Below is a listing of the policy activity that we have posted to our website
from August 23 – September 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 Independence.
Policy #
Title
Notification date
Effective date
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous
Neuromodulation Therapy (PNT)
August 29, 2014
September 30, 2014
06.02.38
Nerve Fiber Density Testing
August 27, 2014
September 26, 2014
08.01.18
Vedolizumab (Entyvio
®)
September 24, 2014
October 24, 2014
11.16.07
Bronchial Thermoplasty
N/A
August 27, 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 Independence.
Policy #
Title
Type of policy change
Notification date
Effective date
00.06.02k
Preventive Care Services
Medical Necessity Criteria; Medical Coding
June 5, 2014
September 3, 2014
02.02.01f
Hospice and Respite Care
Medical Coding
N/A
August 27, 2014
05.00.50j
Ostomy Supplies
Medical Necessity Criteria; Medical Coding
September 19, 2014
October 20, 2014
05.00.58h
Home Oxygen Therapy
Medical Necessity Criteria
August 27, 2014
September 26, 2014
05.00.60e
Pressure-Reducing Support Surfaces
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
August 13, 2014
September 15, 2014
05.00.61d
Cervical Traction for In-home Use
Medical Necessity Criteria
August 11, 2014
September 10, 2014
05.00.73b
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical
Stimulators (FES)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding
September 19, 2014
October 20, 2014
07.00.03l
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
Medical Coding; General Description, Guidelines, or Informational Update
N/A
September 10, 2014
07.00.21f
Allergy Immunotherapy
Medical Necessity Criteria; Coverage and/or Reimbursement Position
August 27, 2014
November 25, 2014
07.03.05q
Sleep Disorder Testing
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
September 8, 2014
October 8, 2014
07.03.07k
Evaluation and Management of Autism Spectrum Disorders (ASD)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
July 28, 2014
August 27, 2014
07.10.05d
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
General Description, Guidelines, or Informational Update
N/A
September 3, 2014
07.12.01d
Pelvic Floor Stimulation as a Treatment of Incontinence
Coverage and/or Reimbursement Position; Medical Coding; General Description,
Guidelines, or Informational Update
August 11, 2014
September 10, 2014
08.00.15c
Off-label Coverage for Prescription Drugs and Biologics
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
N/A
August 27, 2014
08.00.17d
Total Parenteral Nutrition (TPN)/Intradialytic Parenteral Nutrition
(IDPN)/Intraperitoneal Parenteral Nutrition (IPN)
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
September 12, 2014
October 13, 2014
08.00.18j
Medical Foods (i.e., Enteral Nutrition and Nutritional Formulas) and
Low-Protein Modified Food Products
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
N/A
September 10, 2014
08.00.47f
Nesiritide (Natrecor
®)
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
September 10, 2014
October 10, 2014
08.00.55e
Omalizumab (Xolair
®)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding; General Description, Guidelines, or Informational Update
N/A
August 27, 2014
08.00.67h
Cetuximab (Erbitux
®)
Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or
Informational Update
N/A
August 27, 2014
08.00.76d
Oxaliplatin (Eloxatin
®)
Medical Necessity Criteria; Medical Coding
N/A
August 27, 2014
08.00.83d
Pralatrexate (Folotyn
®) for Injection
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
N/A
September 24, 2014
08.00.87b
Pemetrexed (Alimta
®)
Medical Necessity Criteria; Medical Coding
N/A
August 27, 2014
08.00.88b
Ofatumumab (Arzerra?)
Medical Necessity Criteria
N/A
September 24, 2014
08.00.95c
Personalized Vaccines (e.g., Provenge
®)
Medical Necessity Criteria
September 24, 2014
October 24, 2014
08.00.97d
Romidepsin (Istodax
®)
Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or
Informational Update
N/A
September 24, 2014
08.01.07c
Pertuzumab (Perjeta
®)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; General
Description, Guidelines, or Informational Update
July 30, 2014
August 29, 2014
08.01.09c
Omacetaxine mepesuccinate (Synribo
®)
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
N/A
August 27, 2014
08.01.11c
Ado-Trastuzumab Emtansine (Kadcyla
®)
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update; Medical Coding
July 30, 2014
August 29, 2014
08.01.12a
Repository Corticotropin (H.P. Acthar
® Gel Injection)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; General
Description, Guidelines, or Informational Update
August 27, 2014
November 25, 2014
09.00.36h
First-Trimester Prenatal Screening for Fetal Aneuploidy
Medical Coding
August 13, 2014
November 11, 2014
10.01.01k
Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs
Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or
Informational Update
August 27, 2014
September 26, 2014
11.02.17e
Endovascular Stent- Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal
Lesions
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update
N/A
August 27, 2014
11.03.11k
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
General Description, Guidelines, or Informational Update
N/A
August 27, 2014
11.08.15r
Reconstructive Breast Surgery
Coverage and/or Reimbursement Position; Medical Necessity Criteria; General
Description, Guidelines, or Informational Update; Medical Coding
August 27, 2014
September 26, 2014
11.14.07k
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or
Informational Update
N/A
September 10, 2014
11.15.01l
Spinal Cord Stimulation (Dorsal Column Stimulation)
Medical Coding; Medical Necessity Criteria
August 29, 2014
October 1, 2014
11.15.16j
Vagus Nerve Stimulation (VNS)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical
Coding
August 29, 2014
October 1, 2014
11.15.20j
Deep Brain Stimulation (DBS)
Medical Coding
August 29, 2014
October 1, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
00.10.35f
Remote Patient Management: Telemedicine and Telehealth
September 3, 2014 (Published September 3, 2014)
02.01.02b
Private Duty Nursing
September 3, 2014 (Published September 3, 2014)
05.00.24k
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
September 3, 2014 (Published September 3, 2014)
06.02.04c
Fetal Fibronectin Enzyme (fFN) Immunoassay
September 3, 2014 (Published September 3, 2014)
06.02.06m
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2
(BRCA2) Mutations
September 17, 2014 (Published September 19, 2014)
06.02.10l
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite
Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)
September 17, 2014 (Published September 19, 2014)
06.02.27e
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis
September 17, 2014 (Published September 19, 2014)
06.02.30c
Pharmacogenetic Testing to Determine Drug Sensitivity
September 17, 2014 (Published September 19, 2014)
06.02.31c
Genetic Testing for Congenital Long QT Syndrome
September 17, 2014 (Published September 22, 2014)
06.02.35g
Genetic Testing
September 17, 2014 (Published September 19, 2014)
07.00.05f
In Vivo Allergy Sensitivity Testing
September 17, 2014 (Published September 19, 2014)
07.00.10g
Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin
®)
September 17, 2014 (Published September 19, 2014)
07.05.06e
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
September 17, 2014 (Published September 19, 2014)
07.05.07b
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic
Malignancies
September 17, 2014 (Published September 19, 2014)
07.07.03i
Photodynamic Therapy (PDT) Using Levulan
®
Kerastick
® (Aminolevulinic Acid HCl [ALA]) or
Metvixia
® (Methyl Aminolevulinate [MAL])
September 17, 2014 (Published September 19, 2014)
07.07.09e
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived
Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound
Healing and Other Miscellaneous Conditions
September 17, 2014 (Published September 19, 2014)
07.08.03a
Medical and Surgical Treatment of Temporomandibular Joint Disorder
September 3, 2014 (Published September 3, 2014)
07.11.02d
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and
Management of Asthma and Other Respiratory Disorders
September 3, 2014 (Published September 3, 2014)
07.13.05g
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne
®)
September 17, 2014 (Published September 22, 2014)
07.13.07e
Corneal Pachymetry Using Ultrasound
September 17, 2014 (Published September 23, 2014)
08.00.13o
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
September 3, 2014 (Published September 3, 2014)
08.00.25g
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and
Inhaled Pharmacologic Agents Intended for Home Use
September 3, 2014 (Published September 4, 2014)
08.00.26r
Botulinum Toxin Agents
September 3, 2014 (Published September 4, 2014)
08.00.50l
Rituximab (Rituxan
®)
September 17, 2014 (Published September 19, 2014)
08.00.51g
Enzyme Replacement for the Treatment of Gaucher?s Disease
September 3, 2014 (Published September 4, 2014)
08.00.66h
Bevacizumab (Avastin
®)
September 3, 2014 (Published September 4, 2014)
08.00.84a
Eculizumab (Soliris
®)
September 3, 2014 (Published September 4, 2014)
08.00.99a
Belimumab (Benlysta
®)
August 20, 2014 (Published September 18, 2014)
08.01.13
Brentuximab Vedotin (Adcetris
®)
September 3, 2014 (Published September 4, 2014)
09.00.48c
Radioembolization for Primary and Metastatic Tumors of the Liver
September 17, 2014 (Published September 19, 2014)
09.00.51a
Positron Emission Mammography (PEM)
September 17, 2014 (Published September 18, 2014)
09.00.52a
Digital Breast Tomosynthesis
September 3, 2014 (Published September 3, 2014)
10.00.02a
Day Rehabilitation
September 3, 2014 (Published September 4, 2014)
10.02.02e
Chiropractic Spinal and Extraspinal Manipulation Therapy
September 17, 2014 (Published September 18, 2014)
10.06.01h
Speech Therapy
September 3, 2014 (Published September 4, 2014)
11.00.09d
Solid Organ Transplants
September 3, 2014 (Published September 4, 2014)
11.00.13d
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
September 17, 2014 (Published September 19, 2014)
11.01.01i
Otoplasty
September 3, 2014 (Published September 3, 2014)
11.01.02j
Cochlear Implant
September 3, 2014 (Published September 4, 2014)
11.01.06a
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing
Aids
September 3, 2014 (Published September 4, 2014)
11.01.07b
Cataract Surgery
September 17, 2014 (Published September 19, 2014)
11.02.06j
Catheter Ablation of Cardiac Arrhythmias
September 3, 2014 (Published September 3, 2014)
11.02.12e
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting
of the Extracranial Carotid Artery or Intracranial Artery
September 17, 2014 (Published September 19, 2014)
11.02.16o
Ventricular Assist Devices (VADs)
September 3, 2014 (Published September 4, 2014)
11.02.19c
Total Artificial Hearts (TAHs)
September 17, 2014 (Published September 19, 2014)
11.03.01d
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
September 3, 2014 (Published September 4, 2014)
11.05.16a
Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of
Glaucoma
September 17, 2014 (Published September 19, 2014)
11.07.01l
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
September 17, 2014 (Published September 19, 2014)
11.07.02f
Sentinel Lymph Node Biopsy
September 3, 2014 (Published September 3, 2014)
11.08.01e
Hair Transplants and Cranial Prostheses (Wigs)
September 3, 2014 (Published September 4, 2014)
11.08.02f
Reduction Mammoplasty
September 3, 2014 (Published September 4, 2014)
11.08.03i
Lipectomy and Liposuction
September 3, 2014 (Published September 4, 2014)
11.08.06g
Abdominoplasty and/or Panniculectomy
September 3, 2014 (Published September 4, 2014)
11.08.10f
Excision of Redundant Skin
September 3, 2014 (Published September 4, 2014)
11.08.13f
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or
Platysmaplasty
September 3, 2014 (Published September 4, 2014)
11.08.19j
Prophylactic Mastectomy
September 17, 2014 (Published September 19, 2014)
11.08.25j
Scar Revision
September 17, 2014 (Published September 22, 2014)
11.09.02a
Sex Reassignment Surgery (SRS) for Gender Identity Disorder (GID)
September 3, 2014 (Published September 4, 2014)
11.11.01f
Evaluation and Treatment of Erectile Dysfunction (ED)
September 17, 2014 (Published September 19, 2014)
11.14.10k
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
September 3, 2014 (Published September 3, 2014)
11.14.22b
Lumbar Interspinous Process Decompression
September 17, 2014 (Published September 19, 2014)
11.14.26
Surgical Treatments of Athletic Pubalgia
September 3, 2014 (Published September 3, 2014)
11.15.11b
Treatment for Hyperhidrosis (Nonpharmacologic)
September 3, 2014 (Published September 3, 2014)
11.16.01g
Septoplasty, Rhinoplasty, and Septorhinoplasty
September 3, 2014 (Published September 4, 2014)
11.16.06e
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic
Rhinosinusitis
September 17, 2014 (Published September 19, 2014)
11.17.07f
Radiofrequency Micro-remodeling (by transurethral, transvaginal, or
paraurethral approach) for Urinary Stress Incontinence
September 3, 2014 (Published September 4, 2014)
12.05.01g
Outpatient Diabetes Education and Self-Management Training
September 17, 2014 (Published September 19, 2014)
Archived policy
The following policy is deemed no longer necessary by Independence.
Policy #
Title
Notification date
Effective date
08.00.80c
Temozolomide (Temodar
®) for Injection
August 27, 2014
September 26, 2014
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