Commercial

Medical Policy

	MPDocType	Title	MPPolicyNumber	MPNotificationIssuedDate	MPEffectiveDate	MPReissuedDate	MPArchiveNotifEffDate	MPSALogCreatedOn	MPPolicyChangeTypeslt	MPRevisionDate	MPSiteActivityRemovedDate
	News & Announcements	Expanded Coverage of 20-Valent Pneumococcal Conjugate Vaccine for Independence Commercial Members (Retroactively Effective June 27, 2023)						10/10/2023
	News & Announcements	Coverage of the COVID-19 Vaccination for Independence Commercial Members (Updated on October 12, 2023. Retroactively Effective to October 3, 2023.)						10/12/2023
	News & Announcements	Coverage of Respiratory Syncytial Virus Immunizations for Independence Commercial Members (Updated October 18, 2023; Retroactively Effective October 6, 2023)						10/16/2023
	Notifications	Preventive Care Services	00.06.02ao	10/3/2023 10:00 AM	1/1/2024			10/3/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding
	Notifications	Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds	11.08.20ai	10/20/2023 2:00 PM	1/1/2024			10/20/2023	Medical Coding;General Description, Guidelines, or Informational Update
	Notifications	Wheelchair Options and Accessories	05.00.67s	10/21/2023 11:00 AM	11/20/2023			10/21/2023	Coverage and/or Reimbursement Position;Medical Coding
	Notifications	Negative Pressure Wound Therapy Systems	05.00.38m	10/24/2023 12:00 PM	1/22/2024			10/24/2023	Medical Necessity Criteria;General Description, Guidelines, or Informational Update
	New Policies	rozanolixizumab-noli (Rystiggo)	08.02.08		10/9/2023			10/9/2023	This is a New Policy.
	New Policies	Nadofaragene Firadenovec-vncg (Adstiladrin®)	08.02.11		9/11/2023			10/11/2023	This is a New Policy.
	New Policies	Glofitamab-gxbm (Columvi)	08.02.07		10/23/2023			10/23/2023	This is a New Policy.
	New Policies	Valoctocogene roxaparvovec-rvox (ROCTAVIAN™)	08.02.09		10/23/2023			10/23/2023	This is a New Policy.
	Updated Policies	Transcatheter Cardiac Valve Procedures	11.02.25h		10/1/2023			10/2/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
	Updated Policies	Radiation Therapy Services (Independence)	09.00.56q		10/1/2023			10/2/2023	Medical Necessity Criteria
	Updated Policies	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	03.00.06x	6/19/2023 2:00 PM	10/2/2023			10/2/2023	Coverage and/or Reimbursement Position;Medical Coding
	Updated Policies	Efgartigimod alfa - fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)	08.01.84b		10/9/2023			10/9/2023	Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
	Updated Policies	Lipectomy and Liposuction	11.08.03m		10/9/2023			10/9/2023	Medical Necessity Criteria;General Description, Guidelines, or Informational Update
	Updated Policies	Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars	08.00.74t		10/16/2023			10/16/2023	Medical Necessity Criteria
	Updated Policies	Mogamulizumab-kpkc (Poteligeo®)	08.01.52e		10/23/2023			10/23/2023	Medical Necessity Criteria;Medical Coding
	Updated Policies	Always Bundled Procedure Codes	00.01.52t		10/23/2023			10/23/2023	Coverage and/or Reimbursement Position
	Updated Policies	Chimeric Antigen Receptor (CAR) Therapy	08.01.43l		10/23/2023			10/23/2023	Medical Necessity Criteria
	Updated Policies	Loncastuximab tesirine-lpyl (Zynlonta®)	08.00.59c		10/23/2023			10/23/2023	Medical Necessity Criteria
	Updated Policies	Gonadotropin-Releasing Hormone Agonist (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)	08.01.33i		10/23/2023			10/23/2023	Medical Necessity Criteria;General Description, Guidelines, or Informational Update
	Updated Policies	Golimumab (Simponi Aria®) Intravenous (IV) Injection	08.01.15g	8/1/2023 10:00 AM	10/30/2023			10/30/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding
	Reissue Policies	In Vivo Allergy Sensitivity Testing	07.00.05i		12/5/2022	10/4/2023		10/4/2023
	Reissue Policies	Chiropractic Spinal and Extraspinal Manipulation Therapy	10.02.02j		5/18/2020	10/4/2023		10/4/2023
	Reissue Policies	Allergy Immunotherapy	07.00.21i		1/1/2021	10/4/2023		10/4/2023
	Reissue Policies	Ustekinumab (Stelara®)	08.00.82n		10/24/2022	10/4/2023		10/4/2023
	Reissue Policies	In Vitro Allergy Testing	06.02.26e		12/19/2022	10/4/2023		10/4/2023
	Reissue Policies	Compression Garments	05.00.37g		4/1/2023	10/4/2023		10/4/2023
	Reissue Policies	Bioimpedance for the Detection of Lymphedema	07.06.03b		12/29/2014	9/20/2023		10/6/2023			10/6/2023
	Reissue Policies	Etranacogene dezaparvovec-drlb (Hemgenix ®)	08.02.03		5/22/2023	10/4/2023		10/9/2023
	Reissue Policies	Bioimpedance for the Detection of Lymphedema	07.06.03b		12/29/2014	9/20/2023		10/9/2023
	Reissue Policies	Artificial Intervertebral Lumbar Disc Insertion	11.15.31b		1/1/2023	10/18/2023		10/18/2023
	Reissue Policies	Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome	11.06.07d		4/23/2018	10/18/2023		10/18/2023
	Reissue Policies	Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)	07.03.09u		10/1/2023	10/18/2023		10/18/2023
	Reissue Policies	Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy	09.00.10z		7/15/2019	10/18/2023		10/18/2023
	Reissue Policies	Electroconvulsive Therapy (ECT)	14.00.01a		10/1/2023	10/18/2023		10/18/2023
	Reissue Policies	Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies	07.03.18t		10/1/2023	10/18/2023		10/18/2023
	Coding Update	Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy	11.08.19q		10/1/2023			10/2/2023
	Coding Update	Prescription Digital Therapeutics and Mobile-Based Health Management Applications	12.00.05a		10/1/2023			10/2/2023
	Coding Update	Preventive Care Services	00.06.02an		10/1/2023			10/2/2023
	Coding Update	Modifier 62: Two Surgeons	00.10.11w		10/1/2023			10/4/2023
	Coding Update	Modifier 50: Bilateral Procedure	03.00.05v		10/1/2023			10/4/2023
	Coding Update	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	03.00.06y		10/1/2023			10/5/2023
	Coding Update	Mohs Micrographic Surgery	11.08.23k		10/1/2023			10/6/2023			10/6/2023
	Coding Update	Reimbursement for Associated Services Performed in Conjunction with Dental Care	00.01.18g		10/1/2023			10/6/2023
	Coding Update	Mohs Micrographic Surgery	11.08.23k		10/1/2023			10/9/2023
	Coding Update	Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane® for Injectable Suspension)	08.00.90o		7/1/2023			10/9/2023
	Coding Update	Pemetrexed (Alimta®), Pemetrexed (Pemfexy™)	08.00.87l		7/1/2023			10/9/2023
	Coding Update	Teclistamab-cqyv (Tecvayli™)	08.01.98b		7/1/2023			10/9/2023
	Coding Update	Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers	00.10.01aj		10/1/2023	10/1/2023		10/18/2023
	Coding Update	PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services	00.01.25bl		10/1/2023			10/20/2023
	Coding Update	Magnetic Resonance Imaging (MRI) Contrast Agents	09.00.45k		10/1/2023			10/24/2023
	Coding Update	Reimbursement for Radiopharmaceutical Agents for Professional Providers	09.00.32ad		10/1/2023			10/24/2023
	Coding Update	Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products	00.03.07al		10/1/2023	10/1/2023		10/27/2023