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.
05.00.47l, Knee Braces
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/01/2015

08.00.85e, Tocilizumab (Actemra®) for Intravenous Infusion
Notification: 07/01/2015 | Effective: 10/01/2015 (was 09/29/2015) | Posted: 07/01/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

12.01.01ad, Experimental/Investigational Services
Notification: 07/01/2015 (revised 9/17/2015) | Effective: 10/01/2015 | Posted: 07/01/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

06.02.47, Noninvasive Prenatal Testing for Fetal Aneuploidies Using Cell-Free Fetal DNA
Notification: 6/15/2015; Removed from Notification on 7/10/2015 | Effective: | Posted: 07/10/2015
Type of policy change: This is a new policy.

05.00.50k, Ostomy Supplies
Notification: 07/15/2015 | Effective: 08/14/2015 | Posted: 07/15/2015
Type of policy change: Medical Coding

05.00.73c, Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
Notification: 07/15/2015 | Effective: 08/14/2015 | Posted: 07/15/2015
Type of policy change: Medical Coding

08.01.22, Alemtuzumab (Lemtrada™)
Notification: 07/29/2015, revised 08/12/2015 | Effective: 08/28/2015 | Posted: 07/29/2015
Type of policy change: This is a new policy.

08.01.24, Deoxycholic Acid (Kybella™)
Notification: 07/29/2015 | Effective: 08/28/2015 | Posted: 07/29/2015
Type of policy change: This is a new policy.


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
08.01.21, Blinatumomab (Blincyto™)
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015
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.
07.00.10h, Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin®)
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Medical Coding; General Description, Guidelines, or Informational Update

11.11.01g, Evaluation and Treatment of Erectile Dysfunction (ED)
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Medical Necessity Criteria

08.01.12b, Repository Corticotropin (H.P. Acthar® Gel Injection)
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

06.03.05e, Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: General Description, Guidelines, or Informational Update

03.00.08d, Modifiers XE, XS, XP, XU, 59
Effective: 07/01/2015 | Posted: 07/01/2015

11.17.04o, Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Medical Necessity Criteria

08.00.94g, Denosumab (Prolia ®, Xgeva®)
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

07.00.02h, Intravenous Chelation Therapy
Effective: 07/01/2015 | Posted: 07/01/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Necessity Criteria; General Description, Guidelines, or Informational Update

05.00.56g, Hospital Beds and Accessories
Notification: 06/03/2015 | Effective: 07/03/2015 | Posted: 07/02/2015

00.05.01d, Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program
Effective: 07/15/2015 | Posted: 07/15/2015
Type of policy change: General Description, Guidelines, or Informational Update

08.00.95d, Personalized Vaccines (e.g. Provenge®)
Effective: 07/15/2015 | Posted: 07/15/2015
Type of policy change: Medical Necessity Criteria; General Description, Guidelines, or Informational Update

08.00.74h, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (eg, ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®])
Notification: 06/15/2015 | Effective: 07/15/2015 | Posted: 07/15/2015

06.02.27g, Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis
Notification: 06/15/2015 | Effective: 07/15/2015 | Posted: 07/15/2015

08.00.78q, Self-Administered Drugs
Effective: 07/15/2015 | Posted: 07/15/2015
Type of policy change: Coverage and/or Reimbursement Position; Medical Coding

11.00.06f, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults
Notification: 04/23/2015 | Effective: 07/22/2015 | Posted: 07/22/2015

06.02.18i, Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.09f, Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.17d, Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.29a, AlloMap™ Molecular Expression Testing for Heart Transplant Rejection
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.36a, PathFinderTG®
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

06.02.31d, Genetic Testing for Congenital Long QT Syndrome
Effective: 07/29/2015 | Posted: 07/29/2015
Type of policy change: General Description, Guidelines, or Informational Update

05.00.47l, Knee Braces
Notification: 07/01/2015 | Effective: 07/31/2015 | Posted: 07/31/2015


Reissue Policies
The following commercial policies have been reviewed, and no substantive changes were made.
06.02.38a, Nerve Fiber Density Testing
Reissue Effective: 06/24/2015 | Reissue Posted: 07/06/2015

06.02.43, Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
Reissue Effective: 06/24/2015 | Reissue Posted: 07/06/2015

07.00.21f, Allergy Immunotherapy
Reissue Effective: 06/24/15 | Reissue Posted: 07/06/2015

06.02.39a, Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
Reissue Effective: 06/24/2015 | Reissue Posted: 07/06/2015

05.00.75, Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Reissue Effective: 6/24/2015 | Reissue Posted: 07/06/2015

11.08.02f, Reduction Mammoplasty
Reissue Effective: 07/08/2015 | Reissue Posted: 07/08/2015

11.08.12g, Surgery for Gynecomastia
Reissue Effective: 07/08/2014 | Reissue Posted: 07/08/2015

08.00.15c, Off-label Coverage for Prescription Drugs and Biologics
Reissue Effective: 07/22/2015 | Reissue Posted: 07/22/2015


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.
00.01.25aa, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Effective: 07/01/2015 | Posted: 07/02/2015

00.03.07l, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Effective: 07/01/2015 | Posted: 07/02/2015

00.03.02t, Diagnostic Radiology Services Included in Capitation
Effective: 07/01/2015 | Posted: 07/02/2015

08.01.20b, Programmed Cell Death Receptor-1 (PD-1) Antagonists (e.g. Keytruda®, Opdivo®)
Effective: 07/01/2015 | Posted: 07/06/2015

09.00.46p, High-Technology Radiology Services
Effective: 07/01/2015 | Posted: 07/06/2015

08.01.19a, Siltuximab (Sylvant™)
Effective: 07/01/2015 | Posted: 07/06/2015

11.00.10s, Multiple Surgical Reduction Guidelines
Effective: 07/01/2015 | Posted: 07/06/2015

11.07.01m, Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
Effective: 07/01/2015 | Posted: 07/06/2015

11.08.20n, Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
Effective: 07/01/2015 | Posted: 07/06/2015

00.06.02o, Preventive Care Services
Effective: 07/01/2015 | Posted: 07/06/2015

08.01.04k, Preventive Immunization
Effective: 07/01/2015 | Posted: 07/07/2015


Archived Policies
Independence Blue Cross has determined that it is no longer necessary for the following commercial policy to remain active.
00.01.51, Reporting of Healthcare Common Procedure Coding System (HCPCS) C Series Codes
Notification: 6/12/2015 | Archive Effective: 07/15/2015 | Posted: 07/15/2015

08.00.58c, Risperidone (Risperdal® Consta®) Injection
Notification: 6/17/2015 | Archive Effective: 07/17/2015 | Posted: 07/17/2015

03.00.10l, Modifiers LT/RT: Left Side/Right Side Procedures
Notification: 07/28/2015 | Archive Effective: 08/28/2015 | Posted: 07/28/2015


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