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.
11.14.02n, Trigger Point Injections
Notification: 01/02/2019 | Effective: 04/01/2019 | Posted: 01/02/2019
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
12.04.04, Acute Care Facility Inpatient Transfers
Notification: 11/02/2018 | Effective: 01/01/2019 | Posted: 01/02/2019
Type of policy change: This is a new policy.

07.02.22, Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 01/14/2019
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.
12.04.02h, Ground Ambulance Transport Services (Emergency and Nonemergency)
Notification: 11/02/2018 | Effective: 01/01/2019 | Posted: 01/02/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

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

12.04.03c, Air Ambulance Services
Notification: 11/02/2018 | Effective: 01/01/2019 | Posted: 01/02/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.10y, Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
Effective: 01/01/2019 | Posted: 01/02/2019
Type of policy change: Medical Necessity Criteria

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: 10/02/2018 | Effective: 01/01/2019 | Posted: 01/02/2019
Type of policy change: Medical Coding

11.02.16r, Ventricular Assist Devices (VADs)
Effective: 01/07/2019 | Posted: 01/07/2019
Type of policy change: 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: 01/14/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

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

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

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

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

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

11.15.09l, Denervation of the Spinal Nerves for Chronic Pain
Notification: 10/16/2018 | Effective: 01/14/2019 | Posted: 01/14/2019
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: 01/14/2019
Type of policy change: General Description, Guidelines, or Informational Update

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

11.14.21g, Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
Effective: 01/14/2019 | Posted: 01/14/2019
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

07.03.23b, Autonomic Nervous System Testing
Effective: 01/14/2019 | Posted: 01/14/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.01.24g, Obsolete or Unreliable Diagnostic Tests and Medical Services
Effective: 01/14/2019 | Posted: 01/14/2019
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update


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.
07.02.21c, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Effective: 01/01/2019 | Posted: 01/02/2019

07.00.21h, Allergy Immunotherapy
Effective: 01/01/2019 | Posted: 01/02/2019

05.00.58l, Home Oxygen Therapy
Effective: 01/01/2019 | Posted: 01/02/2019

05.00.11i, Therapeutic Shoes and Orthopedic Shoes
Effective: 01/01/2019 | Posted: 01/02/2019

00.10.41d, Telemedicine for Primary Care Services (Independence)
Effective: 01/01/2019 | Posted: 01/02/2019

05.00.14j, High-Frequency Chest Wall Oscillation Devices
Effective: 01/01/2019 | Posted: 01/02/2019

07.03.07r, Evaluation and Management of Autism Spectrum Disorders (ASD)
Effective: 01/01/2019 | Posted: 01/02/2019

07.03.08i, Neuropsychological Testing for Neurologically Based Conditions
Effective: 01/01/2019 | Posted: 01/02/2019

08.00.50r, Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
Effective: 01/01/2019 | Posted: 01/02/2019

07.10.06f, Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
Effective: 01/01/2019 | Posted: 01/02/2019

08.00.66k, Bevacizumab (Avastin®) and related biosimilars
Effective: 01/01/2019 | Posted: 01/02/2019

08.00.34l, Infliximab and Related Biosimilars
Effective: 01/01/2019 | Posted: 01/02/2019

06.02.38d, Nerve Fiber Density Testing
Effective: 01/01/2019 | Posted: 01/02/2019

06.02.44h, Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
Effective: 01/01/2019 | Posted: 01/02/2019

08.01.39b, Cerliponase alfa (Brineura™)
Effective: 01/01/2019 | Posted: 01/02/2019

08.01.44c, Voretigene Neparvovec-rzyl (Luxturna™)
Effective: 01/01/2019 | Posted: 01/02/2019

06.02.56a, Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
Effective: 01/01/2019 | Posted: 01/02/2019

06.02.27l, Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
Effective: 01/01/2019 | Posted: 01/02/2019

08.01.42a, Edaravone (Radicava™)
Effective: 01/01/2019 | Posted: 01/02/2019

08.01.41b, Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
Effective: 01/01/2019 (Revised 01/09/2019) | Posted: 01/02/2019

08.01.43d, Chimeric Antigen Receptor (CAR) Therapy
Effective: 01/01/2019 | Posted: 01/02/2019

06.02.06p, Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
Effective: 01/01/2019 | Posted: 01/02/2019

08.01.50a, Patisiran (Onpattro™)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.46a, ibalizumab-uiyk (Trogarzo™)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.47a, Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
Effective: 01/01/2019 | Posted: 01/03/2019

08.00.70d, Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, Mepsevii™, etc.)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.23e, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.04t, Immunizations
Effective: 01/01/2019 | Posted: 01/03/2019

09.00.17o, Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.49a, Burosumab-twza (Crysvita®)
Effective: 01/01/2019 | Posted: 01/03/2019

08.01.20j, 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: 01/01/2019 | Posted: 01/03/2019

08.00.73k, Bortezomib (Bortezomib for Injection, Velcade®)
Effective: 01/01/2019 | Posted: 01/03/2019

09.00.56g, Radiation Therapy Services (Independence)
Effective: 01/01/2019 | Posted: 01/03/2019

11.02.19f, Total Artificial Hearts (TAHs)
Effective: 01/01/2019 | Posted: 01/03/2019

11.00.06i, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults
Effective: 01/01/2019 | Posted: 01/03/2019

11.03.12q, Colorectal Cancer Screening
Effective: 01/01/2019 | Posted: 01/03/2019

11.02.01q, Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
Effective: 01/01/2019 | Posted: 01/03/2019

11.15.20o, Deep Brain Stimulation (DBS)
Effective: 01/01/2019 | Posted: 01/03/2019

11.16.08b, Implantable Steroid-Eluting Sinus Stents
Effective: 01/01/2019 | Posted: 01/03/2019

11.14.07t, Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Effective: 01/01/2019 | Posted: 01/03/2019

11.09.02f, Treatment of Gender Dysphoria
Effective: 01/01/2019 | Posted: 01/03/2019

11.07.02i, Sentinel Lymph Node Biopsy
Effective: 01/01/2019 | Posted: 01/03/2019

00.10.39j, Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
Effective: 01/01/2019 | Posted: 01/03/2019

00.10.36p, Radiologic Guidance of a Procedure
Effective: 01/01/2019 | Posted: 01/03/2019

03.02.13f, Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
Effective: 01/01/2019 | Posted: 01/03/2019

00.01.60c, Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
Effective: 01/01/2019 | Posted: 01/03/2019

11.17.04s, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Effective: 01/01/2019 | Posted: 01/03/2019

05.00.48j, Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Effective: 01/01/2019 | Posted: 01/04/2019

00.01.59e, Care Management and Care Planning Services
Effective: 01/01/2019 | Posted: 01/04/2019

11.08.20s, Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
Effective: 01/01/2019 | Posted: 01/04/2019

06.02.35t, Genetic Testing (Independence Administrators)
Effective: 01/01/2019 | Posted: 01/04/2019

09.00.46v, High-Technology Radiology Services (Independence)
Effective: 01/01/2019 | Posted: 01/07/2019

05.00.21t, Durable Medical Equipment (DME) and Consumable Medical Supplies
Effective: 01/01/2019 | Posted: 01/10/2019

11.00.11k, Use of an Operating Microscope During a Surgical Procedure
Effective: 01/01/2019 | Posted: 01/11/2019

00.03.02y, Diagnostic Radiology Services Included in Capitation
Effective: 01/01/2019 | Posted: 01/14/2019

00.01.52g, Always Bundled Procedure Codes
Effective: 01/01/2019 | Posted: 01/16/2019


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following commercial policy to remain active.
00.10.32e, Prolonged Face-to-Face Physician Services
Notification: 01/02/2019 | Archive Effective: 02/04/2019 | Posted: 01/02/2019


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