Site Activity
This page provides a monthly listing of publication activity on the Medical Policy Portal including Policy Notifications, New Policies, Updated Policies, Coding Updates, Reissued Policies, and Archived Policies. To view publication activity from prior months, select Past Site Activity.

Past Site Activity

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Updated Policies
The following commercial policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with Independence Blue Cross.
08.00.70e, Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.08d, Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.39c, Cerliponase alfa (Brineura®)
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria

08.00.72h, Alglucosidase alfa (e.g., Lumizyme®)
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.08.15v, Reconstructive Breast Surgery
Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

08.00.15e, Off-label Coverage for Prescription Drugs and/or Biologics
Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.26a, Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.51j, Enzyme Replacement for the Treatment of Gaucher's Disease
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.69b, Agalsidase beta (Fabrazyme®)
Notification: 03/05/2019 | Effective: 06/03/2019 | Posted: 06/03/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

06.02.36c, Molecular Testing for the Management of Pancreatic Cysts or Barrett's Esophagus (Independence Administrators)
Notification: 05/17/2019 | Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.50s, Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
Notification: 03/19/2019 | Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.97i, Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.83h, Pralatrexate (Folotyn®) for Injection
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

06.02.44i, Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
Notification: 05/17/2019 | Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.66l, Bevacizumab (Avastin®) and Related Biosimilars
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

05.00.59j, Lower Limb Prostheses
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

11.16.06i, Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.01.06e, Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: General Description, Guidelines, or Informational Update

08.00.13u, Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
Effective: 06/17/2019 | Posted: 06/17/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.03.05v, Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (Independence)
Notification: 04/30/2019 | Effective: 06/29/2019 | Posted: 06/28/2019
Type of policy change: General Description, Guidelines, or Informational Update


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
11.08.02h, Reduction Mammoplasty
Reissue Effective: 06/05/2019 | Reissue Posted: 06/05/2019

11.08.12h, Surgery for Gynecomastia
Reissue Effective: 06/05/2019 | Reissue Posted: 06/05/2019

11.14.02n, Trigger Point Injections
Reissue Effective: 06/05/2019 | Reissue Posted: 06/05/2019

11.08.06j, Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
Reissue Effective: 06/05/2019 | Reissue Posted: 06/05/2019

11.06.09d, Labiaplasty
Reissue Effective: 06/05/2019 | Reissue Posted: 06/05/2019

05.00.11i, Therapeutic Shoes and Orthopedic Shoes
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

07.07.09f, 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
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.67o, Wheelchair Options and Accessories
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.55i, Wheelchair Cushions and Seating
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.54g, Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

11.11.03d, Cryosurgical Ablation of the Prostate Gland
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

06.02.01i, Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.12g, Manual Wheelchairs
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

07.00.09d, Topical Oxygenation
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.62h, Injectable Dermal Fillers
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.61f, Cervical Traction Devices for In-home Use
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

11.15.15g, Percutaneous Discectomy
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

11.14.17d, Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

11.14.14e, Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
Reissue Effective: 06/052019 | Reissue Posted: 06/06/2019

11.14.13g, Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

11.11.06h, Saturation Needle Biopsy of the Prostate
Reissue Effective: 06/05/2019 | Reissue Posted: 06/06/2019

05.00.71c, Standing Frames
Reissue Effective: 06/19/2019 | Reissue Posted: 06/19/2019


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