All policies are posted prior to their effective date. Below is a listing of
the policy notifications that we have posted to our website as of July 25, 2012.
Policy effective date
Policy No.
Notification title
Notification issue date
August 1, 2012
00.10.01s
Services Paid Above Capitation for Health
Maintenance Organization (HMO) Primary Care
Physicians
July 2, 2012
August 3, 2012
11.02.20d
Maze Procedure
July 3, 2012
August 8, 2012
11.02.01i
Treatment of Varicose Veins of the Lower Extremities
and Perforator Vein Incompetence
May 10, 2012
August 15, 2012
07.07.03i
Photodynamic Therapy (PDT) Using Levulan
?
Kerastick
? (Aminolevulinic Acid HCI [ALA]) or
Metvixia
? (Methyl Aminolevulinate [MAL])
July 16, 2012
August 21, 2012
08.00.68d
Ibandronate Sodium (Boniva
?) for Intravenous
Injection
May 23, 2012
September 1, 2012
00.03.02m
Diagnostic Radiology Services Included in Capitation
June 1, 2012
September 18, 2012
11.03.01c
Repair of Cleft Lip and/or Cleft Palate
June 23, 2012
October 1, 2012
12.01.01o
Experimental/Investigational Services
June 29, 2012
October 3, 2012
07.13.05f
Photodynamic Therapy (PDT) Using Verteporfin
(Visudyne
?)
July 3, 2012
To view the policy notifications, visit our Medical Policy website, select
Accept and Go to Medical Policy Online, and
click on 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 on the Medical Policy homepage. Be sure to check back often, as the site is
updated frequently.
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