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.
11.09.02c, Treatment of Gender Dysphoria
Notification: 11/01/2016 (revised 11/17/2016) | Effective: 01/01/2017 | Posted: 11/01/2016
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.06.02s, Preventive Care Services
Notification: 11/01/2016 (revised 11/21/2016, 12/05/2016, 12/13/2016, 12/23/2016) | Effective: 01/01/2017 | Posted: 11/01/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.78t, Self-Administered Drugs
Notification: 11/11/2016 | Effective: 12/12/2016 | Posted: 11/11/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

11.02.25e, Transcatheter Cardiac Valve Procedures
Notification: 11/23/2016 | Effective: 12/23/2016 | Posted: 11/23/2016
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.17.04q, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Notification: 11/30/2016 | Effective: 01/06/2017 | Posted: 11/30/2016


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.
05.00.61f, Cervical Traction Devices for In-home Use
Notification: 09/30/2016 | Effective: 11/01/2016 | Posted: 11/01/2016
Type of policy change: Coverage and/or Reimbursement Position

05.00.26d, Home Prothrombin Time Monitoring
Notification: 10/05/2016 | Effective: 11/04/2016 | Posted: 11/04/2016
Type of policy change: Medical Coding

08.00.82d, Ustekinumab (Stelara®) for Subcutaneous Injection
Effective: 01/28/2015 | Posted: 11/16/2016

05.00.39m, Ankle-Foot/Knee-Ankle-Foot Orthoses
Notification: 10/20/2016 | Effective: 11/18/2016 | Posted: 11/18/2016
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.82e, Ustekinumab (Stelara®)
Effective: 11/16/2016 | Posted: 11/23/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.14.07p, Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Notification: 10/28/2016 | Effective: 11/28/2016 | Posted: 11/28/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

05.00.21q, Durable Medical Equipment (DME)
Effective: 11/30/2016 | Posted: 11/30/2016

05.00.44h, Repair and Replacement of Durable Medical Equipment (DME)
Effective: 11/30/2016 | Posted: 11/30/2016

08.01.08b, Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
Effective: 11/30/2016 | Posted: 11/30/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.87d, Pemetrexed (Alimta®)
Effective: 11/30/2016 | Posted: 11/30/2016
Type of policy change: Medical Necessity Criteria; Medical Coding

08.00.15d, Off-label Coverage for Prescription Drugs and/or Biologics
Effective: 11/30/2016 | Posted: 11/30/2016
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

10.01.01m, Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs
Notification: 10/05/2016 | Effective: 11/04/2016 | Posted: 11/30/2016
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
08.00.86a, Ecallantide (Kalbitor®)
Reissue Effective: 11/09/2016 | Reissue Posted: 11/09/2016

08.00.26s, Botulinum Toxin Agents
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.00.66i, Bevacizumab (Avastin®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.00.33k, Trastuzumab (Herceptin®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.00.34g, Infliximab (Remicade®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.00.91c, Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.01.26, Pegademase bovine (Adagen®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

08.01.07d, Pertuzumab (Perjeta®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016
Type of policy change: Medical Necessity Criteria; Medical Coding

08.01.11c, Ado-Trastuzumab Emtansine (Kadcyla®)
Reissue Effective: 11/10/2016 | Reissue Posted: 11/10/2016

05.00.30j, Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices
Reissue Effective: 11/09/2016 | Reissue Posted: 11/15/2016

07.06.01b, Complete Decongestive Therapy (CDT)
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

06.02.04d, Fetal Fibronectin Enzyme (fFN) Immunoassay
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

11.14.03e, Meniscal Allograft Transplantation
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

11.14.09f, Osteochondral Autograft Transplantation (OAT) Procedure
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

11.14.06g, Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

11.14.12d, Osteochondral Allograft Transplantation
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

09.00.48f, Radioembolization for Primary and Metastatic Tumors of the Liver (Independence Administrators)
Reissue Effective: 11/09/2016 | Reissue Posted: 11/21/2016

05.00.73c, Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

09.00.42c, Computer-Aided Detection (CAD) System for use with Chest Radiographs
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

06.03.05e, Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

12.04.03b, Air or Sea Ambulance Transport Services
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

11.15.23d, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

09.00.46r, High-Technology Radiology Services
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016

11.06.06c, Magnetic Resonance Imaging (MRI)--Guided Focused Ultrasound Ablation
Reissue Effective: 11/23/2016 | Reissue Posted: 11/23/2016


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.
08.00.50o, Rituximab (Rituxan®)
Effective: 10/01/2016 | Posted: 11/10/2016

00.01.25ah, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Effective: 11/15/2016 | Posted: 11/15/2016

00.03.10b, Obstetrical Ultrasounds for Members enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) product
Effective: 10/01/2016 | Posted: 11/15/2016


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