Below is a listing of the policy activity that we have posted to our website
from June 25 ? July 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
08.01.17
Elosulfase alfa (Vimizim?)
June 18, 2014
July 18, 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
00.01.25u
PPO Network Rules for Provision of Specialty Services for Durable Medical
Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative
Services
Coverage and/or Reimbursement Position; Medical Coding
N/A
July 16, 2014
00.06.02k
Preventive Care Services
Medical Necessity Criteria; Medical Coding
June 5, 2014
September 3, 2014
02.01.01c
Home Health Care Services
Medical Necessity Criteria; Coverage and/or Reimbursement Position; General
Description, Guidelines, or Informational Update
April 23, 2014, Revised
June 19, 2014
July 22, 2014
05.00.14g
High-Frequency Chest Wall Oscillation Devices
Medical Necessity Criteria
June 18, 2014
July 18, 2014
05.00.38h
Negative-Pressure Wound Therapy (NPWT) Systems
Medical Coding; Medical Necessity Criteria
June 30, 2014
July 30, 2014
05.00.42f
Patient Lifts
Medical Necessity Criteria; Medical Coding;
N/A
July 2, 2014
05.00.43e
Seat Lift Mechanisms
Medical Necessity Criteria
N/A
July 2, 2014
05.00.47j
Knee Braces
Medical Coding; Medical Necessity Criteria; Coverage and/or Reimbursement
Position
June 30, 2014
July 30, 2014
05.00.56f
Hospital Beds and Accessories
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
July 3, 2014
August 4, 2014
05.00.59g
Lower Limb Prostheses
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria
N/A
July 16, 2014
07.03.21g
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral
Sphincter
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding
June 30, 2014
July 30, 2014
07.07.02g
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria; Medical Coding
N/A
July 2, 2014
07.10.06a
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
June 30, 2014
July 30, 2014
08.00.33j
Trastuzumab (Herceptin
®)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
April 23, 2014
July 22, 2014
09.00.17j
Intensity Modulated Radiation Therapy (IMRT)
Medical Coding
January 3, 2014
April 2, 2014,
Revised
July 15, 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
11.00.14d
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or
Informational Update
N/A
July 2, 2014
12.01.01x
Experimental/ Investigational Services
Medical Coding; Coverage and/or Reimbursement Position
April 10, 2014
July 9, 2014
12.01.01y
Experimental/Investigational Services
Coverage and/or Reimbursement Position; Medical Coding
N/A
July 10, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
01.00.09b
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric
Infusion Pump
July 23, 2014 (Published July 24, 2014)
05.00.70a
Mechanical Stretching Devices for the Treatment of Joint Stiffness or
Contractures
June 25, 2014 (Published June 25, 2014)
07.02.09b
Ambulatory Blood Pressure Monitoring (ABPM)
July 23, 2014 (Published July 24, 2014)
07.06.01b
Complete Decongestive Therapy (CDT)
July 9, 2014 (Published July 11, 2014)
07.06.03a
Bioimpedance for the Detection of Lymphedema
July 9, 2014 (Published July 11, 2014)
08.00.62e
Abatacept (Orencia
®) for Injection for Intravenous Use
July 9, 2014 (Published July 11, 2014)
08.01.03c
Belatacept (Nulojix
®)
July 9, 2014 (Published July 11, 2014)
09.00.02d
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
June 25, 2014 (Published June 25, 2014)
09.00.24b
Full-Body Computerized Tomography (CT) Scan Screening
June 25, 2014 (Published June 26, 2014)
11.03.12j
Colorectal Cancer Screening
July 23, 2014 (Published July 24, 2014)
11.05.01c
Refractive Keratoplasty
July 9, 2014 (Published July 11, 2014)
11.05.07c
Surgical Correction of Strabismus
July 9, 2014 (Published July 11, 2014)
11.05.08c
Photocoagulation of Macular Drusen
July 9, 2014 (Published July 11, 2014)
11.08.14f
Removal of Breast Implants
June 25, 2014 (Published June 25, 2014)
11.11.05e
Circumcision
July 23, 2014 (Published July 24, 2014)
11.14.01f
Mentoplasty or Genioplasty
June 25, 2014 (Published June 25, 2014)
11.14.17b
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
July 9, 2014 (Published July 11, 2014)
11.14.19g
Artificial Intervertebral Disc Insertion
June 25, 2014 (Published June 25, 2014)
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
July 9, 2014 (Published July 11, 2014)
11.14.24
Manipulation Under Anesthesia
June 25, 2014 (Published June 25, 2014)
12.04.03b
Air or Sea Ambulance Transport Services
July 23, 2014 (Published July 24, 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
00.03.02q
Diagnostic Radiology Services Included in Capitation
July 1, 2014 (Published July 25, 2014)
00.03.07h
Laboratory Services for Members Enrolled in Health Maintenance Organization
(HMO) or Health Maintenance Organization Point-of- Service (HMO-POS) Products
July 1, 2014 (Published July 25, 2014)
03.00.06k
Modifier 25: Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician on the Day of a Procedure or Other Service
July 1, 2014 (Published July 11, 2014)
03.00.10k
Modifiers LT/RT: left Side/Right Side Procedures
July 11, 2014 (Published July 11, 2014)
03.00.15k
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician
during a Postoperative Period
July 1, 2014 (Published July 11, 2014)
03.00.16k
Modifier 57: Decision for Surgery
July 1, 2014 (Published July 11, 2014)
05.00.24k
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
July 1, 2014 (Published July 1, 2014)
05.00.32f
Speech- and Non-Speech-Generating Devices
July 1, 2014 (Published July 1, 2014)
06.02.35g
Genetic Testing
July 1, 2014 (Published July 1, 2014)
07.05.02k
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the
Small Bowel, Esophagus, and Colon
July 1, 2014 (Published July 10, 2014)
08.00.57f
Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
July 1, 2014 (Published July 1, 2014)
08.00.92h
Coagulation Factors for Hemophilia
July 1, 2014 (Published July 1, 2014)
09.00.10q
Brachytherapy
July 1, 2014 (Published July 10, 2014)
10.03.01d
Physical Medicine, Rehabilitation, and Habilitation Services
July 1, 2014 (Published July 2, 2014)
10.06.01h
Speech Therapy
July 1, 2014 (Published July 2, 2014)
Archived policy
The following policy is deemed no longer necessary by IBC.
Policy #
Title
Notification date
Effective date
08.00.54d
Radioimmunotherapy with Tositumomab and Iodine I-131 Tositumomab (the
Bexxar
® Therapeutic Regimen)
July 14, 2014
August 13, 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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