Clinical utilization management guidelines update

The 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.anthe m.com/ca/provide r/policie s/clinical-guide line s/search.

 

Updates:

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

• *CG-LAB-14 — Respiratory Viral Pane l Testing in the Outpatie nt Se tting
  • Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving five targets or less when criteria are met
  • Added RVP testing in the outpatient setting using large panels involving six or more targets as not medically necessary
  • Added RVP testing in the outpatient setting using large panels involving six or more targets as not medically necessary

ACA-NU-0410-22 and ACA-NU-0393-21