February 28, 2021
Medical policies and clinical utilization management guidelines update
This communication applies to the Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).
The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www11.anthem.com/ca_search.html.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
- *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
- *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
- Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
- Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
- *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
- *CG-LAB-15 – Red Blood Cell Folic Acid Testing
- RBC folic acid testing is considered not medically necessary in all cases
- *CG-LAB-16 – Serum Amylase Testing
- Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
- *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
- Added the Afirma Xpression Atlas as not medically necessary
- 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- A new Medical Policy was created from content contained in DME.00011.
- There are no changes to the policy content.
- Publish date is December 16, 2020.
- CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
- A new Clinical Guideline was created from content contained in GENE.00026.
- There are no changes to the guideline content.
- Publish date is December 16, 2020.
Medical Policies
On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These guidelines take effect March 8, 2021.
Publish date |
Medical Policy number |
Medical Policy title |
New or revised |
12/16/2020 |
*GENE.00055 |
Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity |
New |
12/16/2020 |
*LAB.00037 |
Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) |
New |
11/12/2020 |
ANC.00009 |
Cosmetic and Reconstructive Services of the Trunk and Groin |
Revised |
12/16/2020 |
*DME.00011 |
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices |
Revised |
11/12/2020 |
GENE.00052 |
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling |
Revised |
11/12/2020 |
MED.00129 |
Gene Therapy for Spinal Muscular Atrophy |
Revised |
12/16/2020 |
SURG.00011 |
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting |
Revised |
12/16/2020 |
*SURG.00062 |
Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele |
Revised |
Clinical UM Guidelines
On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020.
These guidelines take effect March 8, 2021.
Publish date |
Clinical UM Guideline number |
Clinical UM Guideline title |
New or revised |
12/16/2020 |
*CG-LAB-15 |
Red Blood Cell Folic Acid Testing |
New |
12/16/2020 |
*CG-LAB-16 |
Serum Amylase Testing |
New |
11/12/2020 |
CG-DME-42 |
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices |
Revised |
12/16/2020 |
*CG-GENE-04 |
Molecular Marker Evaluation of Thyroid Nodules |
Revised |
12/16/2020 |
CG-GENE-18 |
Genetic Testing for TP53 Mutations |
Revised |
12/16/2020 |
CG-GENE-20 |
Epidermal Growth Factor Receptor (EGFR) Testing |
Revised |
11/12/2020 |
CG-MED-87 |
Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications |
Revised |
517123MUPENMUB
PUBLICATIONS: March 2021 Anthem Blue Cross Provider News - California
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