (Sandostatin
® LAR Depot)
December 4, 2013
March 4, 2014
11.00.18
Robotic-Assisted Surgery
n/a
January 6, 2014
11.14.24
Manipulation Under Anesthesia
October 3, 2013
January 1, 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
00.06.02i
Preventive Care Services
Coverage and/or Reimbursement
Position; Medical Coding
n/a
January 1, 2014
05.00.24j
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
Coverage and/or Reimbursement Position; Medical Coding; General Description,
Guidelines,
or Informational Update
October 3, 2013
(Revised:
November 25, 2013)
October 3, 2013
(Revised:
November 25, 2013)
05.00.37e
Compression Garments
Medical Necessity Criteria;
Medical Coding
December 2, 2013
January 1, 2014
05.00.39i
Ankle-Foot/Knee-Ankle-Foot Orthoses
Coverage and/or Reimbursement Position; Medical Coding
October 3, 2013
January 1, 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
07.00.03k
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen
Therapy
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding; General
Description, Guidelines, or
Informational Update
October 3, 2013
(Revised:
November 20, 2013)
January 1, 2014
07.00.20e
Routine Costs Associated
with Qualifying Clinical Trials
Coverage and/or Reimbursement
Position; Medical Coding;
General Description, Guidelines,
or Informational Update
October 3, 2013
January 1, 2014
07.02.03g
Implantable Cardiac Loop
Monitor
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria
November 20, 2013
February 18, 2014
07.02.05i
External Counterpulsation (ECP)
Medical Coding; General Description, Guidelines, or Informational Update
December 4, 2013
January 3, 2014
07.03.05p
Sleep Disorder Testing
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding; General
Description, Guidelines, or
Informational Update
October 3, 2013
January 1, 2014
07.03.08d
Neuropsychological Evaluation/Testing
Medical Necessity Criteria
October 9, 2013
January 7, 2014
07.05.02j
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the
Small Bowel, Esophagus, and Colon
Coverage and/or Reimbursement
Position; Medical Coding;
General Description, Guidelines,
or Informational Update
October 3, 2013
January 1, 2014
07.06.01b
Complete Decongestive
Therapy (CDT)
Coverage and/or Reimbursement
Position
n/a
January 1, 2014
07.10.05b
Noncontraceptive Use
of the Levonorgestrel-Releasing Intrauterine System
Coverage and/or Reimbursement
Position
November 21, 2013
January 1, 2014
(policy will be
published on
February 19, 2014)
07.13.01f
Orthoptic/Pleoptic Training
Coverage and/or Reimbursement
Position
n/a
January 1, 2014
07.13.05g
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne
?)
General Description, Guidelines,
or Informational Update; Medical
Coding
n/a
January 2, 2014
07.13.11e
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
Medical Necessity Criteria;
Medical Coding
n/a
January 8, 2014
08.00.13o
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding
October 3, 2013
January 1, 2014
08.00.57e
Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
Medical Necessity Criteria; Medical Coding; General
Description, Guidelines, or
Informational Update
December 11, 2013
January 10, 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
08.00.78j
Self-Administered Drugs
Coverage and/or Reimbursement
Position; Medical Coding;
General Description, Guidelines,
or Informational Update
October 3, 2013
(Revised: October
11, November 8, and
December 20, 2013)
January 1, 2014
08.00.92e
Coagulation Factors for Hemophilia
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding; General
Description, Guidelines, or
Informational Update
October 3, 2013
January 1, 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
09.00.49e
Proton Beam Radiation Therapy
Medical Necessity Criteria;
Medical Coding
January 2, 2014
April 2, 2014
10.03.01c
Physical Medicine, Rehabilitation, and Habilitation Services
General Description, Guidelines,
or Informational Update
October 3, 2013
January 1, 2014
11.01.07b
Cataract Surgery
Medical Necessity Criteria
n/a
January 2, 2014
11.02.01j
Treatment of Varicose Veins of the Lower Extremities and Perforator
Vein Incompetence
Medical Necessity Criteria
n/a
January 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
11.03.01d
Repair of Cleft Lip, Cleft
Nose, and/or Cleft Palate
Medical Necessity Criteria;
Medical Coding
n/a
January 1, 2014
11.07.01l
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding
October 3, 2013
January 1, 2014
11.08.02f
Reduction Mammaplasty
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
11.17.04m
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS)
for the Control of Incontinence
Coverage and/or Reimbursement
Position; Medical Coding
December 9, 2013
January 8, 2014
12.04.03a
Air or Sea Ambulance
Transport Services
Coverage and/or Reimbursement
Position; General Description,
Guidelines, or Informational
Update
December 2, 2013
January 1, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes have
been made.
Policy #
Title
Reissue effective date
07.00.10f
Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin
?)
December 26, 2013
07.13.07e
Corneal Pachymetry Using Ultrasound
December 26, 2013
11.00.13d
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
December 26, 2013
11.05.16
Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
December 26, 2013
11.07.02f
Sentinel Lymph Node Biopsy
December 26, 2013
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
00.06.02j
Preventive Care Services
January 2, 2014
00.10.35f
Remote Patient Management: Telemedicine and Telehealth
January 1, 2014
05.00.21l
Durable Medical Equipment (DME)
January 1, 2014
05.00.30h
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway
Pressure (CPAP) Devices and Bi-level Devices
January 1, 2014
05.00.38g
Negative-Pressure Wound Therapy (NPWT) Systems
January 1, 2014
05.00.39j
Ankle-Foot/Knee-Ankle-Foot Orthoses
January 2, 2014
05.00.47i
Knee Braces
January 1, 2014
05.00.50i
Ostomy Supplies
January 1, 2014
05.00.58g
Home Oxygen Therapy
January 1, 2014
05.00.62f
Injectable Dermal Fillers
January 1, 2014
05.00.67j
Wheelchair Options and Accessories
January 1, 2014
06.02.10l
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite
Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)
January 1, 2014
06.02.35f
Genetic Testing
January 1, 2014
06.03.04i
Apheresis Therapy
January 1, 2014
07.00.10g
Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin
?)
January 1, 2014
07.03.07j
Evaluation and Management of Autism Spectrum Disorders (ASD)
January 1, 2014
07.05.06e
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
January 1, 2014
07.05.07b
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic
Malignancies
January 1, 2014
08.00.44n
Zoledronic Acid (Zometa
?, Reclast
?)
January 1, 2014
08.00.51g
Enzyme Replacement for the Treatment of Gaucher's Disease
January 1, 2014
08.00.57d
Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
January 1, 2014
08.00.78k
Self-Administered Drugs
January 2, 2014
08.00.92f
Coagulation Factors for Hemophilia
January 2, 2014
08.01.04f
Preventive Immunization
January 1, 2014
08.01.05a
Carfilzomib (Kyprolis
TM)
January 1, 2014
08.01.07b
Pertuzumab (Perjeta
?)
January 1, 2014
08.01.09b
Omacetaxine mepesuccinate (Synribo
?)
January 1, 2014
08.01.11b
Ado-trastuzumab emtansine (Kadcyla
?)
January 1, 2014
08.01.15a
Golimumab (Simponi
? Aria
TM) Intravenous (IV) Injection
January 1, 2014
08.09.11r
Medicare Part B vs. Part D Crossover Drugs
January 1, 2014
09.00.10o
Brachytherapy
January 1, 2014
09.00.17i
Intensity Modulated Radiation Therapy (IMRT)
January 1, 2014
09.00.48c
Radioembolization for Primary and Metastatic Tumors of the Liver
January 1, 2014
09.00.49d
Proton Beam Radiation Therapy
January 1, 2014
10.06.01g
Speech Therapy
January 1, 2014
11.00.16d
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
January 1, 2014
11.01.01i
Otoplasty
January 1, 2014
11.02.06i
Catheter Ablation of Cardiac Arrhythmias
January 1, 2014
11.02.10i
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac
Aneurysms, and Infrarenal Aortic Aneurysms
January 1, 2014
11.02.13e
Transcoronary Ablation of Septal Hypertrophy (TASH)
January 1, 2014
11.02.25c
Transcatheter Aortic-Valve Replacement (TAVR)
January 1, 2014
11.03.11i
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
January 1, 2014
11.03.11j
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
January 2, 2014
11.05.16a
Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of
Glaucoma
January 1, 2014
11.06.04h
Uterine Artery Embolization
January 1, 2014
11.06.07b
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion
Syndrome
January 1, 2014
11.08.15p
Reconstructive Breast Surgery
January 1, 2014
11.08.15q
Reconstructive Breast Surgery
January 2, 2014
11.08.20l
Wound Care: Bioengineered Skin Substitutes
January 1, 2014
11.08.23g
Mohs' Micrographic Surgery
January 1, 2014
11.08.25i
Scar Revision
January 1, 2014
11.11.06e
Saturation Needle Biopsy of the Prostate
January 1, 2014
11.14.21d
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
January 1, 2014
11.15.01k
Spinal Cord Stimulation (Dorsal Column Stimulation)
January 1, 2014
11.15.20i
Deep Brain Stimulation (DBS)
January 1, 2014
11.17.04l
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS)
for the Control of Incontinence
January 1, 2014
12.04.02e
Nonemergency Ambulance Transport Services
January 1, 2014
12.04.03b
Air or Sea Ambulance Transport Services
January 2, 2014
To view policy activity, go to our Medical Policy site, select Accept and Go to Medical Policy
Online. You can also view policy notifications 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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