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
 
                                                                                                        

Notifications
The following Independence Blue Cross Medicare Advantage policies have been posted prior to their effective date.
MA05.053a, Implantable and External Infusion Pumps
Notification: 6/3/2015 | Effective: 7/3/2015 | Posted: 06/03/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA08.058, Blinatumomab (Blincyto™)
Notification: 6/3/2015 | Effective: 7/3/2015 | Posted: 06/03/2015
Type of policy change: This is a new policy.

MA05.002a, Hospital Beds and Accessories
Notification: 6/3/2015 | Effective: 7/3/2015 | Posted: 06/03/2015
Type of policy change: Medical Necessity Criteria

MA05.047a, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults
Notification: 4/23/2015; revised 6/10/2015 | Effective: 7/22/2015 | Posted: 06/10/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA08.073a, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®])
Notification: 6/15/2015 | Effective: 7/15/2015 | Posted: 06/15/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.023a, Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Notification: 6/3/2015 | Effective: 9/1/2015 | Posted: 06/03/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA05.030a, Spinal Orthoses
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/01/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA05.013a, Knee Braces
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/01/2015

MA00.005d, Experimental/Investigational Services
Notification: 07/01/2015 (revised 09/16/2015) | Effective: 10/01/2015 | Posted: 07/01/2015
Type of policy change: Coverage and/or Reimbursement Position

MA11.079a, Evaluation and Treatment of Erectile Dysfunction (ED)
Notification: 07/13/2015 | Effective: 08/12/2015 | Posted: 07/13/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

MA07.007, Pulmonary Function Tests
Notification: 07/15/2015 | Effective: 10/13/2015 | Posted: 07/15/2015
Type of policy change: This is a new policy.

MA05.014a, Ostomy Supplies
Notification: 07/15/2015 | Effective: 08/14/2015 | Posted: 07/15/2015
Type of policy change: Medical Coding

MA08.074, Deoxycholic Acid (Kybella™)
Notification: 07/29/2015 | Effective: 08/28/2015 | Posted: 07/29/2015
Type of policy change: This is a new policy.

MA08.015, Alemtuzumab (Lemtrada™)
Notification: 07/29/2015, revised 08/12/2015 | Effective: 08/28/2015 | Posted: 07/29/2015

MA05.027, Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating LIfe-threatening Ventricular Tachyarrhythmia
Notification: 09/02/2015 | Effective: 10/01/2015 | Posted: 09/02/2015
Type of policy change: This is a new policy.

MA07.026, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Notification: 09/09/2015 | Effective: 12/08/2015 | Posted: 09/09/2015
Type of policy change: This is a new policy.

MA05.041a, Blood Pressure Devices for Home Use
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 09/23/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.036a, Surgical Treatment of Nails
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 09/23/2015

MA11.044a, Artificial Intervertebral Disc Insertion
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 09/23/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA09.020b, Radiation Therapy Services (Independence Blue Cross)
Notification: 10/01/2015 | Effective: 01/01/2016 | Posted: 10/01/2015

MA11.108, Spinal Fusion
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 10/02/2015
Type of policy change: This is a new policy.

MA11.041, Spinal Laminectomy
Notification: 10/02/2015, revised 11/24/2015 | Effective: 01/01/2016 | Posted: 10/02/2015
Type of policy change: This is a new policy.

MA11.029, Spinal Discectomy
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 10/02/2015
Type of policy change: This is a new policy.

MA05.012a, Orthopedic Footwear
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: Medical Necessity Criteria

MA08.063a, Pertuzumab (Perjeta®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.037a, Bortezomib (Velcade®)
Notification: 10/07/2015 | Effective: 01/05/2016 | Posted: 10/07/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA09.021, Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: This is a new policy.

MA08.066a, Ado-Trastuzumab Emtansine (Kadcyla®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.018a, Trastuzumab (Herceptin®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA05.018a, Osteogenic Stimulators (i.e., Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 10/07/2015
Type of policy change: Medical Necessity Criteria

MA05.024a, Lower Limb Prostheses
Notification: 10/21/2015 | Effective: 11/20/2015 | Posted: 10/21/2015

MA08.048a, Ofatumumab (Arzerra™)
Notification: 10/30/2015 | Effective: 11/30/2015 | Posted: 10/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.107, Implantable Steroid-Eluting Sinus Stents
Notification: 11/06/2015 (revised 12/04/2015) | Effective: 02/04/2016 | Posted: 11/06/2015
Type of policy change: This is a new policy.

MA11.109, Procedures for the Treatment of Acne
Effective: 12/16/2015 | Posted: 11/16/2015
Type of policy change: This is a new policy.

MA11.078a, Scar Revision
Notification: 11/16/2015 | Effective: 12/16/2015 | Posted: 11/16/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.004b, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Notification: 12/01/2015 | Effective: 08/26/2015 | Posted: 12/01/2015

MA00.027c, Diagnostic Radiology Services Included in Capitation
Notification: 12/01/2015 | Effective: 03/01/2016 | Posted: 12/01/2015

MA08.075, Ramucirumab (Cyramza®)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/01/2015
Type of policy change: This is a new policy.

MA11.106, Sex Reassignment Surgery (SRS) for Gender Identity Disorder (GID)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/01/2015
Type of policy change: This is a new policy.

MA08.009b, Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
Notification: 12/02/2015 | Effective: 03/01/2016 | Posted: 12/02/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.041a, Bendamustine Hydrochloride (Treanda®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.008b, Total Parenteral Nutrition (TPN), Intradialytic Nutrition (IDPN), and Intraperitoneal Nutrition (IPN)
Notification: 12/30/2015 | Effective: 01/29/2016 | Posted: 12/30/2015

MA08.026a, Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
Notification: 12/30/2015 | Effective: 03/29/2016 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA05.028b, Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Notification: 12/31/2015 | Effective: 04/01/2016 | Posted: 12/31/2015


New Policies
The following Medicare Advantage 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.
MA08.058, Blinatumomab (Blincyto™)
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015

MA08.015, Alemtuzumab (Lemtrada™)
Notification: 07/29/2015 | Effective: 08/28/2015 | Posted: 08/28/2015

MA08.074, Deoxycholic Acid (Kybella™)
Notification: 07/29/2015 | Effective: 08/28/2015 | Posted: 08/28/2015

MA05.027, Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating LIfe-threatening Ventricular Tachyarrhythmia
Notification: 09/02/2015 | Effective: 10/01/2015 | Posted: 10/01/2015
Type of policy change: This is a new policy.

MA07.007, Pulmonary Function Tests
Notification: 07/15/2015 | Effective: 10/13/2015 | Posted: 10/13/2015

MA08.043a, Pralatrexate (Folotyn®) for Injection
Effective: 11/04/2015 | Posted: 11/04/2015
Type of policy change: This is a new policy.

MA09.021, Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: This is a new policy.

MA07.026, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Notification: 09/09/2015 | Effective: 12/08/2015 | Posted: 12/08/2015
Type of policy change: This is a new policy.

MA11.109, Procedures for the Treatment of Acne
Notification: 11/16/2015 | Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: This is a new policy.

MA08.077, Talimogene laherparepvec (Imlygic™)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA08.075, Ramucirumab (Cyramza®)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA11.041, Spinal Laminectomy
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA11.029, Spinal Discectomy
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA08.024, Mepolizumab (Nucala®)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA11.108, Spinal Fusion
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA11.106, Sex Reassignment Surgery (SRS) for Gender Identity Disorder (GID)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.


Updated Policies
The following Medicare Advantage 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.
MA08.010a, Programmed Cell Death Receptor-1 (PD-1) antagonists (e.g., Keytruda®, Opdivo®)
Effective: 6/3/2015 | Posted: 06/03/2015
Type of policy change: Medical Necessity Criteria

MA11.093a, Surgical Treatments of Athletic Pubalgia
Effective: 6/3/2015 | Posted: 06/03/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA08.059a, Ipilimumab (Yervoy®)
Effective: 6/3/2015 | Posted: 06/03/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.022b, Rituximab (Rituxan®)
Effective: 6/3/2015 | Posted: 06/03/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

MA00.005b, Experimental/Investigational Services
Notification: 5/20/2015 | Effective: 6/19/2015 | Posted: 06/19/2015
Type of policy change: Coverage and/or Reimbursement Position

MA08.028a, Abatacept (Orencia®) for Injection for Intravenous Use
Effective: 6/17/2015 | Posted: 06/17/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA11.067a, Labiaplasty
Effective: 6/17/2015 | Posted: 06/17/2015
Type of policy change: Medical Necessity Criteria

MA11.015a, Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
Notification: 5/20/2015 | Effective: 6/19/2015 | Posted: 06/19/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.030a, Reconstructive Breast Surgery
Effective: 6/19/2015 | Posted: 06/19/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA11.105a, Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
Effective: 6/3/2015 | Posted: 06/03/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA00.005c, Experimental/Investigational Services
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: Medical Coding

MA03.005a, Modifiers XE, XS, XP, XU, 59
Effective: 07/01/2015 | Posted: 07/02/2015

MA06.020a, Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA00.003a, Preventive Care Services
Effective: 07/01/2015 | Posted: 07/02/2015

MA08.045a, Tocilizumab (Actemra®) for Intravenous Infusion
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA07.030a, Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin®)
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA08.052a, Denosumab (Prolia®, Xgeva®)
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA07.016a, Intravenous Chelation Therapy
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA05.053a, Implantable and External Infusion Pumps
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015

MA05.002a, Hospital Beds and Accessories
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015

MA08.067a, Repository Corticotropin (H.P. Acthar® Gel Injection)
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA05.002a, Hospital Beds and Accessories
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015

MA11.028a, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Effective: 07/01/2015 | Posted: 07/02/2015
Type of policy change: Medical Necessity Criteria

MA05.058a, Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
Effective: 08/14/2015 | Posted: 07/15/2015
Type of policy change: Medical Coding

MA08.073a, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®])
Notification: 06/15/2015 | Effective: 07/15/2015 | Posted: 07/15/2015

MA05.047a, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring in Adults
Notification: 04/23/2015 | Effective: 07/22/2015 | Posted: 07/22/2015

MA06.011a, Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA08.053a, Personalized Vaccines (e.g., Provenge®)
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: Medical Necessity Criteria

MA06.007a, Loss-of-Heterozygosity-Based Topographic Genotyping with PathFinderTG®
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA06.014a, Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA06.013a, Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA06.015a, AlloMap™ Molecular Expression Testing for Heart Transplant Rejection
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA05.013a, Knee Braces
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/31/2015

MA05.030a, Spinal Orthoses
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/31/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA00.026a, Always Bundled Procedure Codes
Effective: 08/05/2015 | Posted: 08/05/2015
Type of policy change: Coverage and/or Reimbursement Position

MA10.004a, Chiropractic Services
Effective: 08/12/2015 | Posted: 08/12/2015

MA11.079a, Evaluation and Treatment of Erectile Dysfunction (ED)
Notification: 07/13/2015 | Effective: 08/12/2015 | Posted: 08/12/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

MA05.014a, Ostomy Supplies
Notification: 07/15/2015 | Effective: 08/14/2015 | Posted: 08/14/2015
Type of policy change: Medical Coding

MA06.009a, Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies
Effective: 08/26/2015 | Posted: 08/26/2015

MA07.002a, Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Effective: 08/26/2015 | Posted: 08/26/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA11.023a, Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Notification: 06/03/2015 | Effective: 09/01/2015 | Posted: 09/01/2015

MA00.032a, Direct Access Obstetrics/Gynecology (OB/GYN)
Effective: 09/09/2015 | Posted: 09/09/2015
Type of policy change: Medical Necessity Criteria

MA02.003a, Home Health Care Services
Effective: 09/09/2015 | Posted: 09/09/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA11.042a, Revision of a Previous Cosmetic Procedure
Effective: 09/09/2015 | Posted: 09/09/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.048a, Lumbar Interspinous Process Decompression System
Effective: 09/23/2015 | Posted: 09/23/2015
Type of policy change: Medical Coding

MA11.088a, Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
Effective: 09/23/2015 | Posted: 09/23/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA00.005d, Experimental/Investigational Services
Notification: 07/01/2015 | Effective: 10/01/2015 | Posted: 10/01/2015
Type of policy change: Coverage and/or Reimbursement Position

MA07.017a, Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Effective: 10/02/2015 | Posted: 10/01/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.104a, Lacrimal Punctum Plugs
Effective: 10/01/2015 | Posted: 10/01/2015
Type of policy change: Medical Coding

MA07.022a, Wireless Capsule Endoscopy
Effective: 10/01/2015 | Posted: 10/01/2015

MA08.007c, Medicare Part B vs. Part D Crossover Drugs
Effective: 10/01/2015 | Posted: 10/01/2015

MA07.041a, Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
Effective: 10/02/2015 | Posted: 10/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA07.040a, Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
Effective: 10/02/2015 | Posted: 10/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.024a, Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
Effective: 10/02/2015 | Posted: 10/02/2015
Type of policy change: Medical Coding

MA11.061a, Transcoronary Ablation of Septal Hypertrophy (TASH)
Effective: 10/02/2015 | Posted: 10/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA07.044a, Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
Effective: 10/07/2015 | Posted: 10/07/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA06.001a, Apheresis Therapy
Effective: 10/07/2015 | Posted: 10/07/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

MA08.025a, Omalizumab (Xolair®)
Effective: 10/21/2015 | Posted: 10/21/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.040a, Transcatheter Closure of Cardiac Septal Defects
Effective: 10/21/2015 | Posted: 10/21/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.062a, Carfilzomib (Kyprolis™)
Effective: 10/21/2015 | Posted: 10/21/2015

MA11.036a, Surgical Treatment of Nails
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 10/23/2015

MA05.041a, Blood Pressure Devices for Home Use
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 10/23/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.044a, Artificial Intervertebral Disc Insertion
Notification: 09/23/2015 | Effective: 10/23/2015 | Posted: 10/23/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA00.031a, X-rays Associated with Fractures in the Office Setting
Notification: 10/01/2014 | Effective: 10/01/2015 | Posted: 10/30/2015
Type of policy change: Medical Coding

MA03.011a, Modifiers 26 (Professional Component) and TC (Technical Component)
Effective: 11/01/2015 | Posted: 11/02/2015

MA00.009b, Reporting and Documentation Requirements for Anesthesia Services
Effective: 11/01/2015 | Posted: 11/02/2015

MA08.057a, Belimumab (Benlysta®)
Effective: 11/04/2015 | Posted: 11/04/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA06.018a, Immune Cell Function Assay
Notification: 10/01/2014 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA08.018a, Trastuzumab (Herceptin®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA06.012a, Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)
Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

MA08.063a, Pertuzumab (Perjeta®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA06.021a, In Vitro Chemosensitivity and Chemoresistance Assays
Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA05.018a, Osteogenic Stimulators (i.e., Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Medical Necessity Criteria

MA08.066a, Ado-Trastuzumab Emtansine (Kadcyla®)
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA05.012a, Orthopedic Footwear
Notification: 10/07/2015 | Effective: 11/06/2015 | Posted: 11/06/2015
Type of policy change: Medical Necessity Criteria

MA11.076a, Removal of Breast Implants
Effective: 11/18/2015 | Posted: 11/18/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA05.024a, Lower Limb Prostheses
Notification: 10/21/2015 | Effective: 11/20/2015 | Posted: 11/20/2015

MA08.048a, Ofatumumab (Arzerra™)
Notification: 10/30/2015 | Effective: 11/30/2015 | Posted: 11/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.049a, Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA08.031a, Cetuximab (Erbitux®)
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA11.084a, Osteochondral Autograft Transplantation Procedure
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA11.102b, Denervation of the Spinal Nerves for Chronic Pain
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: General Description, Guidelines, or Informational Update

MA11.086a, Osteochondral Allograft Transplantation
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Coverage and/or Reimbursement Position

MA07.009b, Routine Foot Care For Certain Medical Conditions
Effective: 10/01/2015 | Posted: 12/11/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA11.014b, Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
Effective: 10/01/2015 | Posted: 12/11/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA11.078a, Scar Revision
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA11.103a, Chemical Peels
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA11.071a, Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

MA08.047a, Pemetrexed (Alimta®)
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.038b, Oxaliplatin (Eloxatin®)
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA08.056a, Eribulin Mesylate (Halaven™)
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

MA09.004a, Echocardiography Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

MA09.010a, Magnetic Resonance Imaging (MRI) Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

MA09.005a, High Osmolar Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

MA09.008a, Low Osmolar Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

MA10.004b, Chiropractic Services
Effective: 12/30/2015 | Posted: 12/30/2015

MA11.004b, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Notification: 12/01/2015 | Effective: 08/26/2015 | Posted: 12/30/2015

MA00.011a, Modifier 62: Two Surgeons
Effective: 01/01/2016 | Posted: 12/31/2015

MA00.014a, Modifier 66: Surgical Team
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.006a, Bronchial Thermoplasty
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA03.008a, Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
Effective: 01/01/2016 | Posted: 12/31/2015

MA03.017a, Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.077a, Prophylactic Mastectomy
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

MA08.041a, Bendamustine Hydrochloride (Treanda®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA07.019a, Reimbursement for the Administration of Immunizations
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

MA07.025a, Intrauterine Systems (IUSs) (e.g. Mirena®, Skyla®, Liletta®)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

MA09.020b, Radiation Therapy Services
Notification: 10/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015


Reissue Policies
The following Medicare Advantage policies have been reviewed, and no substantive changes were made.
MA05.034, Tracheostomy Care Supplies
Reissue Effective: 06/24/2015 | Reissue Posted: 06/25/2015

MA05.037, Walkers
Reissue Effective: 06/24/2015 | Reissue Posted: 06/25/2015

MA07.008, Platelet-Rich Plasma (PRPs) for Chronic Non-Healing Wounds and Stem-Cell Therapy for Orthopedic Applications
Reissue Effective: 06/24/2015 | Reissue Posted: 06/25/2015

MA11.059, Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
Reissue Effective: 06/10/2015 | Reissue Posted: 06/11/2015

MA05.042, Pulse Oximetry Device in the Home Setting
Reissue Effective: 06/10/2015 | Reissue Posted: 06/11/2015

MA11.034, Collagen Meniscus Implant
Reissue Effective: 06/10/2015 | Reissue Posted: 06/11/2015

MA05.029, Heating Pads and Heat Lamps
Reissue Effective: 06/10/2015 | Reissue Posted: 06/11/2015

MA00.042, Humanitarian Use Devices (HUDs)
Reissue Effective: 6/24/2015 | Reissue Posted: 06/25/2015

MA05.022, Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA05.039, Non-Implantable Pelvic Floor Electrical Stimulator
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA05.064, Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA06.019, Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA06.023, Nerve Fiber Density Testing
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA07.055, Allergy Immunotherapy
Reissue Effective: 06/24/2015 | Reissue Posted: 06/30/2015

MA05.061, Home Use of Interferential and Sequential Stimulation Devices
Reissue Effective: 06/24/2015 | Reissue Posted: 07/06/2015

MA05.033, External Breast Prosthesis
Reissue Effective: 06/24/2015 | Reissue Posted: 07/07/2015

MA05.048, Bladder Stimulators (Pacemakers)
Reissue Effective: 07/08/2015 | Reissue Posted: 07/08/2015

MA11.069, Reduction Mammoplasty
Reissue Effective: 07/08/2015 | Reissue Posted: 07/08/2015

MA08.012, Off-label Coverage for Prescription Drugs and/or Biologics
Reissue Effective: 07/22/2015 | Reissue Posted: 07/22/2015

MA09.020a, Radiation Therapy Services (Independence Blue Cross)
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA05.004, Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA07.056, Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.016, Prostate Mapping Biopsy
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA05.050, Eye Prosthesis
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA05.036, Commodes
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.099, Septoplasty, Rhinoplasty, and Septorhinoplasty
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA05.005, Automatic External and Wearable Cardioverter Defibrillators
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA07.060, Oral and Maxillofacial Prosthesis
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.062, Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA07.001, Hyperbaric Oxygen Therapy
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA07.058a, Sleep Disorder Testing and Positive Airway Pressure Therapy
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.011, Artificial Hearts and Ventricular Assist Devices (VADs)
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.040, Transcatheter Closure of Cardiac Septal Defects
Reissue Effective: 08/19/2015 | Reissue Posted: 08/19/2015

MA11.090, Surgical Treatment of Femoroacetabular Impingement
Reissue Effective: 08/20/2015 | Reissue Posted: 08/20/2015

MA05.015, Home Blood Glucose Monitors and Supplies
Reissue Effective: 08/19/2015 | Reissue Posted: 08/20/2015

MA05.063, Repair or Replacement of an External Prosthetic Device
Reissue Effective: 08/19/2015 | Reissue Posted: 08/20/2015

MA05.016, Home Prothrombin Time Monitoring
Reissue Effective: 08/19/2015 | Reissue Posted: 08/24/2015

MA11.074, Excision of Redundant Skin
Reissue Effective: 09/02/2015 | Reissue Posted: 09/03/2015

MA07.069, Real-Time, Outpatient Cardiac Telemetry
Reissue Effective: 09/02/2015 | Reissue Posted: 09/03/2015

MA05.025, Pressure-Reducing Support Surfaces
Reissue Effective: 09/16/2015 | Reissue Posted: 09/17/2015

MA11.080, Mentoplasty or Genioplasty
Reissue Effective: 09/16/2015 | Reissue Posted: 09/18/2015

MA11.075, Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
Reissue Effective: 09/16/2015 | Reissue Posted: 09/18/2015

MA11.056a, Percutaneous Transluminal Angioplasty (PTA) and Extracranial (EC) and Intracranial (IC) Arterial Bypass Surgery
Reissue Effective: 10/02/2015 | Reissue Posted: 10/02/2015

MA00.039, Never Events and Preventable Adverse Events
Reissue Effective: 10/01/2015 | Reissue Posted: 10/01/2015

MA06.022, Biomarkers for Oncology
Reissue Effective: 10/01/2015 | Reissue Posted: 10/01/2015

MA11.073, Abdominoplasty and/or Panniculectomy
Reissue Effective: 10/01/2015 | Reissue Posted: 10/01/2015

MA11.055a, Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
Reissue Effective: 09/30/2015 | Reissue Posted: 10/01/2015

MA07.012, External Counterpulsation (ECP)
Reissue Effective: 10/02/2015 | Reissue Posted: 10/02/2015

MA00.004, Routine Costs of Clinical Trials and Coverage of Investigational Devices A and B
Reissue Effective: 10/02/2015 | Reissue Posted: 10/02/2015

MA11.025, Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
Reissue Effective: 10/02/2015 | Reissue Posted: 10/02/2015

MA05.062, Repair and Replacement of Durable Medical Equipment (DME)
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA12.002, Nonemergency Ambulance Transport
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA08.046, Ecallantide (Kalbitor®)
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA12.007, Air or Sea Ambulance
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA08.061, Belatacept (Nulojix®)
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA08.050, Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
Reissue Effective: 10/15/2015 | Reissue Posted: 10/15/2015

MA08.064, Omacetaxine Mepesuccinate (Synribo®)
Reissue Effective: 10/14/2015 | Reissue Posted: 10/15/2015

MA05.035a, Cold Therapy Devices
Reissue Effective: 10/28/2015 | Reissue Posted: 10/29/2015

MA11.104a, Lacrimal Punctum Plugs
Reissue Effective: 10/28/2015 | Reissue Posted: 10/29/2015

MA05.054a, Urological Supplies
Reissue Effective: 10/28/2015 | Reissue Posted: 10/29/2015

MA08.051a, C1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest®
Reissue Effective: 10/28/2015 | Reissue Posted: 10/29/2015

MA07.046a, Corneal Pachymetry Using Ultrasound
Reissue Effective: 10/28/2015 | Reissue Posted: 10/29/2015

MA11.047a, Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
Reissue Effective: 10/28/2015 | Reissue Posted: 10/30/2015

MA11.026, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Notification: 10/01/2014 | Reissue Effective: 12/02/2015 | Reissue Posted: 11/30/2015

MA08.019, Infliximab (Remicade®)
Reissue Effective: 12/09/2015 | Reissue Posted: 12/09/2015

MA11.012, Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
Reissue Effective: 12/09/2015 | Reissue Posted: 12/10/2015


Coding Update
The following Medicare Advantage 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.
MA05.028a, Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Effective: 6/1/2015 | Posted: 06/08/2015

MA11.015b, Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
Effective: 07/01/2015 | Posted: 07/06/2015

MA11.002a, Hematopoietic Stem Cell Transplantation
Effective: 07/01/2015 | Posted: 07/06/2015

MA11.032b, Multiple Surgical Reduction Guidelines
Effective: 07/01/2015 | Posted: 07/06/2015

MA09.002b, High-Technology Radiology Services
Effective: 07/01/2015 | Posted: 07/06/2015

MA00.027b, Diagnostic Radiology Services Included in Capitation
Effective: 07/01/2015 | Posted: 07/06/2015

MA08.010b, Programmed Cell Death Receptor-1 (PD-1) antagonists (e.g., Keytruda®, Opdivo®)
Effective: 07/01/2015 | Posted: 07/06/2015

MA00.010c, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Effective: 07/01/2015 | Posted: 07/06/2015

MA08.007b, Medicare Part B vs. Part D Crossover Drugs
Effective: 07/01/2015 | Posted: 07/06/2015

MA00.030c, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 07/01/2015 | Posted: 07/06/2015

MA08.006a, Siltuximab (Sylvant™)
Effective: 07/01/2015 | Posted: 07/06/2015

MA06.017a, Molecular Diagnostics
Effective: 07/01/2015 | Posted: 07/07/2015

MA05.054a, Urological Supplies
Effective: 07/22/2015 | Posted: 07/22/2015

MA11.027a, Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR)
Effective: 08/12/2015 | Posted: 08/12/2015

MA05.035a, Cold Therapy Devices
Effective: 08/26/2015 | Posted: 08/26/2015

MA05.006a, Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
Effective: 10/01/2015 | Posted: 10/01/2015

MA07.018a, Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters 
Effective: 10/01/2015 | Posted: 10/01/2015

MA07.013a, Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
Effective: 10/01/2015 | Posted: 10/01/2015

MA08.045b, Tocilizumab (Actemra®) for Intravenous Infusion
Effective: 10/01/2015 | Posted: 10/01/2015

MA08.015a, Alemtuzumab (Lemtrada™)
Effective: 10/01/2015 | Posted: 10/01/2015

MA11.031b, Spinal Cord Stimulation (Dorsal Column Stimulation)
Effective: 10/01/2015 | Posted: 10/01/2015

MA11.102a, Denervation of the Spinal Nerves for Chronic Facet Pain
Effective: 10/01/2015 | Posted: 10/01/2015

MA06.017b, Molecular Diagnostics
Effective: 10/01/2015 | Posted: 10/01/2015

MA07.046a, Corneal Pachymetry Using Ultrasound
Effective: 10/01/2015 | Posted: 10/01/2015

MA00.003b, Preventive Care Services
Effective: 10/01/2015 | Posted: 10/01/2015

MA11.018a, Mohs' Micrographic Surgery (MMS)
Effective: 10/02/2015 | Posted: 10/02/2015

MA05.020a, Therapeutic Shoes
Effective: 10/02/2015 | Posted: 10/02/2015

MA03.004b, Modifier 51: Multiple Procedures
Effective: 07/01/2015 | Posted: 10/14/2015

MA00.007a, Obstetrical Ultrasounds for members enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) product
Effective: 10/01/2015 | Posted: 10/16/2015

MA00.010d, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Effective: 10/01/2015 | Posted: 10/16/2015

MA00.029a, Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 10/01/2015 | Posted: 10/16/2015

MA00.044a, Criteria for Reimbursement of Emergency Room Services
Effective: 10/01/2015 | Posted: 10/16/2015

MA11.056a, Percutaneous Transluminal Angioplasty (PTA) and Extracranial (EC) and Intracranial (IC) Arterial Bypass Surgery
Effective: 10/01/2015 | Posted: 10/01/2015

MA09.009b, Diagnostic and Therapeutic Radiopharmaceutical Agents
Effective: 12/01/2015 | Posted: 12/01/2015

MA11.026a, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Effective: 01/01/2016 | Posted: 12/31/2015

MA07.046b, Corneal Pachymetry Using Ultrasound
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.028b, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.031c, Spinal Cord Stimulation (Dorsal Column Stimulation)
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.033a, Solid Organ Transplants
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.055b, Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
Effective: 01/01/2016 | Posted: 12/31/2015

MA11.064b, Implantable Miniature Telescope™ (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD)
Effective: 01/01/2016 | Posted: 12/31/2015

MA06.001b, Apheresis Therapy
Effective: 01/01/2016 | Posted: 12/31/2015

MA00.030d, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 01/01/2016 | Posted: 12/31/2015


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following Medicare Advantage policy to remain active.
MA09.016, Digital Breast Tomosynthesis
Notification: 06/01/2015 | Archive Effective: 07/01/2015 | Posted: 06/01/2015

MA00.025, Reporting of Healthcare Common Procedure Coding System (HCPCS) C Series Codes
Notification: 06/12/2015 | Archive Effective: 07/15/2015 | Posted: 06/12/2015

MA08.027, Risperidone (Risperdal® Consta®) Injection
Notification: 06/17/2015 | Archive Effective: 07/17/2015 | Posted: 06/17/2015

MA05.049, Electronic Speech Aids
Notification: 07/01/2015 | Archive Effective: 07/31/2015 | Posted: 07/01/2015

MA00.025, Reporting of Healthcare Common Procedure Coding System (HCPCS) C Series Codes
Notification: 06/12/2015 | Archive Effective: 07/15/2015 | Posted: 07/15/2015

MA08.027, Risperidone (Risperdal® Consta®) Injection
Notification: 06/17/2015 | Archive Effective: 07/17/2015 | Posted: 07/17/2015

MA03.006a, Modifiers LT/RT: Left Side/Right Side Procedures
Notification: 07/28/2015 | Archive Effective: 08/28/2015 | Posted: 07/28/2015

MA05.049, Electronic Speech Aids
Notification: 07/01/2015 | Archive Effective: 07/31/2015 | Posted: 07/31/2015

MA08.002, Nesiritide (Natrecor®) for Treatment of Heart Failure Patients
Notification: 09/09/2015 | Archive Effective: 10/09/2015 | Posted: 09/09/2015

MA11.035, Infrared Photocoagulation (IRC) of Hemorrhoids
Notification: 09/15/2015 | Archive Effective: 10/15/2015 | Posted: 09/15/2015

MA11.035, Infrared Photocoagulation (IRC) of Hemorrhoids
Notification: 09/15/2015 | Archive Effective: 10/15/2015 | Posted: 10/15/2015

MA03.013a, Modifier 51 Exempt
Notification: 11/30/2015 | Archive Effective: 01/01/2016 | Posted: 11/30/2015

MA00.016a, Add-on Codes
Notification: 11/30/2015 | Archive Effective: 01/01/2016 | Posted: 11/30/2015

MA07.057, Cardiac Event Detection Monitoring (External Loop Monitoring)
Archive Effective: 12/08/2015 | Posted: 12/08/2015

MA07.069, Real-Time, Outpatient Cardiac Telemetry
Archive Effective: 12/08/2015 | Posted: 12/08/2015

MA07.049 , Implantable Cardiac Loop Monitor
Archive Effective: 12/08/2015 | Posted: 12/08/2015

MA11.089, Hip Resurfacing
Notification: 12/30/2015 | Archive Effective: 01/29/2016 | Posted: 12/30/2015

MA11.092, Total Ankle Arthroplasty/Replacement
Notification: 12/30/2015 | Archive Effective: 01/29/2016 | Posted: 12/30/2015










Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.