March 2019 Medical policies and clinical utilization management guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

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:

• CG-DME-44 — Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
• CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.
• CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
• CG-SURG-30 — Tonsillectomy for Children with or without Adenoidectomy was revised to:
  • Spell out number of episodes of throat infections in MN criteria (A1, A2, A3).
  • Clarify criterion addressing parapharyngeal abscess (B4) to say two or more.
  • Add “asthma” as potential condition improved by tonsillectomy in MN criteria (C1b).
• The following AIM Specialty Health® updates took effect on September 28, 2019:
  • Advanced Imaging
    • Imaging of the Brain
    • Imaging of the Extremities
    • Imaging of the Spine

To view all the updates select the Medical Policies and Clinical Utilization Guidelines attachment.