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.
05.00.80, Cranial Electrotherapy Stimulation
Notification: 07/12/2019 | Effective: 08/12/2019 | Posted: 07/12/2019
Type of policy change: This is a new policy.


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
08.01.57, Lutathera® (Lutetium Lu 177 Dotatate) (Independence Administrators)
Notification: 05/31/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
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.
07.07.03m, Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
Notification: 04/02/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

06.02.39c, Measurement of Serum Antibodies to and Measurement of Serum Levels Using Anser™ or DoseAssure™ Tests
Notification: 05/31/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.84e, Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
Notification: 04/02/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

09.00.46w, High-Technology Radiology Services (Independence)
Notification: 04/01/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

06.02.52m, eviCore Lab Management Program (Independence)
Notification: 05/31/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.49l, Proton Beam Radiation Therapy
Notification: 05/31/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

11.02.27b, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
Notification: 04/01/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

09.00.56i, Radiation Therapy Services (Independence)
Notification: 04/01/2019 | Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: General Description, Guidelines, or Informational Update

08.01.07f, Pertuzumab (Perjeta®)
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria

08.01.11e, Ado-Trastuzumab Emtansine (Kadcyla®)
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria

08.01.04u, Immunizations
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

08.00.33m, Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.05f, Carfilzomib (Kyprolis™)
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

07.10.05l, Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

00.06.02z, Preventive Care Services (Independence)
Effective: 07/01/2019 | Posted: 07/01/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

12.01.01as, Experimental/Investigational Services
Effective: 07/01/2019 | Posted: 07/08/2019
Type of policy change: Medical Coding

00.01.52h, Always Bundled Procedure Codes
Effective: 07/01/2019 | Posted: 07/08/2019
Type of policy change: Medical Coding

11.05.16h, Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
Effective: 07/08/2019 | Posted: 07/08/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.10z, Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
Effective: 07/15/2019 | Posted: 07/15/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

07.03.03g, Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
Effective: 07/15/2019 | Posted: 07/15/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.10.06g, Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
Effective: 07/15/2019 | Posted: 07/15/2019
Type of policy change: General Description, Guidelines, or Informational Update

08.00.94l, Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
Effective: 07/15/2019 | Posted: 07/15/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.08.20t, Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
Notification: 04/30/2019 | Effective: 07/29/2019 | Posted: 07/29/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
05.00.58l, Home Oxygen Therapy
Reissue Effective: 07/03/2019 | Reissue Posted: 07/03/2019

07.13.05k, Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
Reissue Effective: 07/03/2019 | Reissue Posted: 07/03/2019

05.00.50k, Ostomy Supplies
Reissue Effective: 07/03/2019 | Reissue Posted: 07/03/2019

11.14.24b, Manipulation Under Anesthesia
Reissue Effective: 07/03/2019 | Reissue Posted: 07/03/2019

05.00.29k, Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
Reissue Effective: 07/17/2019 | Reissue Posted: 07/18/2019

08.00.17g, Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
Reissue Effective: 07/17/2019 | Reissue Posted: 07/18/2019

08.00.22m, Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
Reissue Effective: 07/17/2019 | Reissue Posted: 07/18/2019

05.00.43f, Seat Lift Mechanisms
Reissue Effective: 07/31/2019 | Reissue Posted: 07/31/2019

11.14.30, Composite Tissue Allotransplantation of the Hand(s) and Face
Reissue Effective: 07/31/2019 | Reissue Posted: 07/31/2019

05.00.42g, Patient Lifts
Reissue Effective: 07/31/2019 | Reissue Posted: 07/31/2019


Coding Update
The following commercial 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.
08.00.78ab, Self-Administered Drugs
Effective: 07/01/2019 | Posted: 07/01/2019

08.00.92z, Coagulation Factors
Effective: 07/01/2019 | Posted: 07/01/2019

08.00.50t, Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
Effective: 07/01/2019 | Posted: 07/01/2019

08.01.55a, Tagraxofusp-erzs (Elzonris™)
Effective: 07/01/2019 | Posted: 07/02/2019

11.05.01f, Refractive Keratoplasty
Effective: 07/01/2019 | Posted: 07/02/2019

08.01.54a, Emapalumab-lzsg (Gamifant®)
Effective: 07/01/2019 | Posted: 07/02/2019

00.01.25as, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Effective: 07/01/2019 | Posted: 07/29/2019

00.03.07w, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 07/01/2019 | Posted: 07/29/2019


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