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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Notifications
The following Independence Blue Cross commercial policies have been posted prior to their effective date.
06.02.52q, eviCore Lab Management Program (Independence)
Notification: 06/01/2020 | Effective: 07/01/2020 | Posted: 06/01/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

05.00.29l, Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
Notification: 06/18/2020 | Effective: 07/20/2020 | Posted: 06/18/2020
Type of policy change: Medical Necessity Criteria


New Policies
The following commercial policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with Independence Blue Cross
08.01.60, Sacituzumab govitecan-hziy (TrodelvyTM)
Effective: 06/22/2020 | Posted: 06/22/2020
Type of policy change: This is a new policy.


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.
08.01.26c, Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., elapegademase-lvlr [Revcovi™)
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.55c, Tagraxofusp-erzs (Elzonris™)
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Medical Necessity Criteria

08.00.26w, Botulinum Toxin Agents
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Medical Necessity Criteria

08.01.10f, Octreotide Acetate (Sandostatin® LAR Depot)
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

11.08.14k, Removal of Breast Implants
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.62j, Abatacept (Orencia®) for Injection for Intravenous Use
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

08.00.10a, Luspatercept–aamt (Reblozyl®)
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.85i, Tocilizumab (Actemra®) for Intravenous Infusion
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.99c, Belimumab (Benlysta®) for Intravenous Use
Effective: 06/08/2020 | Posted: 06/08/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.01.61a, Reimbursement for Components of Comprehensive Laboratory Panels
Notification: 05/15/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

11.15.23i, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.14.28c, Spinal Laminectomy
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.14.03g, Meniscal Allograft Transplantation and Meniscal Implants
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.15.09n, Denervation of the Spinal Nerves for Chronic Pain
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.14.29f, Spinal Discectomy
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.14.19o, Artificial Intervertebral Disc Insertion
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: General Description, Guidelines, or Informational Update

11.14.27d, Spinal Fusion
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.15.01w, Spinal Cord and Dorsal Root Ganglion Stimulation
Notification: 03/11/2020 | Effective: 06/15/2020 | Posted: 06/15/2020
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.03.23c, Autonomic Nervous System Testing
Effective: 06/22/2020 | Posted: 06/22/2020
Type of policy change: Medical Coding

08.01.28d, Sebelipase alfa (Kanuma®)
Effective: 06/22/2020 | Posted: 06/22/2020
Type of policy change: Coverage and/or Reimbursement Position


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
11.08.12h, Surgery for Gynecomastia
Reissue Effective: 06/03/2020 | Reissue Posted: 06/03/2020

07.03.08i, Neuropsychological Testing for Neurologically Based Conditions
Reissue Effective: 06/03/2020 | Reissue Posted: 06/03/2020

11.08.02h, Reduction Mammoplasty
Reissue Effective: 06/03/2020 | Reissue Posted: 06/03/2020

11.14.30, Composite Tissue Allotransplantation of the Hand(s) and Face
Reissue Effective: 06/03/2020 | Reissue Posted: 06/04/2020

11.14.26a, Surgical Treatments of Athletic Pubalgia
Reissue Effective: 06/03/2020 | Reissue Posted: 06/04/2020

05.00.26i, Home Prothrombin Time Monitoring
Reissue Effective: 06/03/2020 | Reissue Posted: 06/04/2020

05.00.30m, Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
Reissue Effective: 06/03/2020 | Reissue Posted: 06/04/2020

08.00.75n, Erythropoiesis-Stimulating Agents (ESAs)
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

08.01.53b, Moxetumomab Pasudotox-tdfk (Lumoxiti™)
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

08.00.88f, Ofatumumab (Arzerra®)
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

11.05.07d, Surgical Correction of Strabismus
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

11.01.07e, Cataract Surgery
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

11.05.11c, Implantation of Intrastromal Corneal Ring Segments (ICRS)
Reissue Effective: 06/05/2020 | Reissue Posted: 06/05/2020

11.14.06i, Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

11.14.10r, Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

11.14.09g, Osteochondral Autograft Transplantation (OAT) Procedure
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

11.14.12e, Osteochondral Allograft Transplantation
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

05.00.09h, Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

11.14.23c, Surgical Treatment of Femoroacetabular Impingement
Reissue Effective: 06/15/2020 | Reissue Posted: 06/15/2020

07.08.01f, Non-Surgical Spinal Decompression Therapy
Reissue Effective: 06/17/2020 | Reissue Posted: 06/18/2020

08.01.38c, Ocrelizumab (Ocrevus®)
Reissue Effective: 06/17/2020 | Reissue Posted: 06/18/2020

10.00.02c, Day Rehabilitation
Reissue Effective: 06/18/2020 | Reissue Posted: 06/18/2020

10.04.01l, Pulmonary Rehabilitation
Reissue Effective: 06/18/2020 | Reissue Posted: 06/18/2020


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following commercial policy to remain active.
05.00.08e, Continuous Passive Motion (CPM) Devices in the Home Setting
Notification: 06/18/2020 | Archive Effective: 07/20/2020 | Posted: 06/18/2020


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