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.
08.01.25, Ramucirumab (Cyramza®)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/01/2015
Type of policy change: This is a new policy.

00.03.02u, Diagnostic Radiology Services Included in Capitation
Notification: 12/01/2015 | Effective: 03/01/2016 | Posted: 12/01/2015

00.10.41, Telemedicine for Primary Care Services
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/01/2015
Type of policy change: This is a new policy.

08.00.81d, Bendamustine Hydrochloride (Treanda®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.26, Pegademase bovine (Adagen®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/02/2015
Type of policy change: This is a new policy.

08.00.13q, Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
Notification: 12/02/2015 | Effective: 03/01/2016 | Posted: 12/02/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.57i, Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
Notification: 12/30/2015 | Effective: 03/29/2016 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.17f, Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
Notification: 12/30/2015 | Effective: 01/29/2016 | Posted: 12/30/2015

05.00.48i, Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Notification: 12/31/2015 | Effective: 04/01/2016 | Posted: 12/31/2015

00.01.49b, Reporting Requirements for Drugs and Biologics
Notification: 12/31/2015 | Effective: 03/01/2016 | Posted: 12/31/2015

00.06.02p, Preventive Care Services
Notification: 10/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; 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
07.02.21, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Notification: 09/09/2015 | Effective: 12/08/2015 | Posted: 12/08/2015
Type of policy change: This is a new policy.

00.10.41, Telemedicine for Primary Care Services
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

08.01.27, Talimogene laherparepvec (Imlygic™)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

08.01.23, Mepolizumab (Nucala®)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

08.01.25, Ramucirumab (Cyramza®)
Notification: 12/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

08.01.26, Pegademase bovine (Adagen®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

11.14.29, Spinal Discectomy
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

11.14.28, Spinal Laminectomy
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: This is a new policy.

11.14.27, Spinal Fusion
Notification: 10/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
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.
09.00.52d, Digital Breast Tomosynthesis (Independence)
Effective: 10/05/2015 | Posted: 12/01/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

05.00.30j, Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.90e, Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria

08.00.67i, Cetuximab (Erbitux®)
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

05.00.21o, Durable Medical Equipment (DME)
Effective: 12/02/2015 | Posted: 12/02/2015

11.14.09f, Osteochondral Autograft Transplantation (OAT) Procedure
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; Medical Coding

11.15.09g, Denervation of the Spinal Nerves for Chronic Pain
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

11.14.12d, Osteochondral Allograft Transplantation
Effective: 12/02/2015 | Posted: 12/02/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

06.02.04d, Fetal Fibronectin Enzyme (fFN) Immunoassay
Effective: 12/04/2015 | Posted: 12/04/2015
Type of policy change: General Description, Guidelines, or Informational Update

11.14.21f, Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
Notification: 11/04/2015 | Effective: 12/04/2015 | Posted: 12/04/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.24h, Preimplantation Genetic Testing
Effective: 12/04/2015 | Posted: 12/04/2015
Type of policy change: General Description, Guidelines, or Informational Update

11.08.17f, Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
Effective: 10/01/2015 | Posted: 12/11/2015
Type of policy change: Medical Coding

07.07.01j, Routine Foot Care For Certain Medical Conditions
Effective: 10/01/2015 | Posted: 12/11/2015
Type of policy change: Medical Coding

08.00.87c, Pemetrexed (Alimta®)
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.08.04h, Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

11.08.08g, Chemical Peels
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

11.08.25l, Scar Revision
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding

11.08.29d, Procedures for the Treatment of Acne
Effective: 12/16/2015 | Posted: 12/16/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

08.00.76f, Oxaliplatin (Eloxatin®)
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.31d, Low Osmolar Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

09.00.45g, Magnetic Resonance Imaging (MRI) Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015

09.00.13c, High Osmolar Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

09.00.11c, Echocardiography Contrast Agents
Effective: 12/30/2015 | Posted: 12/30/2015
Type of policy change: Coverage and/or Reimbursement Position

00.10.11h, Modifier 62: Two Surgeons
Effective: 01/01/2016 | Posted: 12/31/2015

00.10.17f, Modifier 66: Surgical Team
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.81d, Bendamustine Hydrochloride (Treanda®)
Notification: 12/02/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

12.01.01ae, Experimental/Investigational Services
Notification: 11/25/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position

11.05.11b, Implantation of Intrastromal Corneal Ring Segments (INTACS)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: General Description, Guidelines, or Informational Update

11.16.07a, Bronchial Thermoplasty
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

03.00.12e, Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
Effective: 01/01/2016 | Posted: 12/31/2015

09.00.56b, Radiation Therapy Services
Notification: 10/01/2015 | Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: General Description, Guidelines, or Informational Update

07.10.05f, Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.00.15l, Reimbursement for the Administration of Immunizations
Effective: 01/01/2016 | Posted: 12/31/2015

11.08.19k, Prophylactic Mastectomy
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

03.00.31e, Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.08g, Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

08.00.78r, Self-Administered Drugs
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

08.01.14d, Radium Ra 223 dichloride (Xofigo®) Injection
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: General Description, Guidelines, or Informational Update

08.00.98c, Eribulin Mesylate (Halaven®)
Effective: 12/30/2015 | Posted: 12/31/2015

09.00.17l, Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: General Description, Guidelines, or Informational Update

09.00.10t, Brachytherapy (Independence Administrators)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

09.00.49h, Proton Beam Radiation Therapy (Independence Administrators)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

09.00.48f, Radioembolization for Primary and Metastatic Tumors of the Liver (Independence Administrators)
Effective: 01/01/2016 | Posted: 12/31/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
08.00.34g, Infliximab (Remicade®)
Reissue Effective: 12/09/2015 | Reissue Posted: 12/09/2015

11.02.10j, Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
Reissue Effective: 12/09/2015 | Reissue Posted: 12/10/2015

11.08.03i, Lipectomy and Liposuction
Reissue Effective: 12/30/2015 | Reissue Posted: 12/30/2015


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.
09.00.32m, Diagnostic and Therapeutic Radiopharmaceutical Agents
Effective: 12/01/2015 | Posted: 12/01/2015

00.03.07m, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 01/01/2016 | Posted: 12/31/2015

07.13.12d, Instrument-Based Vision Screening
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.17e, Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.18b, Vedolizumab (Entyvio®)
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.04m, Immunizations
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.92n, Coagulation Factors for Hemophilia
Effective: 01/01/2016 | Posted: 12/31/2015

07.03.14j, Intraoperative Neurophysiological Monitoring (INM)
Effective: 01/01/2016 | Posted: 12/31/2015

05.00.67l, Wheelchair Options and Accessories
Effective: 01/01/2016 | Posted: 12/31/2015

11.05.17b, Implantable Miniature Telescope™ (IMT) for the Treatment of End-Stage, Age-Related Macular Degeneration (AMD)
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.21a, Blinatumomab (Blincyto™)
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.93d, C1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest®
Effective: 01/01/2016 | Posted: 12/31/2015

06.03.04k, Apheresis Therapy
Effective: 01/01/2016 | Posted: 12/31/2015

11.15.01p, Spinal Cord Stimulation (Dorsal Column Stimulation)
Effective: 01/01/2016 | Posted: 12/31/2015

11.14.07n, Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Effective: 01/01/2016 | Posted: 12/31/2015

07.13.07g, Corneal Pachymetry Using Ultrasound
Effective: 01/01/2016 | Posted: 12/31/2015

11.00.09e, Solid Organ Transplants
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.13p, Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
Effective: 01/01/2016 | Posted: 12/31/2015

11.15.23d, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Effective: 01/01/2016 | Posted: 12/31/2015

11.14.17d, Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
Effective: 01/01/2016 | Posted: 12/31/2015

05.00.45i, Repair or Replacement of an External Prosthetic Device
Effective: 01/01/2016 | Posted: 12/31/2015

11.07.01n, Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.75j, Erythropoiesis-Stimulating Agents (ESAs)
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.22b, Alemtuzumab (Lemtrada™)
Effective: 01/01/2016 | Posted: 12/31/2015

11.03.11m, Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.20c, Programmed Cell Death Receptor-1 (PD-1) Antagonists (e.g. Keytruda®, Opdivo®)
Effective: 01/01/2016 | Posted: 12/31/2015

11.17.04p, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Effective: 01/01/2016 | Posted: 12/31/2015

05.00.15o, Nebulizers
Effective: 01/01/2016 | Posted: 12/31/2015

08.00.97f, Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g. Istodax®, Beleodaq®)
Effective: 01/01/2016 | Posted: 12/31/2015

11.11.01h, Evaluation and Treatment of Erectile Dysfunction (ED)
Effective: 01/01/2016 | Posted: 12/31/2015

09.00.46q, High-Technology Radiology Services
Effective: 01/01/2016 | Posted: 12/31/2015

11.06.06c, Magnetic Resonance Imaging (MRI)--Guided Focused Ultrasound Ablation
Effective: 01/01/2016 | Posted: 12/31/2015

08.01.19b, Siltuximab (Sylvant™)
Effective: 01/01/2016 | Posted: 12/31/2015

11.14.10n, Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Effective: 01/01/2016 | Posted: 12/31/2015


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following commercial policy to remain active.
07.02.07g, Ambulatory, Real-Time Cardiac Surveillance System
Archive Effective: 12/08/2015 | Posted: 12/08/2015

07.02.12g, Cardiac Event Detection Monitoring (External Loop Monitoring)
Archive Effective: 12/08/2015 | Posted: 12/08/2015

07.02.03h, Implantable Cardiac Loop Monitor
Archive Effective: 12/08/2015 | Posted: 12/08/2015

11.14.20d, Hip Resurfacing
Notification: 12/30/2015 | Archive Effective: 01/29/2016 | Posted: 12/30/2015

11.14.25a, Total Ankle Arthroplasty/Replacement
Notification: 12/30/2015 | Archive Effective: 01/29/2016 | Posted: 12/30/2015

00.01.13d, Infusion Therapy Services as Performed by Home Infusion Providers
Notification: 12/31/2015 | Archive Effective: 03/01/2016 | Posted: 12/31/2015

03.00.07q, Modifier 51: Multiple Procedures
Notification: 12/31/2015 | Archive Effective: 02/01/2016 | Posted: 12/31/2015


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