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. For the most up-to-date information about medical and claim payment policy activity for commercial business, go to www.ibx.com/medpolicy, 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 Independence. Policy # Title Notification date Effective date 00.01.59 Care Management and Coordination Services 12/1/2014 00.01.60 05.00.74 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies 10/1/2014 12/1/2014 06.02.44 Presumptive and Definitive Drug Testing 12/1/2014 07.05.08 Fecal Microbiota Transplantation (FMT) 12/12/2014 08.01.19 Siltuximab (Sylvant ) 08.01.20 Programmed Cell Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda ) 09.00.56 Radiation Services 12/12/2014 N/A 1/15/2015 d 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. Policy # Title Type of policy change Notification date Effective date 00.01.47b 00.01.56a 05.00.05h 07.02.03h 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 ; Coverage and/or Reimbursement Position Position 12/1/2014 10/1/2014 Medical Necessity Criteria 1/5/2015 2/9/2015 Position; Medical Coding; General 10/3/2014 1
Policy # Title Type of policy change Notification date Effective date 07.03.05r Sleep Disorder Testing and Positive Airway Pressure 08.00.76e Oxaliplatin (Eloxatin ) 08.00.84b Eculizumab (Soliris ) 08.00.97e Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax, Beleodaq ) 08.01.02b Pegloticase (Krystexxa ) 09.00.49g 11.00.16e 11.05.17a 11.15.23c 12.00.03c 12.01.01aa Proton Beam Radiation 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 Guidelines, or Informational General Description, Guidelines, or Informational Guidelines, or Informational General Description, Guidelines, or Informational Position; Medical Necessity Criteria Position; Medical Necessity Criteria 1/15/2015 2/15/2015 12/31/2014 3/31/2015 10/3/2014 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 00.01.44e Never Events and Preventable Adverse Events published date 01.00.03b Organ and Tissue Recovery from a Cadaveric Donor and Associated Services 02.01.02b Private Duty Nursing 02.02.01f Hospice and Respite Care 05.00.08d Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/2015 05.00.14g High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/2015 05.00.25f Cranial Remolding Orthoses (Helmets) 1/21/2015 1/21/2015 05.00.29h Automatic External and Wearable Cardioverter Defi brillators 1/21/2015 1/23/2015 05.00.61e Cervical Traction for In-home Use 1/7/2015 1/9/2015 05.00.65d Home Uterine Activity Monitoring (HUAM) Devices 05.00.71b Standing Frames 1/21/2015 1/22/2015 2
Policy # Title published date 05.00.72c Upper Limb Prostheses 1/21/2015 1/23/2015 07.08.01e Non-Surgical Spinal Decompression 07.10.04b Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor 07.10.05e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 07.12.01d Pelvic Floor Stimulation as a Treatment of Incontinence 1/21/2015 1/22/2015 07.13.11e Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects 1/21/2015 1/22/2015 07.13.14a The Argus II Retinal Prosthesis 1/21/2015 1/22/2015 08.00.64e Natalizumab (Tysabri ) 1/21/2015 1/22/2015 08.01.13 Brentuximab Vedotin (Adcetris ) 1/21/2015 1/22/2015 11.01.07b Cataract Surgery 1/21/2015 1/22/2015 11.04.01c Islet Cell Transplantation 1/7/2015 1/9/2015 11.06.02f Elective Abortion 11.08.01e 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. Policy # Title Effective date Published date 00.01.24f Obsolete or Unreliable Diagnostic Tests and Medical Services 1/2/2015 00.06.02m Preventive Care Services 12/31/2014 00.10.15b Cast and Splint Applications and Associated Supplies Provided in the Offi ce Setting 1/23/2015 00.10.20l Add-on Codes 1/2/2015 1/23/2015 03.00.06l 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 1/23/2015 03.00.15l Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/23/2015 03.00.29i Modifi er 51 Exempt 1/23/2015 03.02.13e Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG) 1/23/2015 05.00.05g Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes 12/31/2014 05.00.21n Durable Medical Equipment (DME) 12/31/2014 05.00.38i Negative-Pressure Wound (NPWT) Systems 12/31/2014 05.00.44g Repair and Replacement of Durable Medical Equipment (DME) 12/31/2014 05.00.45h Repair or Replacement of an External Prosthetic Device 12/31/2014 05.00.54g Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices 12/31/2014 05.00.59h Lower Limb Prostheses 12/31/2014 3
Policy # Title Effective date Published date 05.00.61e Cervical Traction for In-home Use 1/7/2015 05.00.72c Upper Limb Prostheses 12/31/2014 06.02.10m Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) 12/31/2014 06.02.18h Pharmacogenetics and Metabolite Monitoring Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) 12/31/2014 06.02.24g Preimplantation Genetic Testing 12/31/2014 06.02.27f Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis 12/31/2014 06.02.35h Genetic Testing 12/31/2014 06.02.38a Nerve Fiber Density Testing 12/31/2014 07.00.03m Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen 12/31/2014 07.03.07l Evaluation and Management of Autism Spectrum Disorders (ASD) 12/31/2014 07.06.03b Bioimpedance for the Detection of Lymphedema 12/31/2014 07.08.03b Medical and Surgical Treatment of Temporomandibular Joint Disorder 12/31/2014 07.10.05e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 12/31/2014 07.10.06b Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation 12/31/2014 08.00.57h Complex Regional Pain Syndrome (CRPS) Parenteral Treatments 12/31/2014 08.00.75i Erythropoiesis-Stimulating Agents (ESAs) 12/31/2014 08.00.78o Self-Administered Drugs 12/31/2014 08.00.92k Coagulation Factors for Hemophilia 12/31/2014 08.01.04i Preventive Immunization 12/31/2014 08.01.14a Radium Ra 223 dichloride (Xofi go ) Injection 12/31/2014 08.01.17a Elosulfase alfa (Vimizim ) 12/31/2014 09.00.40c Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA) 12/31/2014 09.00.46n High-Technology Radiology Services 12/31/2014 09.00.49f Proton Beam Radiation 12/31/2014 09.00.52b Digital Breast Tomosynthesis 12/31/2014 11.02.12f Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial 12/31/2014 Artery 11.03.02o Bariatric Surgery 12/31/2014 11.03.12k Colorectal Cancer Screening 12/31/2014 11.05.16b Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma 12/31/2014 11.08.15s Reconstructive Breast Surgery 12/31/2014 11.08.23h Mohs' Micrographic Surgery 12/31/2014 11.08.25k Scar Revision 12/31/2014 11.11.06f Saturation Needle Biopsy of the Prostate 12/31/2014 4
Policy # Title Effective date Published date 11.14.07l Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis 1/2/2015 12/31/2014 11.14.10l Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty 12/31/2014 11.14.19h Artifi cial Intervertebral Disc Insertion 12/31/2014 11.15.01m Spinal Cord Stimulation (Dorsal Column Stimulation) 12/31/2014 11.17.04n 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 Independence has determined are no longer necessary to remain active. Policy # Title Notification date Archive 08.00.06g Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E. 45 ) 10/8/2014 1/6/2015 08.00.44n Zoledronic Acid (Zometa, Reclast ) 12/2/2014 08.00.65h Pamidronate Disodium (Aredia ) for Intravenous Infusion 12/2/2014 08.00.68e Ibandronate Sodium (Boniva ) for Intravenous Injection 12/2/2014 08.09.11s Medicare Part B vs. Part D Crossover Drugs N/A 09.00.10q Brachytherapy N/A 09.00.17j Intensity Modulated Radiation (IMRT) N/A 09.00.48c Radioembolization for Primary and Metastatic Tumors of the Liver N/A 11.15.17e Sacroiliac Joint and Paravertebral Facet Injection Nerve Blocks N/A Continue to the next page for information about Medicare Advantage policy activity. 5
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. For the most up-to-date information about medical and claim payment policy activity for Medicare Advantage business, go to www.ibx.com/medpolicy, 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 SM for a complete list of Medicare Advantage policies that went into effect on January 1, 2015. 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 Independence. Policy # Title Notification date Effective date MA08.006 Siltuximab (Sylvant ) MA08.010 Programmed Cell Death Receptor-1 (PD-1) antagonists (e.g., Keytruda ) MA09.020 Radiation Services 12/12/2014 d 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 Independence. Policy # Title Type of policy change Notification date Effective date MA07.058a Sleep Disorder Testing and Positive Airway Pressure 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 ) MA11.064a Implantable Miniature Telescope (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD) Guidelines, or Informational Guidelines, or Informational 1/15/2015 2/15/2015 Medical Necessity Criteria 1/15/2015 4/15/2015 6
Policy # Title Type of policy change Notification date Effective date MA12.001a Alternative Therapies and Complementary Medicine 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 MA00.039 Never Events and Preventable Adverse Events published date MA01.003 Organ and Tissue Recovery from a Cadaveric Donor and Associated Services MA02.001 Hospice Care MA02.002 Private Duty Nursing MA05.001 High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/2015 MA05.005 Automated External and Wearable Cardioverter Defibrillators 1/21/2015 1/23/2015 MA05.009 Cervical Traction Devices for In-home Use 1/7/2015 1/9/2015 MA05.019 Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/2015 MA05.055 Standing Frames 1/21/2015 1/23/2015 MA05.057 Upper-Limb Prostheses 1/21/2015 1/22/2015 MA07.014 Magnetic Pelvic Floor Stimulation (MPFS) 1/21/2015 1/23/2015 MA07.025 Intrauterine Systems (IUSs) (e.g., Mirena, Skyla ) MA08.029 Natalizumab (Tysabri ) 1/21/2015 1/23/2015 MA08.068 Brentuximab Vedotin (Adcetris ) 1/21/2015 1/23/2015 MA11.007 Islet Cell Transplantation 1/7/2015 1/9/2015 MA11.010 Abortion MA11.021 Non-Surgical Spinal Decompression MA11.046 Hair Transplants and Cranial Prostheses (Wigs) 1/21/2015 1/22/2015 MA11.054 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. Policy # Title Effective date Published date 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 MA03.009a 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 Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/2/2015 1/23/2015 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. 7