June 20, 2013 #20

MEDICAL POLICIES AVAILABLE FOR PROVIDERS AT WWW.MVPHEALTHCARE.COM

All policies may be viewed by logging in on the provider page of the MVP Health Care Web site at www.mvphealthcare.com. Next, click the “Online Resources” link and then select “Medical Policies” to view all currently effective and updated policies. All policies are reviewed at least once annually. A FastFax is sent out one month prior to the effective date listing the policies and their status. Policies can fall into one of the following categories: • New – Denotes a new policy. • Updated – Updated policies have content changes which may affect coverage criteria for services and/or drugs. • Review/No Changes – Policies that have been reviewed but have no content change. • Archived – Policy is not active. The following policies are effective August 1, 2013 and will be available for viewing on or before July 1, 2013. Hard copies of the policies are available upon request.

Policy Name Status Policy Name Status Ambulatory Holter Monitor Review Mechanized Spinal Distraction Review Artificial Heart Review Medical Policy Development Review Bariatric Updated Monitored Anesthesia Care Review Benign Skin Lesions Updated Needle-free Insulin Injector Review Breast Surgery for Gynecomastia Review Negative Pressure Wound Therapy Pumps Updated Cardiac Output Monitor Review Nesiritide Infusion for Heart Failure Review Cardiac Procedures Review Pectus Excavatum Review Cardiac Rehabilitation Phase II Review PEEK Instrumentation & Devices New Chiropractic Care Updated Photodynamic Therapy Updated Clinical Guideline Development Review Phototherapy, Photochemotherapy Review Cold Therapy Devices Review Pulmonary Rehabilitation Review Continuous Passive Motion Devices Updated Review Deep Brain Stimulation Review Sacral Nerve Stimulation Review Eating Disorders Updated Review Electromyography & Nerve Conduction Studies Updated Skin Endpoint Titration Review Emergency Department Services Review Spinal Cord Stimulator Review FISH Testing for Bladder Cancer Screening New TMJ/NY/NH Updated Foot Care Review TMJ/VT Updated Gender Reassignment Surgery New Thermal Intradiscal Procedures Review Home Uterine Activity Monitoring Review Transplants Review Insulin Infusion Pumps Review Vision Therapy Updated Laminectomy, Hemilaminectomy Review Vitiligo Treatment Review Light Therapy for SAD Review Wheelchair (Manual) Review Magnetoencephalography Review

If you have any questions with respect to this notice, please contact your Professional Relations Representative.