Medical Policies and Clinical Utilization Management Guidelines update

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. 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://mediproviders.anthem.com/ca  > Provider Support > Education & Resources > Communications & Updates > Provider Bulletins > 2019.

 

• Updates:

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

• *SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • o Revised scope of document to only address benign prostatic hyperplasia (BPH)
  • o Revised medically necessary criteria for transurethral incision of the prostate by adding "prostate volume less the 30 mL”
  • o Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL and waterjet tissue ablation as medically necessary indication
  • o Moved transurethral radiofrequency needle ablation from medically necessary to not medically necessary section
  • o Moved placement of prostatic stents from standalone statement to combined not medically necessary statement
• *SURG.00037 - Treatment of Varicose Veins (Lower Extremities)
  • o Added the anterior accessory great saphenous vein (AAGSV) as medically necessary for ablation techniques when criteria are met
  • o Added language to the medically necessary criteria for ablation techniques addressing variant anatomy
  • o Added limits to retreatment to the medically necessary criteria for all procedures
• *SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • o Expanded scope to include gastroparesis
  • o Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as investigational and not medically necessary
• *SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
  • o Expanded scope of document to include vertebral body tethering
  • o Added vertebral body tethering as investigational and not medically necessary
• *CG-LAB-14 - Respiratory Viral Panel Testing in the Outpatient Setting
  • o Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving 5 targets or less when criteria are met
  • o Added RVP testing in the outpatient setting using large panels involving 6 or more targets as not medically necessary
• *CG-MED-68 - Therapeutic Apheresis
  • o Added diagnostic criteria to the condition "chronic inflammatory demyelinating polyradiculoneuropathy" (CIDP) when it is treated by plasmapheresis or immunoadsorption
• The following AIM Specialty Clinical Appropriateness Guidelines have been approved, to view an AIM guideline, visit the AIM Specialty Health® page:
  • o *Joint Surgery
  • o *Advanced Imaging—Vascular Imaging

 

Medical Policies

On November 7, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). 

Click on the attachment to view the list of medical policies and clinical guidelines.