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.
08.01.02d, Pegloticase (Krystexxa®)
Notification: 10/01/2018 | Effective: 01/01/2019 | Posted: 10/01/2018
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

00.01.14q, Reporting and Documentation Requirements for Anesthesia Services
Notification: 10/01/2018 | Effective: 01/01/2019 | Posted: 10/01/2018
Type of policy change: Coverage and/or Reimbursement Position

08.00.18m, Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
Notification: 10/01/2018 (Revised 12/19/2018) | Effective: 01/01/2019 | Posted: 10/01/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

12.00.01f, Acupuncture (Independence)
Notification: 10/02/2018 | Effective: 01/02/2019 | Posted: 10/02/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.10.01z, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Notification: 10/01/2018 | Effective: 01/01/2019 | Posted: 10/02/2018
Type of policy change: Medical Coding

00.06.02x, Preventive Care Services (Independence)
Notification: 10/02/2018 (Revised 12/26/2018) | Effective: 01/01/2019 | Posted: 10/02/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

07.02.22, Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: This is a new policy.

11.14.10q, Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: General Description, Guidelines, or Informational Update

11.14.03f, Meniscal Allograft Transplantation
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.14.06i, Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

11.14.19l, Artificial Intervertebral Disc Insertion
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

11.14.27c, Spinal Fusion
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.15.01u, Spinal Cord and Dorsal Root Ganglion Stimulation
Notification: 10/16/2018 (Revised 01/10/2019) | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

11.14.29c, Spinal Discectomy
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: General Description, Guidelines, or Informational Update

11.15.23g, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

11.15.09l, Denervation of the Spinal Nerves for Chronic Pain
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

11.14.28b, Spinal Laminectomy
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: General Description, Guidelines, or Informational Update

00.01.66b, Musculoskeletal Services (Independence)
Notification: 10/16/2018 (Revised 01/10/2019) | Effective: 01/14/2019 | Posted: 10/16/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update


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.
12.01.01aq, Experimental/Investigational Services
Effective: 10/01/2018 | Posted: 10/01/2018
Type of policy change: Medical Coding

09.00.56f, Radiation Therapy Services (Independence)
Notification: 06/29/2018 | Effective: 10/01/2018 | Posted: 10/01/2018
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

09.00.49j, Proton Beam Radiation Therapy
Notification: 07/03/2018 | Effective: 10/01/2018 | Posted: 10/01/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

05.00.77a, Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
Effective: 10/08/2018 | Posted: 10/08/2018
Type of policy change: Medical Necessity Criteria

05.00.30l, Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
Effective: 10/08/2018 | Posted: 10/08/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

08.01.21c, Blinatumomab (Blincyto®)
Notification: 07/10/2018 | Effective: 10/08/2018 | Posted: 10/08/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.05.16g, Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
Notification: 07/25/2018 | Effective: 10/22/2018 | Posted: 10/22/2018
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

09.00.46u, High-Technology Radiology Services (Independence)
Notification: 08/01/2018 | Effective: 10/29/2018 | Posted: 10/29/2018
Type of policy change: General Description, Guidelines, or Informational Update

11.06.06e, Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
Effective: 10/29/2018 | Posted: 10/29/2018
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.
11.08.23j, Mohs' Micrographic Surgery
Reissue Effective: 10/11/2018 | Reissue Posted: 10/11/2018

11.14.23c, Surgical Treatment of Femoroacetabular Impingement
Reissue Effective: 10/10/2018 | Reissue Posted: 10/11/2018

05.00.62h, Injectable Dermal Fillers
Reissue Effective: 10/11/2018 | Reissue Posted: 10/11/2018

08.00.97h, Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
Reissue Effective: 10/11/2018 | Reissue Posted: 10/11/2018

09.00.24c, Full-Body Computerized Tomography (CT) Scan Screening
Reissue Effective: 10/11/2018 | Reissue Posted: 10/11/2018

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: 10/11/2018 | Reissue Posted: 10/11/2018

11.14.09g, Osteochondral Autograft Transplantation (OAT) Procedure
Reissue Effective: 10/10/2018 | Reissue Posted: 10/15/2018

11.14.12e, Osteochondral Allograft Transplantation
Reissue Effective: 10/10/2018 | Reissue Posted: 10/15/2018

05.00.09h, Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
Reissue Effective: 10/10/2018 | Reissue Posted: 10/15/2018

05.00.11h, Therapeutic Shoes and Orthopedic Shoes
Reissue Effective: 10/25/2018 | Reissue Posted: 10/25/2018

11.11.03d, Cryosurgical Ablation of the Prostate Gland
Reissue Effective: 10/24/2018 | Reissue Posted: 10/25/2018

08.00.51i, Enzyme Replacement for the Treatment of Gaucher's Disease
Reissue Effective: 10/25/2018 | Reissue Posted: 10/25/2018

00.01.49c, Reporting Requirements for Drugs and Biologics
Reissue Effective: 10/24/2018 | Reissue Posted: 10/25/2018

00.01.18c, Reimbursement for Associated Services Performed in Conjunction with Dental Care
Notification: 10/23/2018 | Reissue Effective: 10/24/2018 | Reissue Posted: 10/25/2018

12.01.03, Cosmetic Procedures
Reissue Effective: 10/25/2018 | Reissue Posted: 10/25/2018


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.
05.00.14i, High-Frequency Chest Wall Oscillation Devices
Effective: 10/01/2018 | Posted: 10/01/2018

05.00.67o, Wheelchair Options and Accessories
Effective: 10/01/2018 | Posted: 10/01/2018

00.06.02w, Preventive Care Services (Independence)
Effective: 10/01/2018 | Posted: 10/01/2018

07.02.21b, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Effective: 10/01/2018 | Posted: 10/01/2018

07.03.08h, Neuropsychological Testing for Neurologically Based Conditions
Effective: 10/01/2018 | Posted: 10/01/2018

08.00.26t, Botulinum Toxin Agents
Effective: 10/01/2018 | Posted: 10/01/2018

07.03.18n, Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
Effective: 10/01/2018 | Posted: 10/01/2018

08.01.00g, Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
Effective: 10/01/2018 | Posted: 10/01/2018

08.00.67k, Cetuximab (Erbitux®)
Effective: 10/01/2018 | Posted: 10/01/2018

07.03.21j, Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
Effective: 10/01/2018 | Posted: 10/01/2018

08.00.90h, Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
Effective: 10/01/2018 | Posted: 10/01/2018

07.03.09o, Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Effective: 10/01/2018 | Posted: 10/01/2018

07.07.03l, Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
Effective: 10/01/2018 | Posted: 10/01/2018

10.02.02i, Chiropractic Spinal and Extraspinal Manipulation Therapy
Effective: 10/01/2018 | Posted: 10/01/2018

08.01.01h, Ipilimumab (Yervoy®)
Effective: 10/01/2018 | Posted: 10/01/2018

08.01.27d, Talimogene laherparepvec (Imlygic™)
Effective: 10/01/2018 | Posted: 10/01/2018

08.01.20i, Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
Effective: 10/01/2018 | Posted: 10/01/2018

07.13.11i, Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
Effective: 10/01/2018 | Posted: 10/01/2018

11.05.02i, Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
Effective: 10/01/2018 | Posted: 10/01/2018

11.07.01s, Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
Effective: 10/01/2018 | Posted: 10/01/2018

11.06.02i, Elective Abortion
Effective: 10/01/2018 | Posted: 10/01/2018

11.02.12i, Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
Effective: 10/01/2018 | Posted: 10/01/2018

11.14.02m, Trigger Point Injections
Effective: 10/01/2018 | Posted: 10/01/2018

11.08.23j, Mohs' Micrographic Surgery
Effective: 10/01/2018 | Posted: 10/01/2018

00.01.44h, Never Events and Preventable Adverse Events
Effective: 10/01/2018 | Posted: 10/01/2018

11.08.06j, Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
Effective: 10/01/2018 | Posted: 10/01/2018

11.08.14j, Removal of Breast Implants
Effective: 10/01/2018 | Posted: 10/01/2018

07.13.13c, Prescription Lenses and Visual Devices
Effective: 10/01/2018 | Posted: 10/01/2018

11.07.02h, Sentinel Lymph Node Biopsy
Effective: 10/01/2018 | Posted: 10/02/2018

05.00.44k, Repair and Replacement of Durable Medical Equipment (DME)
Effective: 10/01/2018 | Posted: 10/02/2018


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