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Policy notifications posted as of December 21, 2011

December 29, 2011

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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 December 21, 2011.

Policy effective date

Policy No.

Notification title

Notification issue date

December 22, 2011

05.00.14f

High Frequency Chest Wall Oscillation Devices

November 22, 2011

December 23, 2011

00.01.25m

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

November 23, 2011

January 1, 2012

07.03.14e

Intraoperative Neurophysiological Monitoring (INM)

October 3, 2011

January 4, 2012

05.00.59d

Lower Limb Prosthesis

December 5, 2011

January 6, 2012

08.00.18i

Medical Foods, Low-Protein Modified Food Products, Enteral Nutrition, and Nutritional Formulas

December 7, 2011

January 6, 2012

05.00.32c

Speech- and Non-Speech-Generating Devices

December 7, 2011

January 6, 2012

05.00.23b

Electronic Speech Aids

December 7, 2011

January 10, 2012

05.00.56e

Hospital Beds and Accessories

October 14, 2011

January 11, 2012

08.01.04

Preventive Immunization

October 13, 2011

January 18, 2012

11.14.02i

Trigger Point Injections

December 19, 2011

January 20, 2012

00.01.18b

Reimbursement for Associated Services Performed in Conjunction with Dental Services

December 21, 2011

January 20, 2012

12.00.03a

Alternative Therapies and Complementary Medicine

December 21, 2011

January 20, 2012

08.00.75d

Erythropoiesis Stimulating Agents (ESAs)

December 21, 2011

January 20, 2012

00.10.21b

Collection and Interpretation of Physiologic Data

December 21, 2011

January 24, 2012

08.00.62d

Abatacept (Orencia®) for injection for intravenous use

October 26, 2011

January 24, 2012

11.08.15m

Reconstructive Breast Surgery

October 26, 2011

March 20, 2012

11.08.03h

Lipectomy and Liposuction

December 21, 2011

To view the policy notifications, go to www.ibx.com/medpolicy, 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.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

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