Medical and claim payment policy activity

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 January 24 February 20, 2015. For the most up-to-date information about medical and claim payment policy activity for commercial business, go to www.amerihealth.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 AmeriHealth. Policy # Title Notification date Effective date 00.01.61 Reimbursement for Components of Comprehensive Laboratory Panels February 4, 2015 March 6, 2015 09.00.56 Radiation Therapy Services (AmeriHealth Pennsylvania) December 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. January 1, 2015 Policy # Title Type of policy change Notification date Effective date 01.00.09c 05.00.05h 05.00.24l 05.00.32g 06.02.01f 07.03.05r 07.03.10e 07.13.05h Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes Interstitial Continuous Glucose Monitoring Systems (CGMSs) and Artificial Pancreas Device Systems (APDS) Speech and Non-Speech Generating Devices Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment Sleep Disorder Testing and Positive Airway Pressure Therapy Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI) Photodynamic Therapy (PDT) Using Verteporfin (Visudyne ) Medical Necessity Criteria January 5, 2015 February 9, 2015 Coding; General Description, Guidelines, or Coding Position; Medical Coding; General Description, Guidelines, or Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or January 26, 2015 February 25, 2015 January 15, 2015 February 15, 2015 Published Medical Coding January 24 February 20, 2015 1

Policy # Title Type of policy change Notification date Effective date 08.00.25h 08.00.26s 08.00.51h Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use Botulinum Toxin Agents Enzyme Replacement for the Treatment of Gaucher's Disease 08.00.69a Agalsidase beta (Fabrazyme ) 08.00.70b 08.00.72f 08.00.82d 08.00.92l Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme, Elaprase, Vimizim, Naglazyme, etc.) Alglucosidase alfa (e.g., Myozyme, Lumizyme ) Ustekinumab (Stelara ) for Subcutaneous Injection Coagulation Factors for Hemophilia 08.00.96c Cabazitaxel (Jevtana ) 08.01.14b 09.00.10r 09.00.17k 09.00.48d 09.00.49g 10.00.02b 11.01.06b 11.03.15g 11.06.04i 11.07.02g Radium Ra 223 dichloride (Xofigo ) Injection Brachytherapy (AmeriHealth New Jersey) Intensity Modulated Radiation Therapy (IMRT) (AmeriHealth New Jersey) Radioembolization for Primary and Metastatic Tumors of the Liver (AmeriHealth New Jersey) Proton Beam Radiation Therapy (AmeriHealth New Jersey) Day Rehabilitation Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids Gastric Electrical Stimulation (Enterra ), Gastric Pacing Uterine Artery Embolization Sentinel Lymph Node Biopsy Guidelines, or Coding; General Description, Guidelines, or Medical Necessity Criteria; Guidelines, or Coding Position; Medical Necessity Criteria Position; Medical Necessity Criteria; February 9, 2015 March 11, 2015 N/A N/A N/A December 31, 2014 February 12, 2015 January 1, 2015 January 1, 2015 January 1, 2015 April 1, 2015 (Tentative) February 5, 2015 May 6, 2015 Medical Coding Position; Medical Necessity Criteria; January 28, 2015 Removed from Notification on February 12, 2015 January 24 February 20, 2015 2

Policy # Title Type of policy change Notification date Effective date 11.14.06g 11.14.11f Autologous Chondrocyte Implantation (ACI)/Carticel and Other Cell-based Treatments of Focal Articular Cartilage Lesions Arthroscopic Electrothermal Joint Repair Guidelines, or Reissued policies The following commercial policies have been reviewed, and no substantive changes were made. Policy # Title Reissue effective date Reissue published date 00.10.35g Remote Patient Management: Telemedicine and Telehealth February 4, 2015 February 4, 2015 05.00.37e Compression Garments February 4, 2015 February 4, 2015 05.00.70a Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures February 4, 2015 February 4, 2015 07.03.09j Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) February 18, 2015 February 19, 2015 07.03.15c Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS) February 4, 2015 February 4, 2015 07.03.18i Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies February 18, 2015 February 19, 2015 07.03.21g 07.05.02l Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon February 18, 2015 February 19, 2015 February 18, 2015 February 19, 2015 07.08.03b Medical and Surgical Treatment of Temporomandibular Joint Disorder February 18, 2015 February 19, 2015 09.00.53 Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone- Gel-Filled Breast Implants in Asymptomatic Individuals February 18, 2015 February 19, 2015 11.00.09d Solid Organ Transplants February 4, 2015 February 5, 2015 11.02.16o Ventricular Assist Devices (VADs) February 4, 2015 February 4, 2015 11.14.24 Manipulation Under Anesthesia February 18, 2015 February 19, 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 00.01.14l Reporting and Documentation Requirements for Anesthesia Services January 1, 2015 February 9, 2015 00.01.25y 00.01.41b 00.01.55c PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstance January 1, 2015 January 26, 2015 January 1, 2015 February 9, 2015 January 1, 2015 January 26, 2015 00.03.02s Diagnostic Radiology Services Included in Capitation January 1, 2015 February 6, 2015 00.03.07j Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products January 1, 2015 January 26, 2015 00.10.36l Radiologic Guidance of a Procedure January 1, 2015 February 9, 2015 January 24 February 20, 2015 3

Policy # Title Effective date Published date 00.10.39e Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus January 1, 2015 February 6, 2015 03.00.07p Modifier 51: Multiple Procedures January 1, 2015 03.00.16l Modifier 57: Decision for Surgery January 1, 2015 February 9, 2015 11.00.11h Use of an Operating Microscope During a Surgical Procedure January 1, 2015 February 9, 2015 Archived policy AmeriHealth has determined that it is is no longer necessary for the following commercial policy to remain active. Policy # Title Notification date Archive effective date 11.17.07f Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence February 11, 2015 March 13, 2015 Continue to the next page for information about Medicare Advantage policy activity. January 24 February 20, 2015 4

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 January 24 February 20, 2015. For the most up-to-date information about medical and claim payment policy activity for Medicare Advantage business, go to www.amerihealth.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. 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 MA01.006 Reimbursement for Components of Comprehensive Laboratory Panels February 4, 2015 March 6, 2015 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 MA00.002a MA01.004a MA05.003a MA06.006a MA07.003a MA07.039a MA07.058a MA08.004a Continuous Glucose Monitor and Artificial Pancreas Device Systems (APDS) Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump Speech and Non-Speech Generating Devices Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment Photodynamic Therapy (PDT) Using Verteporfin (Visudyne ) Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI) Sleep Disorder Testing and Positive Airway Pressure Therapy Coagulation Factors for Hemophilia Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Coding Position; Medical Coding; General Description, Guidelines, or January 26, 2015 February 25, 2015 Medical Coding Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Guidelines, or January 15, 2015 February 15, 2015 Published January 24 February 20, 2015 5

Policy # Title Type of policy change Notification date Effective date MA08.016a MA08.017a MA08.023a Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use Botulinum Toxin Agents Enzyme Replacement for the Treatment of Gaucher's Disease MA08.033a Agalsidase beta (Fabrazyme ) MA08.034a MA08.036a MA08.042a Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme, Elaprase, Vimizim, Naglazyme, etc.) Alglucosidase alfa (e.g., Myozyme, Lumizyme ) Ustekinumab (StelaraTM ) for Subcutaneous Injection MA08.054a Cabazitaxel (Jevtana ) MA08.069a MA09.007a MA10.005a MA11.045a MA11.049a MA11.064a MA11.068a MA11.082a MA11.085a Radium Ra 223 Dichloride (Xofigo ) Injection Proton Beam Therapy (AmeriHealth New Jersey) Day Rehabilitation Uterine Artery Embolization Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids Implantable Miniature Telescope TM (IMT) for the Treatment of End- Stage Age-Related Macular Degeneration (AMD) Sentinel Lymph Node Biopsy Autologous Chondrocyte Implantation (ACI)/Carticel and Other Cell-based Treatments of Focal Articular Cartilage Lesions Arthroscopic Electrothermal Joint Repair Guidelines, or Medical Coding; Medical Necessity Criteria; General Description, Guidelines, or General Description, Guidelines, or ; Medical Necessity Criteria Medical Coding; Medical Necessity Criteria Position; Medical Necessity Criteria Guidelines, or ; Medical Necessity Criteria Guidelines, or ; Medical Necessity Criteria February 9, 2015 March 11, 2015 January 14, 2015 April 1, 2015 (Tentative) January 28, 2015 Removed from Notification on February 12, 2015 February 5, 2015 May 6, 2015 Medical Necessity Criteria January 15, 2015 April 15, 2015 Guidelines, or January 24 February 20, 2015 6

Reissued policies The following Medicare Advantage policies have been reviewed, and no substantive changes were made. Policy # Title Reissue effective date Reissue published date MA00.036 Remote Patient Management: Telemedicine and Telehealth February 4, 2015 February 5, 2015 MA05.043 Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures February 4, 2015 February 5, 2015 MA05.045 Compression Garments February 4, 2015 February 5, 2015 MA07.005 Ambulatory Blood Pressure Monitoring (ABPM) February 4, 2015 February 5, 2015 MA07.015 MA07.018 Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS) Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters February 4, 2015 February 5, 2015 February 18, 2015 February 20, 2015 MA07.022 Wireless Capsule Endoscopy February 18, 2015 February 20, 2015 MA07.024 Medical and Surgical Treatment of Temporomandibular Joint Disorder February 18, 2015 February 20, 2015 MA07.033 Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies February 18, 2015 February 20, 2015 MA07.050 Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) February 18, 2015 February 20, 2015 MA09.019 Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone- Gel-Filled Breast Implants in Asymptomatic Individuals February 18, 2015 February 20, 2015 MA11.011 Artificial Hearts and Ventricular Assist Devices (VADs) February 4, 2015 February 5, 2015 MA11.033 Solid Organ Transplants February 4, 2015 February 5, 2015 MA11.091 Manipulation Under Anesthesia February 18, 2015 February 20, 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 MA00.009a Reporting and Documentation Requirements for Anesthesia Services January 2, 2015 February 9, 2015 MA00.010a PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services January 2, 2015 January 26, 2015 MA00.019a Radiologic Guidance of a Procedure January 2, 2015 February 9, 2015 MA00.021a STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products January 2, 2015 February 9, 2015 MA00.027a Diagnostic Radiology Services Included in Capitation January 2, 2015 February 6, 2015 MA00.030a MA00.037a MA00.043a Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstance January 2, 2015 January 26, 2015 January 2, 2015 February 6, 2015 January 2, 2015 January 26, 2015 MA03.004a Modifier 51: Multiple Procedures January 2, 2015 January 24 February 20, 2015 7

Policy # Title Effective date Published date MA03.010a Modifier 57: Decision for Surgery January 2, 2015 February 9, 2015 MA03.013a Modifier 51 Exempt January 2, 2015 January 26, 2015 MA11.037a Use of an Operating Microscope During a Surgical Procedure January 2, 2015 February 9, 2015 Archived policy AmeriHealth has determined that the following Medicare Advantage policy is no longer necessary to remain active. Policy # Title Notification date Archive effective date MA11.038 Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence February 11, 2015 March 13, 2015 NaviNet is a registered trademark of NaviNet, Inc. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. January 24 February 20, 2015 8