Medical policies and clinical utilization Management guidelines update

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://www.anthem.com/ca/provider/policies/clinical-guidelines.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• *CG-LAB-20 — Thyroid Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
• Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
• Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
• The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
• Endometrial receptivity analysis
• Sperm-capacitation test
• Sperm deoxyribonucleic acid (DNA) fragmentation test
• Sperm penetration assay
• Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
• Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
• Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
• The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
• Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

 

Medical Policies

On February 17, 2022, the Medical Policy, and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). These guidelines take effect June 4, 2022.

 

Publish date	Medical Policy number	Medical Policy title	New or revised
04/13/2022	*LAB.00043	Immune Biomarker Tests for Cancer	New
04/13/2022	*LAB.00044	Saliva-based Testing to Determine Drug-Metabolizer Status	New
04/13/2022	*LAB.00045	Selected Tests for the Evaluation and Management of Infertility	New
04/13/2022	*LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	New
04/13/2022	*RAD.00067	Quantitative Ultrasound for Tissue Characterization	New
04/13/2022	*SURG.00160	Implanted Port Delivery Systems to Treat Ocular Disease	New
03/25/2022	*TRANS.00038	Thymus Tissue Transplantation	New
04/13/2022	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
04/1/2022	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
02/24/2022	SURG.00036	Fetal Surgery for Prenatally Diagnosed Malformations	Revised
04/13/2022	SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	Revised
04/13/2022	*SURG.00154	Microsurgical Procedures for the Prevention or Treatment of Lymphedema	Revised

 

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for our members on
March 24, 2022. These guidelines take effect June 4, 2022.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or Revised
04/13/2022	*CG-LAB-20	Thyroid Testing	New
04/13/2022	*CG-LAB-21	Serum Iron Testing	New
04/13/2022	CG-ANC-03	Acupuncture	Revised
04/13/2022	CG-GENE-14	Gene Mutation Testing for Cancer Susceptibility and Management	Revised
04/13/2022	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	Revised
04/13/2022	CG-SURG-36	Adenoidectomy	Revised
02/24/2022	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	Revised

ABCCRNU-0243-22