MedicaidMay 21, 2025
Medical Policies and Clinical Utilization Management Guidelines update
Effective August 24, 2025
The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit the Medical Policies and Clinical UM Guidelines page.
Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 24, 2025.
Publish date | Medical Policy number | Medical Policy title | Status |
1/30/2025 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised |
1/30/2025 | DME.00053 | Home Video-Assisted Robotic Rehabilitation Systems | New |
1/30/2025 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | Revised |
1/30/2025 | LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | Revised |
1/30/2025 | MED.00151 | Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency | New |
1/30/2025 | MED.00152 | Outpatient Intravenous Insulin Therapy | New |
1/30/2025 | SURG.00165 | Histotripsy | New |
1/30/2025 | TRANS.00029 | Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | Revised |
1/30/2025 | TRANS.00033 | Heart Transplantation | Revised |
Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members. These guidelines take effect August 24, 2025.
Publish date | Clinical UM Guideline number | Clinical UM Guideline title | Status |
1/30/2025 | CG-DME-06 | Compression Devices for Lymphedema | Revised |
1/30/2025 | CG-MED-98 | Parenteral Antibiotics for the Treatment of Lyme Disease | Conversion New |
1/30/2025 | CG-OR-PR-04 | Cranial Remodeling Bands and Helmets (Cranial Orthoses) | Revised |
1/30/2025 | CG-RAD-26 | Maternity Ultrasound in the Outpatient Setting | Conversion New |
1/30/2025 | CG-SURG-123 | Autologous Fat Grafting and Injectable Soft Tissue Fillers | Conversion New |
1/30/2025 | CG-SURG-124 | Viscocanalostomy | Conversion New |
1/30/2025 | CG-SURG-125 | Canaloplasty | Conversion New |
1/30/2025 | CG-THER-RAD-07 | Intravascular Coronary and Non-Coronary Brachytherapy | Revised |
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
CABC-CD-083067-25-CPN82473
PUBLICATIONS: June 2025 Provider Newsletter
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