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.
11.05.16f, Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
Notification: 11/01/2017 | Effective: 01/30/2018 | Posted: 11/01/2017
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.03.10e, Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

00.10.01y, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

00.01.25ao, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

00.03.09d, X-rays Associated with Fractures in the Office Setting
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

00.03.07t, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

00.10.40b, Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)
Notification: 11/01/2017 | Effective: 12/01/2017 | Posted: 11/01/2017
Type of policy change: Coverage and/or Reimbursement Position

05.00.45j, Repair or Replacement of an External Prosthetic Device
Notification: 11/15/2017 | Effective: 12/15/2017 | Posted: 11/15/2017
Type of policy change: Medical Coding

07.03.24, Laboratory-Based Vestibular Function Testing
Notification: 11/15/2017 | Effective: 02/13/2018 | Posted: 11/15/2017
Type of policy change: This is a new policy.

11.17.04r, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Notification: 11/15/2017 | Effective: 12/15/2017 | Posted: 11/15/2017
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

08.00.08i, Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
Notification: 11/16/2017 | Effective: 02/14/2018 | Posted: 11/16/2017
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

07.07.01m, Routine Foot Care for Certain Medical Conditions
Notification: 11/17/2017 | Effective: 02/15/2018 | Posted: 11/17/2017
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

05.00.31d, Pulse Oximetry Devices in the Home Setting
Notification: 11/29/2017 | Effective: 12/29/2017 | Posted: 11/29/2017
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update


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
08.01.42, Edaravone (Radicava™)
Notification: 10/18/2017 | Effective: 11/17/2017 | Posted: 11/17/2017
Type of policy change: This is a new policy.

08.01.43, Chimeric Antigen Receptor (CAR) Therapy
Effective: 11/29/2017 | Posted: 11/29/2017
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.
08.01.13c, Brentuximab Vedotin (Adcetris®)
Effective: 11/01/2017 | Posted: 11/01/2017
Type of policy change: Medical Necessity Criteria; Medical Coding

05.00.44j, Repair and Replacement of Durable Medical Equipment (DME)
Effective: 11/01/2017 | Posted: 11/01/2017
Type of policy change: Medical Coding

08.00.82i, Ustekinumab (Stelara®)
Effective: 11/01/2017 | Posted: 11/01/2017
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.07e, Pertuzumab (Perjeta®)
Effective: 11/01/2017 | Posted: 11/01/2017
Type of policy change: Medical Necessity Criteria

11.09.02d, Treatment of Gender Dysphoria
Effective: 11/03/2017 | Posted: 11/03/2017
Type of policy change: Medical Necessity Criteria

07.03.05t, Sleep Disorder Testing and Positive Airway Pressure Therapy
Effective: 11/10/2017 | Posted: 11/10/2017
Type of policy change: Medical Necessity Criteria

08.00.85g, Tocilizumab (Actemra®) for Intravenous Infusion
Effective: 11/15/2017 | Posted: 11/15/2017
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.10w, Brachytherapy (Independence Administrators)
Effective: 11/17/2017 | Posted: 11/17/2017
Type of policy change: Medical Necessity Criteria

09.00.17n, Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
Effective: 11/17/2017 | Posted: 11/17/2017
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.02.11g, Transcatheter Closure of Cardiac Septal Defects
Effective: 11/17/2017 | Posted: 11/17/2017
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

11.15.01r, Spinal Cord and Dorsal Root Ganglion Stimulation
Notification: 08/23/2017 | Effective: 11/21/2017 | Posted: 11/21/2017
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
05.00.37f, Compression Garments
Reissue Effective: 11/08/2017 | Reissue Posted: 11/08/2017

09.00.02e, Electron Beam Computed Tomography (EBCT) for Screening Evaluations
Reissue Effective: 11/08/2017 | Reissue Posted: 11/08/2017

08.01.14d, Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
Reissue Effective: 11/08/2017 | Reissue Posted: 11/08/2017

07.02.21, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Reissue Effective: 11/08/2017 | Reissue Posted: 11/09/2017

05.00.14h, High-Frequency Chest Wall Oscillation Devices
Reissue Effective: 11/22/2017 | Reissue Posted: 11/22/2017

05.00.73c, Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
Reissue Effective: 11/22/2017 | Reissue Posted: 11/22/2017

08.01.32, Pegfilgrastim (Neulasta®)
Notification: 09/30/2016 | Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

08.00.94i, Denosumab (Prolia ®, Xgeva®)
Notification: 12/15/2016 | Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

11.14.07q, Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

08.00.64f, Natalizumab (Tysabri®)
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

11.02.12h, Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

08.00.18l, Nutritional Formulas, Enteral Nutrition, Medical Foods, and Low-Protein Modified Food Products
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.43b, Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.39b, Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.06o, Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.24j, Preimplantation Genetic Testing (Independence Administrators)
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

07.00.05f, In Vivo Allergy Sensitivity Testing
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

11.02.26a, Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.26b, In Vitro Allergy Testing
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.27j, Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
Reissue Effective: 11/27/2017 | Reissue Posted: 11/27/2017

06.02.29d, AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
Reissue Effective: 11/28/2017 | Reissue Posted: 11/28/2017

06.02.30e, Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
Reissue Effective: 11/28/2017 | Reissue Posted: 11/28/2017

11.06.06d, Magnetic Resonance Imaging (MRI)--Guided Focused Ultrasound Ablation
Reissue Effective: 11/28/2017 | Reissue Posted: 11/28/2017

06.02.35o, Genetic Testing (Independence Administrators)
Reissue Effective: 11/29/2017 | Reissue Posted: 11/29/2017

11.17.06l, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Reissue Effective: 11/29/2017 | Reissue Posted: 11/29/2017

12.04.02f, Nonemergency Ambulance Transport Services
Notification: 09/12/2012 | Reissue Effective: 11/29/2017 | Reissue Posted: 11/29/2017


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