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Policy notifications posted as of July 31, 2013

August 1, 2013

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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 July 31, 2013.

Policy effective date

Policy No.

Notification title

Notification issue date

April 4, 2013

11.03.11h

Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)

July 15, 2013

July 24, 2013

05.00.72b

Upper Limb Prostheses

June 24, 2013

July 24, 2013

11.14.21c

Microprocessor-Controlled Prostheses for
Lower-Extremity Amputees

June 24, 2013

July 31, 2013

00.01.25s

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

July 1, 2013

July 31, 2013

00.03.07f

Laboratory Services for Members Enrolled in
Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

July 1, 2013

August 2, 2013

11.01.04c

Auditory Brainstem Implant

July 3, 2013

August 2, 2013

11.15.03g

Insertion of Implantable Infusion Pumps

July 3, 2013

August 6, 2013

11.14.07j

Intra-articular Injection of Hyaluronan for the Treatment of Osteoarthritis

May 8, 2013

August 14, 2013

05.00.01h

Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency

July 15, 2013

August 14, 2013

07.02.09b

Ambulatory Blood Pressure Monitoring (ABPM)

July 15, 2013

August 14, 2013

11.08.15o

Reconstructive Breast Surgery

July 15, 2013

August 14, 2013

11.15.01j

Spinal Cord Stimulation (Dorsal Column Stimulation)

July 15, 2013

September 1, 2013

07.03.05o

Sleep Disorder Testing

June 3, 2013

October 1, 2013

05.00.38f

Negative-Pressure Wound Therapy (NPWT) Systems

July 3, 2013

October 1, 2013

07.03.14i

Intraoperative Neurophysiological Monitoring (INM)

July 3, 2013

To view the policy notifications, visit our Medical Policy portal, 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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