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Policy notifications posted as of December 30, 2013

January 9, 2014

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Beginning with the February 2014 edition of Partners in Health Update, the policy notifications article will include new policies, re-issued policies, policy updates, and coding updates. This additional information is intended to give providers greater detail regarding our medical policy activity.

Below is a listing of the policy notifications that we have posted to our website as of December 30, 2013.

Policy effective date Policy # Notification title Notification issue date December 26, 2013 06.03.04h Apheresis Therapy September 27, 2013 December 26, 2013 11.01.02j Cochlear Implant September 27, 2013 January 1, 2014 05.00.24j Interstitial Continuous Glucose Monitoring Systems (CGMSs) October 3, 2013
(Revised Nov. 25, 2013) January 1, 2014 05.00.37e Compression Garments December 2, 2013 January 1, 2014 05.00.39i Ankle-Foot/Knee-Ankle-Foot Orthosis October 3, 2013 January 1, 2014 07.00.03k Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy October 3, 2013
(Revised Nov. 22, 2013) January 1, 2014 07.00.20e Routine Costs Associated with Qualifying Clinical Trials October 3, 2013 January 1, 2014 07.03.05p Sleep Disorder Testing October 3, 2013 January 1, 2014 07.05.02j Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon October 3, 2013 January 1, 2014 07.10.05b Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System November 21, 2013 January 1, 2014 08.00.13o Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG) October 3, 2013
(Revised Dec. 16, 2013) January 1, 2014 08.00.78j Self-Administered Drugs October 3, 2013 January 1, 2014 08.00.92e Coagulation Factors for Hemophilia October 3, 2013 January 1, 2014 10.03.01c Physical Medicine, Rehabilitation, and Habilitation Services October 3, 2013 January 1, 2014 11.07.01l Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) October 3, 2013 January 1, 2014 11.14.24 Manipulation under Anesthesia October 3, 2013 January 1, 2014 12.04.03a Air or Sea Ambulance Transport Services December 2, 2013 January 3, 2014 07.02.05i External Counterpulsation (ECP) December 4, 2013 January 7, 2014 07.03.08d Neuropsychological Evaluation/Testing October 9, 2013 January 8, 2014 11.17.04l Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence December 9, 2013 January 10, 2014 08.00.57e Complex Regional Pain Syndrome (CRPS) Parenteral Treatments December 11, 2013
(Revised Dec. 16, 2013) February 4, 2014 11.08.02f Reduction Mammoplasty November 6, 2013 February 5, 2014 05.00.42e Patient Lifts November 6, 2013 February 5, 2014 07.00.02g Intravenous Chelation Therapy November 7, 2013 February 5, 2014 11.14.10k Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty November 6, 2013 February 18, 2014 07.02.03g Implantable Cardiac Loop Monitor November 20, 2013 February 18, 2014 11.02.12e Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery November 20, 2013 February 19, 2014 11.11.01f Evaluation and Treatment of Erectile Dysfunction (ED) November 21, 2013 March 4, 2014 08.01.10 Octreotide acetate (Sandostatin® LAR Depot) December 4, 2013 March 19, 2014 09.00.10p Brachytherapy December 19, 2013 March 19, 2014 11.16.01g Septoplasty, Rhinoplasty, and Septorhinoplasty December 19, 2013

To view the policy notifications visit our Medical Policy select Accept and Go to Medical Policy Online, and clickon the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box in the Medical Policy homepage. 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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