Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy

Policy #:11.05.02i

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract

Blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthopexy are considered medically necessary and, therefore, covered when performed as functional or reconstructive surgeries in certain clinical situations. However, blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthopexy performed solely to change the appearance of any portion of the face, without improving the physiologic functioning of that portion of the body, is considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

BLEPHAROPLASTY

UPPER EYELID BLEPHAROPLASTY
Upper eyelid blepharoplasty is considered medically necessary and, therefore, covered when performed to correct the following:
  • Prosthetic difficulties in an anophthalmic (without an eye) socket
  • Disorders of visual impairment caused by redundant skin of the eyelid resting on or over upper eyelashes or redundant skin of the eyebrow include, but are not limited to, the following:
    • Visual impairment due to dermatochalasis, blepharochalasis, or ptosis of the eyelid
    • Symptomatic, redundant skin that is resting on or over the upper eyelashes
    • Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin

Upper Eyelid Blepharoplasty Performed to Correct Visual Impairment

When upper eyelid blepharoplasty is performed to correct visual impairment and has met all of the medical necessity criteria outlined above, blepharoplasty performed to correct visual impairment is considered medically necessary and, therefore, covered when ALL of the following additional criteria are met:
  • Preoperative, dated, color photographs that include frontal and lateral views of the individual (in forward gaze, looking up, and looking down) and that demonstrate one or more of the following:
    • The upper eyelid margin is within 2 mm (one-fourth of the diameter of the visible iris) of the corneal light reflex (margin-to-reflex distance [MRD] less than 2 mm) with the individual in forward gaze.
    • The upper eyelid skin rests on or over the upper eyelashes.
    • The upper eyelid indicates the presence of dermatitis.
    • The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket.
    • The brow position is below the superior orbital rim.
  • A written interpretation of the results of both the taped and untaped Automated Visual Field studies must be submitted and must demonstrate one of the following:
    • The upper visual field has improved by at least eight degrees or 20 percent with the eyelid taped up as compared with the visual field obtained without taping (two sets of visual fields are required).
    • Visual field obstruction by the eyelid limits the upper visual field to within 30 degrees of fixation.
  • Congruity is demonstrated between Automated Visual Field studies and photographs presented.

The individual's medical record must include the following documentation to support the request for upper eyelid blepharoplasty:
  • Assessment and documentation of a visual impairment (except in an anaphthalmic socket) must have been performed within a 12-month period of the request for surgery by a licensed, board-certified, eye care professional provider other than the operating surgeon. However, if the operating surgeon is an eye care professional provider, then such documentation may be provided by the operating surgeon.

If both a upper eyelid blepharoplasty and a brow ptosis repair are planned, the need for both must be documented. This requires photographs showing the effect of the drooping, redundant skin, the skin resting on or over the upper eyelashes, the presence of dermatitis, or the actual presence of blepharoptosis. 

LOWER EYELID BLEPHAROPLASTY
Lower eyelid blepharoplasty, which may include canthoplasty/canthopexy, is generally not medically indicated to treat conditions that cause visual field obstruction because the lower eyelids are not usually associated with visual impairment. In the absence of visual impairment, lower eyelid blepharoplasty, which may include canthoplasty/canthopexy, is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Requests for lower eyelid blepharoplasty, which may include canthoplasty/canthoplexy, are considered on an individual basis when documentation (including the individual's chief complaint and preoperative photographs) demonstrates that the procedure is medically necessary for reconstructive reasons.

REPAIR OF BLEPHAROPTOSIS

The repair of blepharoptosis performed as functional/reconstructive surgery to correct visual impairment due to laxity of the muscles causing drooping or displacement of the upper eyelid is considered medically necessary and, therefore, covered when ALL of the following additional criteria are met:
  • Preoperative, dated, color photographs that include frontal and lateral views of the individual (in forward gaze, looking up, and looking down) and that demonstrate one or more of the following:
    • The upper eyelid margin is within 2 mm (one-fourth of the diameter of the visible iris) of the corneal light reflex (margin-to-reflex distance [MRD] less than 2 mm) with the individual in forward gaze.
    • The upper eyelid skin rests on or over the upper eyelashes.
    • The upper eyelid indicates the presence of dermatitis.
    • The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket.
    • The brow position is below the superior orbital rim.
  • A written interpretation of the results of both the taped and untaped Automated Visual Field studies must be submitted and must demonstrate one of the following:
    • The upper visual field has improved by at least eight degrees or 20 percent with the eyelid taped up as compared with the visual field obtained without taping (two sets of visual fields are required).
    • Visual field obstruction by the eyelid limits the upper visual field to within 30 degrees of fixation.
  • Congruity is demonstrated between Automated Visual Field studies and photographs presented.

The individual's medical record must include the following documentation to support the request for repair of blepharoptosis:
  • Assessment and documentation of a visual impairment must have been performed within a 12-month period of the request for surgery by a licensed, board certified, eye care professional provider other than the operating surgeon. However, if the operating surgeon is an eye care professional provider, then such documentation may be provided by the operating surgeon.

REPAIR OF BROW PTOSIS

The repair of brow ptosis is considered medically necessary and, therefore, covered when performed as functional/reconstructive surgery to correct either of the following:
  • Visual impairment due to droop or displacement of the eyebrow below the superior orbital rim
  • Brow malposition that would prevent adequate correction of dermatochalasis, blepharochalasis, or blepharoptosis

REPAIR OF BROW PTOSIS PERFORMED TO CORRECT VISUAL IMPAIRMENT
When repair of brow ptosis is performed to correct visual impairment and has met all of the medical necessity criteria outlined above, repair of brow ptosis performed to correct visual impairment is considered medically necessary and, therefore, covered when ALL of the following additional criteria are met:
  • Preoperative, dated, color photographs that include frontal and lateral views of the individual (in forward gaze, looking up, and looking down) and that demonstrate one or more of the following:
    • The upper eyelid margin is within 2 mm (one-fourth of the diameter of the visible iris) of the corneal light reflex (margin-to-reflex distance [MRD] less than 2 mm) with the individual in forward gaze.
    • The upper eyelid skin rests on or over the upper eyelashes.
    • The upper eyelid indicates the presence of dermatitis.
    • The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket.
    • The brow position is below the superior orbital rim.
  • A written interpretation of the results of both the taped and untaped Automated Visual Field studies must be submitted and must demonstrate one of the following:
    • The upper visual field has improved by at least eight degrees or 20 percent with the eyelid taped up as compared with the visual field obtained without taping (two sets of visual fields are required).
    • Visual field obstruction by the eyelid limits the upper visual field to within 30 degrees of fixation.
  • Congruity is demonstrated between Automated Visual Field studies and photographs presented.

The individual's medical record must include the following documentation to support the request for repair of brow ptosis :
  • Assessment and documentation of a visual impairment must have been performed within a 12-month period of the request for surgery by a licensed, board certified, eye care professional provider other than the operating surgeon. However, if the operating surgeon is an eye care professional provider, then such documentation may be provided by the operating surgeon.

If both upper eyelid blepharoplasty and a brow ptosis repair are planned, the need for both must be documented. This requires photographs showing the effect of the drooping, redundant skin, the skin resting on or over the upper eyelashes, the presence of dermatitis, or the actual presence of blepharoptosis. 

BILLING AND CODING

Excess upper eyelid skin, upper eyelid ptosis, can be present alone or in any combination, and each presentation may require correction. When performed on the same eye and during the same patient encounter, blepharoplasty of the upper eyelid is a component of primary repair of blepharoptosis. Therefore, when upper eyelid blepharoplasty (15822, 15823) is billed in conjunction with primary repair of blepharoptosis (67901- 67908), upper eyelid blepharoplasty is not eligible for separate reimbursement.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

CANTHOPLASTY/CANTHOPEXY

Canthoplasty/canthopexy is considered medically necessary and, therefore, covered when performed to correct the following conditions confirmed by slit lamp corneal exam:
  • Pathologic entropion/ectropion resulting in conditions that include but are not limited to the following:
    • Epiphora
    • Desiccation of the corneal epithelium
    • Corneal ulceration

PHOTOGRAPHY SERVICES
  • The following Current Procedural Terminology (CPT) code is neither intended, nor reimbursable, for the photographic documentation of blepharoplasty, repair of blepharoptosisrepair of brow ptosis, or canthoplasty/canthoplexy procedures:
    • 92285: External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography)
  • Similarly, the photographs taken in order to document the need for blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthoplexy are considered integral to the evaluation and management (E&M) service. Therefore, payment for the photography services is included in the reimbursement for E&M services. For additional information, refer to the Cross References section in this policy.

COSMETIC SERVICES

Requests for blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthoplexy that do not meet medical necessity criteria as outlined above are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. 

All requests for blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthopexy, require review by the Company and must include documentation that describes the individual's chief complaints and justifies the need for surgery to correct the functional impairment.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthopexy are covered under the medical benefits of the Company's products when medical necessity criteria in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

BLEPHAROPLASTY

Blepharoplasty is a surgical procedure in which redundant skin of the upper and/or lower eyelids and protruding periorbital fat are removed. This procedure can be performed for either cosmetic or reconstructive purposes.

REPAIR OF BLEPHAROPTOSIS

Blepharoptosis (upper eyelid ptosis) is the drooping of the upper eyelid due to underlying eye muscle dysfunction (e.g., levator muscle or Muller's muscle). Surgical repair of blepharoptosis, including repair of the eye muscle, is sometimes performed in conjunction with blepharoplasty.

REPAIR OF BROW PTOSIS

Blepharoplasty can be performed alone or in conjunction with other procedures, such as a brow lift. A brow lift for brow ptosis (drooping of the eyebrow) restores the proper anatomical and functional position of the brow and/or alleviates complaints of ocular fatigue secondary to continuous action of the frontalis muscle. A brow lift may be indicated at the time of blepharoplasty in order to correct a functional impairment.

CONDITIONS THAT MAY REQUIRE BLEPHAROPLASTY, REPAIR OF BLEPHAROPTOSIS, AND REPAIR OF BROW PTOSIS

A deficit in the upper or peripheral field of vision can be identified by photographing an individual in a forward-gazing position and noting whether excessive skin rests on or over the upper eyelashes. The following are examples of conditions that may contribute to such a deficit and lead to a visual impairment for which corrective surgery is indicated:
  • Dermatochalasis: Excessive skin around the eye with loss of elasticity, usually the result of the aging process.
  • Blepharochalasis: Excessive skin around the eye, usually associated with the disease process of chronic blepharedema, which physically stretches and thins the skin.
  • Blepharoptosis (upper eyelid ptosis): Drooping of the upper eyelid that relates to the position of the eyelid margin in forward gaze with respect to the eyeball and visual axis. This measured distance noted on a forward gaze from the upper lid margin to the midpoint of the pupil is called the margin-to-reflex distance (MRD).
  • Pseudoptosis (false ptosis): Pseudoptosis generally refers to a change in the position of the globe, causing the appearance of ptosis. Upward deviation of the affected eye and retraction of the upper lid of the contralateral eye are examples of pseudoptosis.
  • Brow ptosis: Drooping of the eyebrow that relates to the position of the brow relative to the superior orbital rim.
  • Congenital ptosis: Drooping of the upper eyelid that is usually present at birth but may occur within the first year of life. Congenital ptosis may affect one or both eyes and create varying degrees of impairment. It can be mild (the drooping eyelid partially covers the pupil) or severe (the eyelid completely covers the pupil).
  • Traumatic ptosis: Ptosis caused by injury to the levator aponeurosis.
  • Other ptosis of the eyelid: Etiology can be traced to idiopathic, neurogenic, or mechanical causes.
  • Status post-periorbital tumor resection: When a functional impairment exists after tumor resection of any eye related structure.

CANTHOPLASTY, CANTHOPEXY

Canthoplasty is a procedure designed to reinforce lower eyelid support by detaching the lateral canthal tendon from the orbital bone and constructing a replacement. Canthopexy is a procedure designed to stabilize or tighten the existing tendon and surrounding structures without removing the tendon from its normal attachment.

Canthoplasty and canthopexy are appropriate treatments in conditions such as post-traumatic ectropion that can cause the lower lid to pull away from the cornea. Conditions such as post-traumatic ectropion where the lid margin has an outward turning away from the globe may lead to epiphora (excessive tearing), corneal desiccation (state of extreme dryness), and/or ulceration. In recent years, canthoplasty and canthopexy are performed in conjunction with lower lid blepharoplasty. There reportedly is the potential risk of inducing lower eyelid malposition if support is not applied through either canthoplasty or canthopexy.

COSMETIC AND RECONSTRUCTIVE SERVICES

Cosmetic services are services provided to improve an individual’s physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function. When performed for cosmetic reasons, blepharoplasty reshapes eye related structures in order to improve appearance and self-esteem.

Reconstructive services are defined as any medical or surgical service designed to restore bodily function or to correct a deformity that has resulted from trauma, the treatment of disease, or a congenital defect. When provided as part of a reconstructive procedure, blepharoplasty, repair of blepharoptosis, repair of brow ptosis, and canthoplasty/canthopexy usually involves the excision of skin, repair of the underlying eye muscle, and/or stabilization of tendons in order to improve the physiologic functioning of that portion of the eyelid.
References


American Academy of Ophthalmology (AAO). Interventions for Involutional Lower Eyelid Entropion - PPP Clinical Question. [AAO Web site]. 06/20/2014. Available at:
https://www.aao.org/clinical-questions/interventions-involutional-lower-eyelid-entropion-. Accessed October 22, 2018.

American Academy of Ophthalmology (AAO). Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery Ophthalmic Technology Assessment. December 2011. [AAO Web site]. Available at:https://www.aao.org/ophthalmic-technology-assessment/functional-indications-upper-eyelid-ptosis-blephar. Accessed October 22, 2018.

American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Patient information. Eyelid surgery. [ASOPRS Web site]. 2015. Available at: http://www.asoprs.org/i4a/pages/index.cfm?pageid=3654. Accessed October 22, 2018.

American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology. 1995;102:693-695.

American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. [ASPS Web site]. March 2007. Available at:
http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/ASPS-Recommended-Insurance-Coverage-Criteria-for-Blepharoplasty.pdf. Accessed October 22, 2018.

American Society of Plastic Surgeons (ASPS). Practice parameter for blepharoplasty. [ASPS Web site]. March 2007. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Blepharoplasty-Practice-Parameter.pdf. Accessed October 22, 2018.

Buchanan ED, Hollier LH. Syndromes with craniofacial abnormalities. [UpToDate Web site]. 05/01/2018. Available at:
http://www.uptodate.com/online/content/topic.do?topicKey=dis_chld/2240&view=print [via subscription only]. Accessed October 22, 2018.

Cahill KV, Burns JA, Weber PA. The effect of blepharoptosis on the field of vision. Ophthal Plas Reconstr Surg.1987;3(3):121-5.

Coban YK. Surgical treatment of posttraumatic enophthalmos with diced medpor implants through mini-lateral canthoplasty incision. J Craniofac Surg.2008;19(2): 539-41.

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative Edits. April 2012. [CMS web site]. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Edits-April-2012-Release.html. Accessed October 22, 2018.

Edmonson B, Wulc A. Ptosis evaluation and management. Otolaryngol Clin North Am.2005;38(5):921-946.

Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999;106(9):1705-12.

Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3):193-204.

Fritsch MH. Incisionless tarsal-strip, canthoplasty, and oral commissureplasty procedures for correction of facial nerve paralysis. Facial Plast Surg.2008; 24(1):43-9.

Gaus Aas RE. Advances in applied anatomy of the eyelid and orbit. Curr Opin Ophthalmol. 2004;15(5):422-5.

Holt JE, Holt GR. Blepharoplasty. Indications and preoperative assessment. Arch Otolaryngol. 1985;111(6):394-7.

Joshi AS, Janjanin S, Tanna N, et al. Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties. Laryngoscope. 2007;117(6):981-4. [Published correction appears in Laryngoscope. 2007;117(8):1510].

Meyer DR. Functional eyelid surgery. Ophthal Plast Reconstr Surg. 1997;13(2):77-80.

Meyer DR, Stern JH, Jarvis JM, et al. Evaluating the visual field effects of blepharoptosis using automated static perimetry. Ophthalmology. 1993;100(5):651-8.

Mühlbauer W, Holm C. Orbital septorhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg. 2000;24(6):418-23.

Novitas Solutions, Inc. Local Coverage Determination(LCD). L35004: Surgery: Blepharoplasty. [Novitas Solutions, Inc. Web site]. 10/01/2018. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35004&ver=10&Keyword=blepharoplasty&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACABAAAA&. Accessed October 22, 2018.

Rapp SJ. Lower lid subciliary blepharoplasty. [Medscape Web site]. 06/18/2017. Available at: http://emedicine.medscape.com/article/1281677-overview. Accessed October 22, 2018.

Riemann CD, Hanson S, Foster JA. A comparison of manual kinetic and automated static perimetry in obtaining ptosis fields. Arch Ophthalmol. 2000;118(1):65-9.

Yanoff M, Duker JS. Orbit and occuloplastics. In: Dutton JT, ed. Ophthalmology. 3rd ed. St. Louis, MO: Elsevier, Health Sciences Division; 2008: 1379-1506.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

15820. 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950


THE FOLLOWING CODE IS NOT SEPARATELY REIMBURSABLE WHEN BILLED WITH AN EVALUATION AND MANAGEMENT SERVICE
92285



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
Description: ICD-10 Codes




Policy History

Revisions from 11.05.02i:
12/05/2018This policy has been reviewed and reissued to communicate the Company's continuing position on Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: H02.151, H02.152, H02. 153, H02.154, H02.155, H02.156, H02.159.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 12/05/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.