Below is a listing of the policy activity that we have posted to our website
from July 26 ? August 22, 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
00.06.02k
Preventive Care Services
Medical Necessity Criteria; Medical Coding
June 5, 2014
September 3, 2014
05.00.38h
Negative-Pressure Wound Therapy (NPWT) Systems
Medical Necessity Criteria; Medical Coding
June 30, 2014
July 30, 2014
05.00.47j
Knee Braces
Medical Necessity Criteria; Medical Coding; 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
05.00.60e
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
05.00.62g
Injectable Dermal Fillers
General Description, Guidelines, or Informational Update; Medical Necessity
Criteria; Medical Coding
Not available
August 6, 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
07.03.21g
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
07.10.06a
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
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
08.00.22l
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
Coverage and/or Reimbursement Position; Medical Necessity Criteria; General
Description, Guidelines, or Informational Update
Not available
August 19, 2014
08.00.78m
Self-Administered Drugs
Coverage and/or Reimbursement Position
Not available
July 30, 2014
08.00.86a
Ecallantide (Kalbitor
®)
Medical Necessity Criteria
Not available
July 30, 2014
08.00.92i
Coagulation Factors for Hemophilia
Medical Coding; General Description, Guidelines, or Informational Update
Not available
July 30, 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
08.01.11c
Ado-trastuzumab emtansine (Kadcyla
®)
Medical Necessity Criteria; General Description, Guidelines, or Informational
Update; Medical Coding
July 30, 2014
August 29, 2014
09.00.36h
First-Trimester Prenatal Screening for Fetal Aneuploidy
Medical Coding
August 13, 2014
November 11, 2014
12.04.02f
Nonemergency Ambulance Transport Services
Medical Necessity Criteria
Not available
July 30, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
05.00.37e
Compression Garments
August 6, 2014 (Published August 6, 2014)
06.02.09e
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping
August 20, 2014 (Published August 21, 2014)
06.02.29
AlloMap? Molecular Expression Testing for Heart Transplant Rejection
August 20, 2014 (Published August 21, 2014)
06.02.32a
Multigene Expression Assays for Predicting Recurrence in Colon Cancer
August 6, 2014 (Published August 6, 2014)
06.02.36
PathFinderTG®
August 20, 2014 (Published August 21, 2014)
06.02.39a
Measurement of Serum Antibodies to and Measurement of Serum Levels of
Infliximab and Adalimumab
August 20, 2014 (Published August 21, 2014)
06.02.43
Proteomic (protein)-based Testing for the Evaluation of Ovarian (Adnexal)
Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm
(ROMA?)
August 6, 2014 (Published August 6, 2014)
06.03.05d
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative
Salvage)
August 6, 2014 (Published August 6, 2014)
07.02.05
External Counterpulsation (ECP)
August 6, 2014 (Published August 6, 2014)
07.13.12c
Instrument-based Vision Screening
August 6, 2014 (Published August 6, 2014)
08.00.44n
Zoledronic Acid (Zometa®, Reclast®)
August 20, 2014 (Published August 21, 2014)
08.00.64
Natalizumab (Tysabri®)
August 20, 2014 (Published August 21, 2014)
08.00.65h
Pamidronate Disodium (Aredia®) for Intravenous Infusion
August 20, 2014 (Published August 21, 2014)
08.00.68e
Ibandronate Sodium (Boniva®) for Intravenous Injection
August 20, 2014 (Published August 21, 2014)
08.00.69
Agalsidase beta (Fabrazyme®)
August 6, 2014 (Published August 7, 2014)
08.00.71c
Idursulfase (Elaprase?)
August 6, 2014 (Published August 7, 2014)
08.00.74g
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists
(e.g., ranibizumab [Lucentis®], pegaptanib sodium
[Macugen®], aflibercept [Eylea®])
August 20, 2014 (Published August 21, 2014)
08.00.79
Plerixafor Injection (Mozobil?)
August 20, 2014 (Published August 21, 2014)
08.00.82c
Ustekinumab (Stelara?) for Subcutaneous Injection
August 6, 2014 (Published August 7, 2014)
08.00.96b
Cabazitaxel (Jevtana®)
August 20, 2014 (Published August 21, 2014)
08.00.99a
Belimumab (Benlysta®)
August 20, 2014 (Published August 21, 2014)
08.01.02a
Pegloticase (Krystexxa®)
August 6, 2014 (Published August 7, 2014)
08.01.10
Octreotide acetate (Sandostatin® LAR Depot)
August 20, 2014 (Published August 21, 2014)
08.01.14
radium Ra 223 dichloride (Xofigo®)
August 6, 2014 (Published August 7, 2014)
08.01.16
galsulfase (Naglazyme®)
August 6, 2014 (Published August 7, 2014)
09.00.10q
Brachytherapy
August 6, 2014 (Published August 7, 2014)
09.00.17j
Intensity Modulated Radiation Therapy (IMRT)
August 6, 2014 (Published August 7, 2014)
09.00.49e
Proton Beam Radiation Therapy
August 6, 2014 (Published August 7, 2014)
11.00.01d
Revision of a Previous Cosmetic Procedure
August 20, 2014 (Published August 20, 2014)
11.00.03h
Fetal Surgery
August 20, 2014 (Published August 20, 2014)
11.02.11e
Transcatheter Closure of Cardiac Septal Defects
August 20, 2014 (Published August 20, 2014)
11.02.13e
Transcoronary Ablation of Septal Hypertrophy (TASH)
August 6, 2014 (Published August 6, 2014)
11.03.15f
Gastric Electrical Stimulation (Enterra®), Gastric Pacing
August 20, 2014 (Published August 20, 2014)
11.05.17
Implantable Miniature Telescope (IMT) for the Treatment of End-Stage
Age-Related Macular Degeneration (AMD)
August 6, 2014 (Published August 6, 2014)
11.08.08
Chemical Peels
August 20, 2014 (Published August 21, 2014)
11.11.03c
Cryosurgical Ablation of the Prostate Gland
August 20, 2014 (Published August 20, 2014)
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
August 20, 2014 (Published August 20, 2014)
11.15.15e
Percutaneous Discectomy
August 20, 2014 (Published August 20, 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
00.10.20k
Add-on Codes
July 1, 2014 (Publish July 29, 2014)
03.00.07o
Modifier 51: Multiple Procedures
July 1, 2014 (Publish August 1, 2014)
03.00.28j
Modifier 79: Unrelated Procedure or Service by the Same Physician During the
Postoperative Period
July 1, 2014 (Publish July 29, 2014)
11.00.10q
Multiple Surgical Reduction Guidelines
July 1, 2014 (Publish July 29, 2014)
Archived policies
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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