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Below is a listing of the policy activity that we have posted to our
website from January 26 – February 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 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
08.01.10
Octreotide acetate (Sandostatin
® LAR Depot)
December 4, 2013
March 4, 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
00.01.25t
PPO Network Rules for Provision of Specialty Services for Durable Medical
Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative
Services
Medical Codes
n/a
February 1, 2014
00.03.07g
Laboratory Services for Members Enrolled in Health Maintenance Organization
(HMO) or Health Maintenance Organization Point-of- Service (HMO-POS) Products
Medical Codes
n/a
February 1, 2014
05.00.04c
Food and Drug Administration (FDA)
Approval of Medical Devices
General Description, Guidelines, or Informational Update
n/a
February 12, 2014
05.00.09g
Electrical Bone Growth Stimulation and
Low-Intensity Ultrasound Accelerated Fracture Healing System
Medical Necessity Criteria;
Medical Codes; General
Description, Guidelines, or
Informational Update
February 14, 2014
March 14, 2014
05.00.21m
Durable Medical Equipment (DME)
Coverage and/or Reimbursement
Position; Medical Codes;
General Description, Guidelines,
or Informational Update
n/a
February 5, 2014
05.00.35c
Foot Orthotics and Other Podiatric Appliances
Coverage and/or Reimbursement Position; Medical Codes
February 13, 2014
March 12, 2014
05.00.42e
Patient Lifts
Medical Necessity Criteria;
Medical Coding
November 6, 2013
February 5, 2014
06.02.39a
Measurement of Serum Antibodies to and
Measurement of Serum Levels of Infliximab and Adalimumab
Coverage and/or Reimbursement
Position; General Description,
Guidelines, or Informational
Update
January 3, 2014
February 3, 2014
07.00.02g
Intravenous Chelation Therapy
Coverage and/or Reimbursement Position; Medical Necessity Criteria; General
Description,
Guidelines, or Informational
Update
November 7, 2013
February 5, 2014
07.02.03g
Implantable Cardiac Loop Monitor
Coverage and/or
Reimbursement Position;
Medical Necessity Criteria
November 20, 2013
February 18, 2014
07.10.05b
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
Coverage and/or
Reimbursement Position
November 21, 2013
January 1, 2014
(Policy published on
February 19, 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
09.00.10p
Brachytherapy
Coverage and/or Reimbursement Position; Medical Coding; General Description,
Guidelines,
or Informational Update
December 19, 2013
March 19, 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 (Revised February 12, 2014)
May 1, 2014
09.00.49e
Proton Beam Radiation Therapy
Medical Necessity Criteria;
Medical Coding
January 2, 2014
April 2, 2014
11.02.12e
Percutaneous Transluminal Angioplasty
(PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or
Intracranial Artery
Medical Necessity Criteria;
Medical Coding
November 20, 2013
(Revised
January 23, 2014)
February 19, 2014
11.03.02n
Bariatric Surgery
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Codes
n/a
January 1, 2014
(Published on
February 4, 2014)
11.08.02f
Reduction Mammoplasty
Coverage and/or Reimbursement
Position; Medical Coding
November 6, 2013
(Revised
December 2, 2013)
February 4, 2014
11.08.06g
Abdominoplasty and/or Panniculectomy
Coverage and/or Reimbursement
Position; Medical Necessity
Criteria; Medical Coding
January 3, 2014
February 3, 2014
11.08.10f
Excision of Redundant Skin
Medical Necessity Criteria;
Medical Coding
January 3, 2014
February 3, 2014
11.08.25j
Scar Revision
Coverage and/or Reimbursement
Position; Medical Coding
January 2, 2014
April 2, 2014
11.11.01f
Evaluation and Treatment of Erectile Dysfunction (ED)
Medical Coding
November 21, 2013
February 19, 2014
11.14.10k
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Medical Coding
November 6, 2013
February 5, 2014
11.16.01g
Septoplasty, Rhinoplasty, and Septorhinoplasty
Medical Necessity Criteria;
General Description, Guidelines, or Informational Update
December 19, 2013
March 19, 2014
12.01.01v
Experimental/Investigational Services
Coverage and/or
Reimbursement Position;
Medical Codes
n/a
January 1, 2014
(Published on
February 7, 2014)
Reissued policies
The following policies have been reviewed, and no substantive changes were made.
Policy #
Title
Reissue effective date
00.01.18c
Reimbursement for Associated Services Performed in Conjunction with Dental Care
February 19, 2014
05.00.12e
Manual Wheelchairs
February 19, 2014
05.00.25f
Cranial Remolding Orthoses (Helmets)
February 19, 2014
05.00.72b
Upper Limb Prostheses
February 19, 2014
07.00.14d
Cold Laser Therapy
February 19, 2014
07.08.01e
Non-Surgical Spinal Decompression Therapy
February 19, 2014
07.10.04b
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment
of Pre-Term Labor
February 19, 2014
11.06.04h
Uterine Artery Embolization
February 19, 2014
11.06.05b
Endometrial Ablation
February 19, 2014
11.06.07b
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion
Syndrome
February 19, 2014
11.08.12g
Surgery for Gynecomastia
February 19, 2014
11.14.11e
Arthroscopic Electrothermal Joint Repair
February 19, 2014
Archived policies
The following are policies that IBC has determined are no longer necessary to
remain active.
Policy #
Title
Notification date
Archive effective date
07.03.16b
Electrosleep Therapy using a Cranial Electrical Stimulation Device
January 16, 2014
February 17, 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
00.01.49a
Reporting Requirements for Drugs and Biologicals
January 1, 2014
(Published on February 7, 2014)
00.03.02p
Diagnostic Radiology Services Included in Capitation
January 1, 2014
(Published on February 7, 2014)
00.10.20j
Add-on Codes
January 1, 2014
(Published on February 21, 2014)
00.10.36k
Radiologic Guidance of a Procedure
January 1, 2014
(Published on February 7, 2014)
03.00.06j
Modifier 25: Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician on the Day of a Procedure or Other Service
January 1, 2014
(Published on February 7, 2014)
03.00.15j
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician
during a Postoperative Period
January 1, 2014
(Published on February 7, 2014)
03.00.16j
Modifier 57: Decision for Surgery
January 1, 2014
(Published on February 7, 2014)
07.10.05c
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
January 2, 2014
(Published on February 20, 2014)
09.00.32k
Diagnostic and Therapeutic Radiopharmaceutical Agents
January 1, 2014
(Published on February 7, 2014)
09.00.45f
Magnetic Resonance Imaging (MRI) Contrast Agents
January 1, 2014
(Published on February 7, 2014)
11.15.16i
Vagus Nerve Stimulation (VNS)
January 1, 2014
(Published on February 7, 2014)
To view policy activity, visit 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.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
CPT copyright 2012 American
Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association.
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