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News & AnnouncementsCoverage of the COVID-19 Vaccination for Independence Commercial Members (Updated November 3, 2021)11/3/2021
NotificationsModifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS00.10.18r11/5/2021 2:00 PM2/14/202211/5/2021Coverage and/or Reimbursement Position
NotificationsPegfilgrastim (Neulasta®) and related biosimilars08.01.32f11/9/2021 11:00 AM2/7/202211/9/2021Coverage and/or Reimbursement Position;Medical Necessity Criteria;General Description, Guidelines, or Informational Update
NotificationsNutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk08.00.18o11/19/2021 8:00 AM12/20/202111/19/2021Coverage and/or Reimbursement Position;Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated PoliciesHigh-Technology Radiology Services09.00.46ah11/7/202111/8/2021Medical Necessity Criteria
Updated PoliciesUse of a Robotic-Assisted Surgical System11.00.18b11/8/202111/8/2021Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesNutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk08.00.18n10/1/202111/19/2021Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesTotal Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)08.00.17i11/22/202111/22/2021Medical Necessity Criteria
Updated PoliciesTreatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents08.00.25m8/18/2021 1:00 PM11/22/202111/22/2021Medical Necessity Criteria
Updated PoliciesFilgrastim  (Neupogen ®) and Related Biosimilars, and tbo-filgrastim (Granix ®)08.01.73a11/22/202111/22/2021Medical Necessity Criteria
Reissue PoliciesApplication and Removal of Tattoos11.08.05g7/20/201210/20/202111/2/2021
Reissue PoliciesDeep Brain Stimulation (DBS)11.15.20p1/25/202111/3/202111/3/2021
Reissue PoliciesIslet Cell Transplantation11.04.01d1/1/202011/3/202111/3/2021
Reissue PoliciesElectromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter07.03.21l10/1/201911/3/202111/3/2021
Reissue PoliciesPhotocoagulation of Macular Drusen11.05.08d6/14/201711/3/202111/3/2021
Reissue PoliciesAutologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators)11.14.06j1/10/202111/3/202111/3/2021
Reissue PoliciesOsteochondral Allograft Transplantation (Independence Administrators)11.14.12f1/10/202111/3/202111/3/2021
Reissue PoliciesSpinal Discectomy (Independence Administrators)11.14.29h7/1/202111/3/202111/3/2021
Reissue PoliciesTranscatheter Closure of Cardiac Septal Defects11.02.11g11/17/201711/3/202111/3/2021
Reissue PoliciesEndovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions11.02.17f3/26/201811/3/202111/3/2021
Reissue PoliciesPrivate Duty Nursing02.01.02d1/18/202111/3/202111/3/2021
Reissue PoliciesSpinal Fusion (Independence Administrators)11.14.27e1/10/202111/3/202111/3/2021
Reissue PoliciesSpinal Laminectomy (Independence Administrators)11.14.28d1/10/202111/3/202111/3/2021
Reissue PoliciesSurgical Treatment of Femoroacetabular Impingement (Independence Administrators)11.14.23d1/10/202111/3/202111/3/2021
Reissue PoliciesDirect Access to Obstetrics/Gynecology (OB/GYN) Services00.09.01h1/1/202111/3/202111/3/2021
Reissue PoliciesRadiofrequency Ablation and Cryosurgical Ablation of Lung Tumors11.00.16g4/9/201811/3/202111/4/2021
Reissue PoliciesHyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies11.00.13h10/1/202111/3/202111/5/2021
Reissue PoliciesTranscatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies07.05.06g12/2/201911/3/202111/5/2021
Reissue PoliciesRadioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)08.00.08j3/4/201911/3/202111/5/2021
Reissue PoliciesGenetic Testing (Independence Administrators)06.02.35ad10/1/202111/3/202111/5/2021
Reissue PoliciesTesting Serum Vitamin D Levels06.02.51d10/1/202011/3/202111/5/2021
Reissue PoliciesVoretigene Neparvovec-rzyl (Luxturna™)08.01.44c1/1/201911/3/202111/5/2021
Reissue PoliciesExtraction of Bony Impacted Teeth and Exposure of Impacted Teeth04.00.05d3/26/201411/3/202111/8/2021
Reissue PoliciesInpatient Hospital Readmission00.01.47c1/15/201711/17/202111/17/2021
Reissue PoliciesHome Health Care Services02.01.01e1/4/202111/17/202111/17/2021
Reissue PoliciesIncident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)00.10.40d9/23/201911/17/202111/17/2021
Reissue PoliciesBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy11.05.02j1/18/202111/17/202111/17/2021
Reissue PoliciesDenervation of the Spinal  Nerves for Chronic Pain (Independence Administrators)11.15.09p10/1/202111/17/202111/17/2021
Reissue PoliciesCorneal Pachymetry Using Ultrasound07.13.07k10/1/202011/17/202111/17/2021
Reissue PoliciesPrescription Lenses and Visual Devices07.13.13d10/1/202111/17/202111/17/2021
Reissue PoliciesEpidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management (Independence Administrators)11.15.23j1/10/202111/17/202111/17/2021
Reissue PoliciesAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation07.10.06i1/1/202111/17/202111/17/2021
Reissue PoliciesOrthoptic/Pleoptic Training07.13.01h10/7/201911/17/202111/17/2021
Reissue PoliciesRepair of Cleft Lip, Cleft Nose, and/or Cleft Palate11.03.01f12/21/202011/17/202111/17/2021
Reissue PoliciesSkilled Nursing Facility (SNF): Skilled and Subacute Levels of Care02.03.0011/1/202011/17/202111/17/2021
Reissue PoliciesAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)08.00.91e1/4/202111/17/202111/18/2021
Reissue PoliciesNatalizumab (Tysabri®)08.00.64g10/21/201911/17/202111/18/2021
Reissue PoliciesBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis11.16.06j1/1/202011/17/202111/18/2021
Reissue PoliciesContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects07.13.11k10/1/202111/17/202111/18/2021
Reissue PoliciesPartial Coherence Interferometry07.13.08e4/23/201811/17/202111/18/2021
Reissue PoliciesSmell and Taste Dysfunction Testing07.11.01c5/7/201811/17/202111/18/2021
Reissue PoliciesTumor Treating Fields07.03.26a1/27/202011/17/202111/18/2021
Reissue PoliciesBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids11.01.06e6/17/201911/17/202111/18/2021
Reissue PoliciesSentinel Lymph Node Biopsy and Mapping11.07.02j5/31/201911/17/202111/18/2021
Reissue PoliciesMohs' Micrographic Surgery11.08.23j10/1/201811/17/202111/18/2021
Reissue PoliciesRhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty11.08.13g5/19/201711/17/202111/19/2021
Reissue PoliciesOrthognathic Surgery11.14.08d6/30/201711/17/202111/19/2021
Reissue PoliciesCervical Traction Devices for In-home Use05.00.61g11/9/202011/17/202111/19/2021
Reissue PoliciesProcedures for the Treatment of Acne11.08.29e10/1/201611/17/202111/19/2021
Reissue PoliciesHome-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD) 05.00.69b8/24/201611/17/202111/19/2021
Reissue PoliciesCranial Electrotherapy Stimulation05.00.80a1/1/202011/17/202111/19/2021
Reissue PoliciesPercutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)05.00.759/30/201411/17/202111/19/2021
Reissue PoliciesMeasurement of Serum Antibodies to and Measurement of Serum Levels of Biologics06.02.39d1/1/202011/3/202111/30/2021
Reissue PoliciesProteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)06.02.43b2/1/201711/3/202111/30/2021
Reissue PoliciesExon Skipping Drugs for Duchenne Muscular Dystrophy (DMD) (Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45)08.01.34c10/1/202111/3/202111/30/2021
Coding UpdateLaboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products00.03.07ad10/1/202111/11/2021
Archived PoliciesBronchial Thermoplasty11.16.07b11/29/2021 2:00 PM1/3/202211/29/2021