Below is a listing of the policy activity that we have posted to our website
from March 26 ? April 25, 2014.
New Policy
The following policy has 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
00.01.56
National Correct Coding Initiative (NCCI) Modifier Indicator 0 (Zero) Procedure
Code Pairs
February 12, 2014
May 13, 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
00.01.24e
Obsolete or Unreliable Diagnostic Tests and Medical Services
Medical Necessity Criteria; Medical Coding; Guidelines
March 26, 2014
May 7, 2014
00.01.48a
Marijuana for Medical Use
General Description
N/A
March 26, 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
July 22, 2014
04.00.05d
Extraction of Bony Impacted Teeth and
Exposure of Impacted Teeth
General Description; Guidelines
N/A
March 26, 2014
05.00.08d
Continuous Passive Motion (CPM) Devices in the Home Setting
General Description, Guidelines,
or Informational Update; Medical
Necessity Criteria
N/A
April 23, 2014
05.00.31c
Pulse Oximetry Device in the Home Setting
General Description, Guidelines, or
Informational Update
N/A
April 23, 2014
05.00.32e
Speech- and Non-Speech-Generating Devices
Medical Coding; General Description, Guidelines, or Informational Update
N/A
April 23, 2014
05.00.54f
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and
Push-Rim Activated Power-Assist Devices
Medical Necessity Criteria
April 9, 2014
May 9, 2014
05.00.55h
Wheelchair Cushions and Seating
Medical Coding; Medical Necessity
Criteria
April 9, 2014
May 9, 2014
05.00.65d
Home Uterine Activity Monitoring (HUAM)
Devices
General Description, Guidelines, or
Informational Update
N/A
April 23, 2014
05.00.67k
Wheelchair Options and Accessories
Medical Coding; Medical Necessity Criteria
April 21, 2014
May 21, 2014
07.03.18i
Nerve Conduction Studies
(NCS) and Related
Electrodiagnostic Studies
Medical Coding; General
Description, Guidelines, or
Informational Update
N/A
April 23, 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
08.00.50l
Rituximab (Rituxan®)
Medical Coding
March 5, 2014
June 3, 2014
08.00.62e
Abatacept (Orencia®) for injection for intravenous use
Coverage Position; Medical
Necessity Criteria; General Description
March 5, 2014
June 3, 2014
08.00.70a
Laronidase (Aldurazyme®)
Medical Necessity Criteria
N/A
March 26, 2014
08.00.73e
Bortezomib (Velcade®)
Medical Necessity Criteria; Medical
Coding
January 2, 2014
April 2, 2014
08.00.74g
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists
(e.g., ranibizumab [Lucentis®], pegaptanib sodium
[Macugen®], aflibercept [Eylea®])
Coverage and/or Reimbursement Position; Medical Coding; General Description,
Guidelines, or Informational Update
January 2, 2014
April 2, 2014
08.00.81c
Bendamustine Hydrochloride (Treanda®)
Medical Necessity Criteria
February 12, 2014
May 13, 2014
08.00.85d
Tocilizumab (Actemra®) for Intravenous Infusion
Medical Necessity Criteria; General
Description
March 5, 2014
June 3, 2014
08.00.92g
Coagulation Factors for Hemophilia
General Description; Billing
Requirements; Guidelines; Medical
Coding
N/A
March 26, 2014
08.00.94f
Denosumab (ProliaTM, XgevaTM)
Medical Necessity Criteria; Medical
Coding; General Description,
Guidelines, or Informational Update
April 23, 2014
May 23, 2014
09.00.17j
Intensity Modulated Radiation Therapy (IMRT)
Coverage and/or Reimbursement
Position; Medical Coding; General
Description, Guidelines, or
Informational Update
January 3, 2014
April 2, 2014
09.00.46l
High-Technology
Radiology Services
Coverage and/or Reimbursement
Position; Medical Codes
January 31, 2014
(Notification revised on February 12,
2014)
May 1, 2014
09.00.49e
Proton Beam Radiation
Therapy
Medical Necessity Criteria; Medical
Coding
January 2, 2014
April 2, 2014
10.04.01k
Pulmonary Rehabilitation
General Description, Guidelines,
Medical Coding
N/A
April 23, 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
11.02.06j
Catheter Ablation of
Cardiac Arrhythmias
Coverage and/or Reimbursement
Position; Medical Necessity Criteria;
Medical Codes; General Description,
Guidelines, or Informational Update
February 26, 2014
March 26, 2014
11.02.10j
Endovascular Grafts for Abdominal Aortic
Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
General Description; Coverage
Position; Medical Necessity Criteria; Medical Coding
March 26, 2014
June 24, 2014
11.04.01c
Islet Cell Transplantation
Guidelines; Medical Coding
N/A
March 26, 2014
11.08.25j
Scar Revision
Coverage and/or Reimbursement
Position; Medical Coding
January 2, 2014
April 2, 2014
11.14.21e
Microprocessor-Controlled
Prostheses for Lower-Extremity Amputees
Coverage Position; Medical
Necessity Criteria
March 26, 2014
April 25, 2014
11.16.03f
Lung Volume Reduction Surgery
Medical Necessity Criteria; Medical
Coding
N/A
April 23, 2014
12.01.01w
Experimental/Investigational Services
Medical Coding; Coverage Position
N/A
April 9, 2014
12.01.01x
Experimental/Investigational Services
Medical Coding; Coverage Position
April 10, 2014
July 9, 2014
Reissued policies
The following policies have been reviewed, and no substantive changes were
made.
Policy #
Title
Reissue effective date
06.02.17c
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the
Prometheus® IBD sgi DiagnosticTM Test
April 2, 2014
07.00.09c
Topical Oxygenation
April 2, 2014
07.03.14i
Intraoperative Neurophysiological Monitoring (INM)
March 19, 2014
(Published on March 27, 2014)
08.00.08e
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®)
April 16, 2014
(Published on April 17, 2014)
08.00.72e
Alglucosidase alfas, rhGAA (Myozyme®, Lumizyme®)
April 2, 2014
(Published on April 3, 2014)
08.01.15a
Golimumab (Simponi® AriaTM) Intravenous (IV)
Injection
April 2, 2014
(Published on April 4, 2014)
11.14.08c
Orthognathic Surgery
April 2, 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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