Medicare AdvantageNovember 21, 2023
Medical Policies and Clinical Utilization Management Guidelines update for May 2023
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 providers in your practice and office staff.
To view a guideline, visit anthem.com/ca.
Notes/updates
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- MED.00004 – Noninvasive Imaging Technologies for the Evaluation of Skin Lesions; Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography):
- Revised title
- Added additional technologies to Investigational & Not Medically Necessary section.
- SURG.00161 – Nanoparticle-Mediated Thermal Ablation:
- Nanoparticle-mediated thermal ablation is considered Investigational & Not Medically Necessary for all indications
- CG-ANC-06 – Ambulance Services: Ground; Non-Emergent:
- Revised Medically Necessary and Not Medically Necessary statements regarding mileage.
- Revised Not Medically Necessary statement to remove list of non-covered indications.
- CG-LAB-29 – Gamma Glutamyl Transferase Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing of gamma glutamyl transferase (GGT) in blood.
- CG-LAB-30 – Outpatient Laboratory-based Blood Glucose Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing to determine blood glucose concentration.
- CG-SURG-95 – Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention; Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention:
- Revised title
- Added Medically Necessary criteria for temporary SNS for urinary and fecal conditions.
- Reformatted Medically Necessary criteria for permanent SNS for urinary and fecal conditions.
- Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices.
Medical Policies
On May 11, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). These medical policies take effect December 27, 2023.
Publish date | Medical Policy number | Medical Policy title | New or revised |
5/25/2023 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Revised |
6/28/2023 | *MED.00004 | Noninvasive Imaging Technologies for the Evaluation of Skin Lesions Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography) | Revised |
7/18/2023 | MED.00135 | Gene Therapy for Hemophilia | Revised |
5/25/2023 | SURG.00121 | Transcatheter Heart Valve Procedures | Revised |
6/28/2023 | *SURG.00161 | Nanoparticle-Mediated Thermal Ablation | New |
6/28/2023 | TRANS.00025 | Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection | Revised |
Clinical UM Guidelines
On May 11, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare members on June 22, 2023. These guidelines take effect December 27, 2023.
Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised |
6/28/2023 | *CG-ANC-06 | Ambulance Services: Ground; Non-Emergent | Revised |
6/28/2023 | CG-DME-31 | Powered Wheeled Mobility Devices | Revised |
6/28/2023 | CG-DME-36 | Pediatric Gait Trainers | Revised |
6/28/2023 | CG-DME-42 | Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps | Revised |
6/28/2023 | CG-GENE-16 | BRCA Genetic Testing | Revised |
6/28/2023 | CG-GENE-22 | Gene Expression Profiling for Managing Breast Cancer Treatment | Revised |
5/25/2023 | CG-LAB-22 | Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Vaginitis Previously Titled: Nucleic Acid Amplification Tests Using Algorithmic Analysis for the Diagnosis of Bacterial Vaginosis | Revised |
6/28/2023 | CG-LAB-25 | Outpatient Glycated Hemoglobin and Protein Testing | Revised |
6/28/2023 | *CG-LAB-29 | Gamma Glutamyl Transferase Testing | New |
6/28/2023 | *CG-LAB-30 | Outpatient Laboratory-based Blood Glucose Testing | New |
6/28/2023 | CG-MED-59 | Upper Gastrointestinal Endoscopy in Adults | Revised |
6/28/2023 | CG-MED-66 | Cryopreservation of Oocytes or Ovarian Tissue | Revised |
6/28/2023 | CG-SURG-101 | Ablative Techniques as a Treatment for Barrett's Esophagus | Revised |
5/25/2023 | CG-SURG-115 | Mechanical Embolectomy for Treatment of Stroke | Revised |
6/28/2023 | CG-SURG-61 | Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver | Revised |
6/28/2023 | CG-SURG-78 | Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies Previously Titled: Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies | Revised |
6/22/2023 | CG-SURG-81 | Cochlear Implants and Auditory Brainstem Implants | Revised |
6/28/2023 | *CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | Revised |
Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
CABC-CR-043576-23-CPN42042
PUBLICATIONS: December 2023 Provider Newsletter
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