Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
   


Policy #
Policy Bulletin Title
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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.62i
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.62i Abatacept (Orencia®) for Injection for Intravenous Use
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12.00.01f
Acupuncture (Independence)
12.00.01f
Attachment A (ICD-10 CM Codes Eligible to be Reported for Acupuncture) to 12.00.01f Acupuncture (Independence)
12.04.04a
Acute Care Facility Inpatient Transfers
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.11e
Attachment A (ICD-10-CM Codes and Narratives) to 08.01.11e Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69b
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22c
Alemtuzumab (Lemtrada®)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52i
Always Bundled Procedure Codes
00.01.52i
Attachment A (CPT Codes and HCPCS Codes) to 00.01.52i Always Bundled Procedure Codes
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.39o
Attachment A (HCPCS Codes) to 05.00.39o Ankle-Foot/Knee-Ankle-Foot Orthoses
06.03.04n
Apheresis Therapy
11.08.05g
Application and Removal of Tattoos
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.41c
Attachment A (Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents) to 08.01.41c Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.05.16h
Attachment A (ICD-10 codes ) to 11.05.16h Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19n
Artificial Intervertebral Disc Insertion
08.01.35b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06h
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment A (ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment B (ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
07.03.23b
Autonomic Nervous System Testing
11.16.06j
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02s
Bariatric Surgery
11.03.02s
Attachment A (Body Mass Index (BMI) Charts) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment B (Tanner Staging System Criteria for Adolescents) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment C (ICD-10-CM codes) to 11.03.02s Bariatric Surgery
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
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08.00.66m
Bevacizumab (Avastin®) and Related Biosimilars
08.00.66m
Attachment A (Dosing and Frequency Requirements) to 08.00.66m Bevacizumab (Avastin®) and Related Biosimilars
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00.10.39k
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.39k
Attachment A (CPT/HCPCS Codes) to 00.10.39k Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
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00.10.38a
Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment A (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment B (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment C (CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment D (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
07.00.01i
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
11.05.02i
Attachment A (ICD-10 Codes) to 11.05.02i Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
08.01.21c
Blinatumomab (Blincyto®)
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
09.00.04j
Bone Mineral Density (BMD) Testing
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26v
Botulinum Toxin Agents
08.00.26v
Attachment A (ICD-10 Diagnosis Codes) to 08.00.26v Botulinum Toxin Agents
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76c
Breast Pumps
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08.01.13d
Brentuximab Vedotin (Adcetris®)
08.01.13d
Attachment A (ICD CODES AND NARRATIVES) to 08.01.13d Brentuximab Vedotin (Adcetris®)
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96d
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.01.01n
Attachment A (ICD-10 Codes) to 10.01.01n Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
00.01.59f
Care Management and Care Planning Services
08.01.05f
Carfilzomib (Kyprolis™)
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.15c
Attachment A to 00.10.15c Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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11.01.07e
Cataract Surgery
11.01.07e
Attachment A (ICD 10 codes for policy 11.01.07d, Cataract Surgery) to 11.01.07e Cataract Surgery
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
08.01.39c
Cerliponase alfa (Brineura®)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67l
Cetuximab (Erbitux®)
08.00.67l
Attachment A (Dosing and Frequency Requirements) to 08.00.67l Cetuximab (Erbitux®)
08.00.67l
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to 08.00.67l Cetuximab (Erbitux®)
11.08.08g
Chemical Peels
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08.01.43e
Chimeric Antigen Receptor (CAR) Therapy
08.01.43e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.43e Chimeric Antigen Receptor (CAR) Therapy
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10.02.02i
Chiropractic Spinal and Extraspinal Manipulation Therapy
10.02.02i
Attachment A (Medically necessary ICD-10 diagnosis codes) to 10.02.02i Chiropractic Spinal and Extraspinal Manipulation Therapy
08.00.92aa
Coagulation Factors
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.54
Attachment A (MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747) ) to 06.02.54 Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
11.01.02o
Cochlear Implant
11.03.12r
Colorectal Cancer Screening
12.00.03f
Complementary and Integrative Health Services
07.06.01b
Complete Decongestive Therapy (CDT)
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
05.00.37f
Compression Garments
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.11i
Attachment A (ICD-10 Codes) to 07.13.11i Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
09.00.11d
Contrast Agents Used in Conjunction with Echocardiography
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07.13.07j
Corneal Pachymetry Using Ultrasound
07.13.07j
Attachment A (ICD-10-CM codes) to 07.13.07j Corneal Pachymetry Using Ultrasound
12.01.03
Cosmetic Procedures
05.00.04e
Coverage of Medical Devices
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.80a
Cranial Electrotherapy Stimulation
05.00.25h
Cranial Remolding Orthoses (Helmets)
00.10.03i
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29e
Daratumumab (Darzalex™)
10.00.02c
Day Rehabilitation
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment A (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment B (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment C (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment D (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment E (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09m
Denervation of the Spinal Nerves for Chronic Pain
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.94m
Attachment A (ICD-10-CM Codes) to 08.00.94m Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.01.24
Deoxycholic Acid (Kybella™)
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00.03.02y
Diagnostic Radiology Services Included in Capitation
00.03.02y
Attachment A (Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members ) to 00.03.02y Diagnostic Radiology Services Included in Capitation
00.03.02y
Attachment B (Diagnostic Radiology Procedure Codes Included in Capitation for New Jersey (NJ) Commercial Health Maintenance Organization (HMO) Members) to 00.03.02y Diagnostic Radiology Services Included in Capitation
00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07d
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
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05.00.21u
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A1 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A2 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment B (Items that Do Not Meet the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
08.00.84f
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
08.01.42a
Edaravone (Radicava™)
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11.06.02i
Elective Abortion
11.06.02i
Attachment A (Diagnosis codes ICD-10) to 11.06.02i Elective Abortion
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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07.07.07g
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
07.07.07g
Attachment A (ICD-10 Codes) to 07.07.07g Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment B (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment C (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment D (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment E (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment F (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment G (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment H (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment I (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment J (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment K (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21k
Attachment A (ICD-10-CM codes) to 07.03.21k Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54b
Emapalumab-lzsg (Gamifant®)
11.06.05f
Endometrial Ablation
11.02.10n
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
08.01.26b
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
11.15.23h
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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05.00.05l
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment A (ICD 10 Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment B (HCPCS Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.98e
Attachment A (ICD-10 Codes and Narratives) to 08.00.98e Eribulin Mesylate (Halaven®)
08.00.75n
Erythropoiesis-Stimulating Agents (ESAs)
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
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06.02.52o
eviCore Lab Management Program (Independence)
06.02.52o
Attachment A (Procedure Codes Requiring Pre-service and Prepayment Reviews) to 06.02.52o eviCore Lab Management Program (Independence)
06.02.52o
Attachment B (Procedure Codes Requiring Prepayment Reviews) to 06.02.52o eviCore Lab Management Program (Independence)
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12.01.01au
Experimental/Investigational Services
12.01.01au
Attachment A (Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01au Experimental/Investigational Services
12.01.01au
Attachment B (Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01au Experimental/Investigational Services
12.01.01au
Attachment C (Experimental/Investigational services with a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code, that are reported for other services.) to 12.01.01au Experimental/Investigational Services
07.02.05j
External Counterpulsation (ECP)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
00.01.19d
Facility Reporting of Observation Services
07.05.08a
Fecal Microbiota Transplantation (FMT)
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
11.00.03j
Fetal Surgery
09.00.36k
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
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05.00.35e
Foot Orthotics and Other Podiatric Appliances
05.00.35e
Attachment A (ICD-10 Codes) to 05.00.35e Foot Orthotics and Other Podiatric Appliances
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy

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