June 2019 medical policies and clinical utilization management guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit the provider website at www.anthem.com/ca/medicareprovider.

 

Notes/updates

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

• * DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
• * LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
• * LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
• * OR-PR.00003:
  • Clarified medically necessary position statement criteria 2 through 4
  • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
• * SURG.00011:
  • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
  • Added new products to investigational and not medically necessary statement
• * SURG.00045:
  • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
  • Revised title
• * SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

 

• The following AIM Specialty Health® updates were approved on June 6, 2019:
  • Advanced imaging:
    • Imaging of the heart
    • Oncologic imaging
    • Vascular imaging
  • Proton beam therapy
  • Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)