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1 Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from December 20, 2014 January 23, For the most up-to-date information about medical and claim payment policy activity for commercial business, go to select Accept and Go to Medical Policy Online, and then select the Commercial tab. You can also view policy activity using the NaviNet web portal by selecting the Reference Tools transaction, then Medical 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 AmeriHealth. Policy # Title Notification date Effective date Care Management and Coordination Services 12/1/ Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies 10/1/ /1/ Presumptive and Defi nitive Drug Testing 12/1/ Fecal Microbiota Transplantation (FMT) 12/12/ Siltuximab (Sylvant ) Programmed Cell Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda ) Radiation Therapy Services (AmeriHealth Pennsylvania) 12/12/2014 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 AmeriHealth. Policy # Title Type of policy change Notification date Effective date b a h h Inpatient Hospital Readmission National Correct Coding Initiative (NCCI) Code Pair Edits Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes Implantable Cardiac Loop Monitor General Description, Guidelines, or Informational Update; Coverage and/ or Reimbursement Position Position 12/1/ /1/2014 Medical Necessity Criteria 1/5/2015 2/9/2015 Position; Medical Coding; General Description, Guidelines, or Informational Update 10/3/2014 December 20, 2014 January 23,

2 Policy # Title Type of policy change Notification date Effective date r Sleep Disorder Testing and Positive Airway Pressure Therapy e Oxaliplatin (Eloxatin ) b Eculizumab (Soliris ) e Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax, Beleodaq ) b Pegloticase (Krystexxa ) d g e a c c aa Radioembolization for Primary and Metastatic Tumors of the Liver Proton Beam Radiation Therapy Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors Implantable Miniature Telescope (IMT) for the Treatment of End-Stage, Age-Related Macular Degeneration (AMD) Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management Alternative Therapies and Complementary Medicine Experimental/ Investigational Services Medical Necessity Criteria; General Description, Guidelines, or Informational Update General Description, Guidelines, or Informational Update General Description, Guidelines, or Informational Update General Description, Guidelines, or Informational Update Position; Medical Necessity Criteria Position; Medical Necessity Criteria 1/15/2015 2/15/2015 N/A 12/31/2014 3/31/ /3/2014 Medical Necessity Criteria Medical Coding 10/3/2014 Medical Necessity Criteria N/A 1/14/2015 Medical Coding; Medical Necessity Criteria d policies The following commercial policies have been reviewed, and no substantive changes were made. Policy # Title N/A effective date e Never Events and Preventable Adverse Events 1/6/2015 1/9/2015 published date b Organ and Tissue Recovery from a Cadaveric Donor and Associated Services 1/6/2015 1/9/ b Private Duty Nursing 1/6/2015 1/9/ f Hospice and Respite Care 1/6/2015 1/9/ d Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/ g High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/ f Cranial Remolding Orthoses (Helmets) 1/21/2015 1/21/ h Automatic External and Wearable Cardioverter Defi brillators 1/21/2015 1/23/ e Cervical Traction for In-home Use 1/7/2015 1/9/ d Home Uterine Activity Monitoring (HUAM) Devices 1/6/2015 1/9/2015 December 20, 2014 January 23,

3 Policy # Title effective date published date b Standing Frames 1/21/2015 1/22/ c Upper Limb Prostheses 1/21/2015 1/23/ e Non-Surgical Spinal Decompression Therapy 1/6/2015 1/9/ b Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor 1/6/2015 1/9/ e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 1/6/2015 1/9/ d Pelvic Floor Stimulation as a Treatment of Incontinence 1/21/2015 1/22/ e Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects 1/21/2015 1/22/ a The Argus II Retinal Prosthesis 1/21/2015 1/22/ e Natalizumab (Tysabri ) 1/21/2015 1/22/ Brentuximab Vedotin (Adcetris ) 1/21/2015 1/22/ b Cataract Surgery 1/21/2015 1/22/ c Islet Cell Transplantation 1/7/2015 1/9/ f Elective Abortion 1/6/2015 1/9/ e Hair Transplants and Cranial Prostheses (Wigs) 1/21/2015 1/22/2015 Coding updates 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 f Obsolete or Unreliable Diagnostic Tests and Medical Services 1/2/ m Preventive Care Services 12/31/ b Cast and Splint Applications and Associated Supplies Provided in the Offi ce Setting 1/23/ l Add-on Codes 1/2/2015 1/23/ l Modifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service 1/23/ l Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/23/ i Modifi er 51 Exempt 1/23/ e Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG) 1/23/ g Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes 12/31/ n Durable Medical Equipment (DME) 12/31/ i Negative-Pressure Wound Therapy (NPWT) Systems 12/31/ g Repair and Replacement of Durable Medical Equipment (DME) 12/31/ h Repair or Replacement of an External Prosthetic Device 12/31/2014 December 20, 2014 January 23,

4 g Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices 12/31/ h Lower Limb Prostheses 12/31/ e Cervical Traction for In-home Use 1/7/ c Upper Limb Prostheses 12/31/ m Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) 12/31/ h Pharmacogenetics and Metabolite Monitoring Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy 12/31/ g Preimplantation Genetic Testing 12/31/ f Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis 12/31/ h Genetic Testing 12/31/ a Nerve Fiber Density Testing 12/31/ m Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy 12/31/ l Evaluation and Management of Autism Spectrum Disorders (ASD) 12/31/ b Bioimpedance for the Detection of Lymphedema 12/31/ b Medical and Surgical Treatment of Temporomandibular Joint Disorder 12/31/ e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 12/31/ b Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation 12/31/ h Complex Regional Pain Syndrome (CRPS) Parenteral Treatments 12/31/ i Erythropoiesis-Stimulating Agents (ESAs) 12/31/ o Self-Administered Drugs 12/31/ k Coagulation Factors for Hemophilia 12/31/ i Preventive Immunization 12/31/ a Radium Ra 223 dichloride (Xofi go ) Injection 12/31/ a Elosulfase alfa (Vimizim ) 12/31/ r Brachytherapy 12/31/ k Intensity Modulated Radiation Therapy (IMRT) 12/31/ c Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA) 12/31/ n High-Technology Radiology Services 12/31/ f Proton Beam Radiation Therapy 12/31/ b Digital Breast Tomosynthesis 12/31/ f Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial 12/31/2014 Artery o Bariatric Surgery 12/31/2014 December 20, 2014 January 23,

5 k Colorectal Cancer Screening 12/31/ b Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma 12/31/ s Reconstructive Breast Surgery 12/31/ h Mohs' Micrographic Surgery 12/31/ k Scar Revision 12/31/ f Saturation Needle Biopsy of the Prostate 12/31/ l Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis 1/2/ /31/ l Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty 12/31/ h Artifi cial Intervertebral Disc Insertion 12/31/ m Spinal Cord Stimulation (Dorsal Column Stimulation) 12/31/ n Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence 12/31/2014 Archived policies The following are commercial policies that AmeriHealth has determined are no longer necessary to remain active. Policy # Title Notification date Archive effective date g Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E. 45 ) 10/8/2014 1/6/ n Zoledronic Acid (Zometa, Reclast ) 12/2/ h Pamidronate Disodium (Aredia ) for Intravenous Infusion 12/2/ e Ibandronate Sodium (Boniva ) for Intravenous Injection 12/2/ s Medicare Part B vs. Part D Crossover Drugs N/A e Sacroiliac Joint and Paravertebral Facet Injection Nerve Blocks N/A Continue to the next page for information about Medicare Advantage policy activity. December 20, 2014 January 23,

6 Medical and claim payment policy activity Medicare Advantage business The following pages list the policy activity for Medicare Advantage business that we have posted to our Medical Policy Portal from December 20, 2014 January 23, For the most up-to-date information about medical and claim payment policy activity for Medicare Advantage business, go to select Accept and Go to Medical Policy Online, and then select the Medicare Advantage tab. You can also view policy activity using the NaviNet web portal by selecting the Reference Tools transaction, then Medical Policy. Note: Please refer to the January 2015 edition of Partners in Health Update SM for a complete list of Medicare Advantage policies that went into effect on January 1, New policies The following Medicare Advantage policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with AmeriHealth. Policy # Title Notification date Effective date MA Siltuximab (Sylvant ) MA Programmed Cell Death Receptor-1 (PD-1) antagonists (e.g., Keytruda ) Updated policies The following Medicare Advantage policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with AmeriHealth. Policy # Title Type of policy change Notification date Effective date MA07.058a Sleep Disorder Testing and Positive Airway Pressure Therapy MA08.038a Oxaliplatin (Eloxatin ) MA08.044a Eculizumab (Soliris ) MA08.055a Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax, Beleodaq ) MA08.060a Pegloticase (Krystexxa ) MA09.007a Proton Beam Therapy Medical Necessity Criteria; General Description, Guidelines, or Informational Update Medical Necessity Criteria; General Description, Guidelines, or Informational Update Medical Necessity Criteria; General Description, Guidelines, or Informational Update 1/15/2015 2/15/2015 1/14/2015 4/1/2015 December 20, 2014 January 23,

7 Policy # Title Type of policy change Notification date Effective date MA11.064a MA12.001a Implantable Miniature Telescope (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD) Alternative Therapies and Complementary Medicine Medical Necessity Criteria 1/15/2015 4/15/2015 Medical Necessity Criteria N/A 1/14/2015 d policies The following Medicare Advantage policies have been reviewed, and no substantive changes were made. Policy # Title effective date MA Never Events and Preventable Adverse Events 1/6/2015 1/9/2015 published date MA Organ and Tissue Recovery from a Cadaveric Donor and Associated Services 1/6/2015 1/9/2015 MA Hospice Care 1/6/2015 1/9/2015 MA Private Duty Nursing 1/6/2015 1/9/2015 MA High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/2015 MA Automated External and Wearable Cardioverter Defibrillators 1/21/2015 1/23/2015 MA Cervical Traction Devices for In-home Use 1/7/2015 1/9/2015 MA Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/2015 MA Standing Frames 1/21/2015 1/23/2015 MA Upper-Limb Prostheses 1/21/2015 1/22/2015 MA Magnetic Pelvic Floor Stimulation (MPFS) 1/21/2015 1/23/2015 MA Intrauterine Systems (IUSs) (e.g., Mirena, Skyla ) 1/6/2015 1/9/2015 MA Natalizumab (Tysabri ) 1/21/2015 1/23/2015 MA Brentuximab Vedotin (Adcetris ) 1/21/2015 1/23/2015 MA Islet Cell Transplantation 1/7/2015 1/9/2015 MA Abortion 1/6/2015 1/9/2015 MA Non-Surgical Spinal Decompression Therapy 1/6/2015 1/9/2015 MA Hair Transplants and Cranial Prostheses (Wigs) 1/21/2015 1/22/2015 MA Cataract Surgery 1/21/2015 1/23/2015 Coding updates The following Medicare Advantage 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. MA00.012a Cast and Splint Applications and Associated Supplies Provided in the Offi ce Setting 1/2/2015 1/23/2015 MA00.016a Add-on Codes 1/2/2015 1/23/2015 MA03.003a Modifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service 1/2/2015 1/23/2015 December 20, 2014 January 23,

8 MA03.009a Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/2/2015 1/23/2015 NaviNet is a registered trademark of NaviNet, Inc., an independent company. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. December 20, 2014 January 23,

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