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.
00.06.02ab, Preventive Care Services (Independence)
Notification: 12/02/2019 | Effective: 01/01/2020 | Posted: 12/02/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

06.02.52o, eviCore Lab Management Program (Independence)
Notification: 12/02/2019 | Effective: 01/01/2020 | Posted: 12/02/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

12.04.04a, Acute Care Facility Inpatient Transfers
Notification: 12/02/2019 | Effective: 12/30/2019 | Posted: 12/02/2019
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

08.00.91d, Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
Notification: 12/03/2019 (Revised 01/14/2020) | Effective: 03/02/2020 | Posted: 12/04/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

10.00.02c, Day Rehabilitation
Notification: 12/13/2019 | Effective: 01/13/2020 | Posted: 12/13/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

07.03.22d, Transcranial Magnetic Stimulation (TMS)
Notification: 12/17/2019 | Effective: 07/01/2019 | Posted: 12/17/2019
Type of policy change: Medical Necessity Criteria

07.03.26a, Tumor Treating Fields
Notification: 12/27/2019 | Effective: 01/27/2020 | Posted: 12/27/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

11.00.10w, Multiple Surgery Payment Reduction
Notification: 12/30/2019 | Effective: 03/30/2020 | Posted: 12/30/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

03.00.06r, Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
Notification: 12/31/2019 (Revised: 01/15/2020) | Effective: 04/15/2020 | Posted: 12/31/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding


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.
09.00.32u, Reimbursement for Radiopharmaceutical Agents for Professional Providers
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

08.00.67l, Cetuximab (Erbitux®)
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

11.17.06m, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Notification: 09/03/2019 | Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

08.01.29e, Daratumumab (Darzalex™)
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.33b, Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

09.00.48g, Radioembolization for Primary and Metastatic Tumors of the Liver (Independence Administrators)
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Coding

07.03.07s, Evaluation and Management of Autism Spectrum Disorder (ASD)
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.05.06g, Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
Effective: 12/02/2019 | Posted: 12/02/2019
Type of policy change: Medical Coding

11.14.21h, Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
Effective: 12/09/2019 | Posted: 12/09/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.43e, Chimeric Antigen Receptor (CAR) Therapy
Effective: 12/09/2019 | Posted: 12/09/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

00.05.01f, Guidelines for Home Care Visits Following Inpatient Maternity Stay
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

00.01.60d, Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

03.00.02b, Modifier 76: Repeat Procedure or Service by Same Physician or Qualified Health Professional
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Coverage and/or Reimbursement Position

00.01.18d, Reimbursement for Associated Services Performed in Conjunction with Dental Care
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Coding

03.00.12f, 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: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

03.00.08e, Modifiers XE, XS, XP, XU, and 59
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

03.00.11b, Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

08.01.18d, Vedolizumab (Entyvio®)
Effective: 12/16/2019 (Revised: 01/07/2020) | Posted: 12/16/2019
Type of policy change: Medical Necessity Criteria

03.00.31f, Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

05.00.15q, Nebulizers and Inhalation Solutions
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Coding

08.00.26v, Botulinum Toxin Agents
Notification: 09/18/2019 | Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.01.23f, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.87f, Pemetrexed (Alimta®)
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Necessity Criteria

08.01.35b, Asparaginase Erwinia Chrysanthemi (Erwinaze®)
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Necessity Criteria

07.05.07d, Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

03.00.15o, Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

03.00.28m, Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

03.00.16o, Modifier 57 Decision for Surgery
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: General Description, Guidelines, or Informational Update

00.10.17i, Modifier 66: Surgical Team
Effective: 12/16/2019 | Posted: 12/16/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

12.04.04a, Acute Care Facility Inpatient Transfers
Notification: 12/02/2019 | Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

11.02.10n, Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
Notification: 10/01/2019 | Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: General Description, Guidelines, or Informational Update

08.01.52b, Mogamulizumab-kpkc (Poteligeo®)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria

10.04.01l, Pulmonary Rehabilitation
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.01i, Ipilimumab (Yervoy®)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.13d, Brentuximab Vedotin (Adcetris®)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria

00.10.38a, Billing Requirements for Multiple Births for Professional Providers
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Coverage and/or Reimbursement Position; General Description, Guidelines, or Informational Update

08.01.25d, Ramucirumab (Cyramza®)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria

08.01.10e, Octreotide Acetate (Sandostatin® LAR Depot)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.01.40b, Lanreotide (Somatuline® Depot)
Effective: 12/30/2019 | Posted: 12/30/2019
Type of policy change: Medical Necessity Criteria

12.04.02i, Ground Ambulance Services (Emergency and Nonemergency) (Independence)
Notification: 10/03/2019 | Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

08.00.25l, Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
Notification: 10/03/2019 | Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

11.14.07u, Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Notification: 10/03/2019 | Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria

06.02.52o, eviCore Lab Management Program (Independence)
Notification: 12/02/2019 | Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

00.06.02ab, Preventive Care Services (Independence)
Notification: 12/02/2019 | Effective: 01/01/2020 (Revised: 01/22/2020) | Posted: 12/31/2019
Type of policy change: Medical Necessity Criteria; Medical Coding

00.01.52i, Always Bundled Procedure Codes
Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Medical Coding

10.06.01l, Speech Therapy
Effective: 01/01/2020 | Posted: 12/31/2019

07.02.21e, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Effective: 01/01/2020 | Posted: 12/31/2019
Type of policy change: Medical Coding


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
08.00.98e, Eribulin Mesylate (Halaven®)
Reissue Effective: 12/06/2019 | Reissue Posted: 12/06/2019

07.06.01b, Complete Decongestive Therapy (CDT)
Reissue Effective: 12/04/2019 | Reissue Posted: 12/06/2019

11.08.25m, Scar Revision
Reissue Effective: 12/04/2019 | Reissue Posted: 12/06/2019

08.01.00g, Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
Reissue Effective: 12/04/2019 | Reissue Posted: 12/06/2019

07.06.03b, Bioimpedance for the Detection of Lymphedema
Reissue Effective: 12/06/2019 | Reissue Posted: 12/06/2019

11.14.26a, Surgical Treatments of Athletic Pubalgia
Reissue Effective: 12/04/2019 | Reissue Posted: 12/06/2019

07.00.03n, Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

05.00.30m, Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

10.03.01j, Physical Medicine, Rehabilitation, and Habilitation Services
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

11.02.12i, Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

11.00.16g, Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

11.02.16r, Ventricular Assist Devices (VADs)
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

11.17.04s, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Reissue Effective: 12/18/2019 | Reissue Posted: 12/19/2019

11.02.19f, Total Artificial Hearts (TAHs)
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019

07.07.02j, Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Reissue Effective: 12/18/2019 | Reissue Posted: 12/19/2019

11.16.07b, Bronchial Thermoplasty
Reissue Effective: 12/18/2019 | Reissue Posted: 12/19/2019

02.01.02c, Private Duty Nursing
Reissue Effective: 12/18/2019 | Reissue Posted: 12/19/2019

11.02.17f, Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
Reissue Effective: 12/19/2019 | Reissue Posted: 12/19/2019


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.
05.00.76c, Breast Pumps
Effective: 01/01/2020 | Posted: 12/30/2019

05.00.67p, Wheelchair Options and Accessories
Effective: 01/01/2020 | Posted: 12/30/2019

05.00.05l, Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
Effective: 01/01/2020 | Posted: 12/30/2019

05.00.79b, Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
Effective: 01/01/2020 | Posted: 12/30/2019

11.15.09m, Denervation of the Spinal Nerves for Chronic Pain
Effective: 01/01/2020 | Posted: 12/30/2019

11.08.19o, Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
Effective: 01/01/2020 | Posted: 12/30/2019

10.03.01k, Physical Medicine, Rehabilitation, and Habilitation Services
Effective: 01/01/2020 | Posted: 12/30/2019

05.00.80a, Cranial Electrotherapy Stimulation
Effective: 01/01/2020 | Posted: 12/30/2019

08.00.75n, Erythropoiesis-Stimulating Agents (ESAs)
Effective: 01/01/2020 | Posted: 12/30/2019

11.17.06n, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Effective: 01/01/2020 | Posted: 12/30/2019

11.02.25g, Transcatheter Cardiac Valve Procedures
Effective: 01/01/2020 | Posted: 12/30/2019

11.16.06j, Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
Effective: 01/01/2020 | Posted: 12/30/2019

08.00.17h, Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
Effective: 01/01/2020 | Posted: 12/30/2019

11.15.23h, Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Effective: 01/01/2020 | Posted: 12/30/2019

07.08.03e, Medical and Surgical Treatment of Temporomandibular Joint Disorder
Effective: 01/01/2020 | Posted: 12/30/2019

07.00.01i, Biofeedback Therapy
Effective: 01/01/2020 | Posted: 12/30/2019

07.03.14o, Intraoperative Neurophysiological Monitoring (INM)
Effective: 01/01/2020 | Posted: 12/30/2019

08.01.59a, Polatuzumab Vedotin-Piiq (Polivy™)
Effective: 01/01/2020 | Posted: 12/30/2019

08.00.57n, Treatments for Complex Regional Pain Syndrome (CRPS)
Effective: 01/01/2020 | Posted: 12/30/2019

07.03.07t, Evaluation and Management of Autism Spectrum Disorder (ASD)
Effective: 01/01/2020 | Posted: 12/30/2019

11.14.02o, Trigger Point Injections
Effective: 01/01/2020 | Posted: 12/30/2019

00.10.41f, Telemedicine Services (Independence)
Effective: 01/01/2020 | Posted: 12/31/2019

11.09.02h, Treatment of Gender Dysphoria
Effective: 01/01/2020 | Posted: 12/31/2019

06.02.14i, In Vitro Chemosensitivity and Chemoresistance Assays
Effective: 01/01/2020 | Posted: 12/31/2019

06.02.35w, Genetic Testing (Independence Administrators)
Effective: 01/01/2020 | Posted: 12/31/2019

06.02.44l, Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
Effective: 01/01/2020 | Posted: 12/31/2019

06.02.17g, Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
Effective: 01/01/2020 | Posted: 12/31/2019

06.02.39d, Measurement of Serum Antibodies to and Measurement of Serum Levels of Biologics
Effective: 01/01/2020 | Posted: 12/31/2019


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following commercial policy to remain active.
08.00.97i, Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
Notification: 12/02/2019 | Archive Effective: 01/01/2020 | Posted: 12/02/2019

08.01.03c, Belatacept (Nulojix®)
Notification: 12/02/2019 | Archive Effective: 01/01/2020 | Posted: 12/02/2019

08.01.27d, Talimogene laherparepvec (Imlygic™)
Notification: 12/10/2019 | Archive Effective: 01/01/2020 | Posted: 12/10/2019

03.12.04c, Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
Notification: 12/13/2019 | Archive Effective: 01/13/2020 | Posted: 12/13/2019

03.02.13f, Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
Notification: 12/27/2019 | Archive Effective: 01/27/2020 | Posted: 12/27/2019

03.02.12c, Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
Notification: 12/27/2019 | Archive Effective: 03/30/2020 | Posted: 12/27/2019

07.07.07g, Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
Notification: 12/30/2019 | Archive Effective: 04/01/2020 | Posted: 12/30/2019


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