MedicaidSeptember 1, 2020
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.
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:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
- Expanded scope of document and revised Medically Necessary statement
- CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure
- Revised Medically Necessary and Discussion/General Information sections
- CG-GENE-02 — Analysis of RAS Status
- Clarified scope of document and revised the Not Medically Necessary and Coding sections
- CG-MED-64 — Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
- Revised the Medically Necessary statement
- CG-MED-68 — Therapeutic Apheresis
- Revised Medically Necessary, Not Medically Necessary, Coding and Discussion/General Information sections
- 00011 — Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- Revised Investigational and Not Medically Necessary, Rationale and Coding sections
- 00004 — Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- Revised the Not Medically Necessary, Rationale and Coding sections
Medical Policies
On November 7, 2019, February 20, 2020 and May 14, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem).
|
Publish date |
|
Medical Policy number |
Medical Policy title |
New or revised |
|
7/8/2020 |
|
*DME.00042 |
Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea |
New |
|
7/8/2020 |
|
*MED.00131 |
Electronic Home Visual Field Monitoring |
New |
|
7/1/2020 |
|
*MED.00132 |
Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures |
New |
|
7/8/2020 |
|
*MED.00133 |
Ingestion Event Monitors |
New |
|
7/8/2020 |
|
*THER-RAD.00012 |
Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation |
New |
|
4/15/2020 |
|
*DME.00041 |
Low Intensity Therapeutic Ultrasound for the Treatment of Pain |
New |
|
4/15/2020 |
|
*GENE.00053 |
Metagenomic Sequencing for Infectious Disease in the Outpatient Setting |
New |
|
4/15/2020 |
|
*GENE.00054 |
Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer |
New |
|
4/15/2020 |
|
*SURG.00154 |
Microsurgical Procedures for the Treatment of Lymphedema |
New |
|
2/27/2020 |
|
*SURG.00155 |
Cryoneurolysis for Treatment of Peripheral Nerve Pain |
New |
|
5/21/2020 |
|
DME.00009 |
Vacuum Assisted Wound Therapy in the Outpatient Setting |
Revised |
|
7/8/2020 |
|
*DME.00011 |
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices |
Revised |
|
5/21/2020 |
|
DME.00034 |
Standing Frames |
Revised |
|
7/8/2020 |
|
*MED.00004 |
Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography) |
Revised |
|
5/21/2020 |
|
SURG.00026 |
Deep Brain, Cortical, and Cerebellar Stimulation |
Revised |
|
5/21/2020 |
|
SURG.00047 |
Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis |
Revised |
Clinical UM Guidelines
On November 7, 2019, February 20, 2020 and May 14, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 28, 2019, April 23, 2020 and May 25, 2020.
|
Publish date |
Clinical UM Guidelines number |
Clinical UM Guideline title |
New or revised |
|
4/15/2020 |
*CG-ANC-08 |
Mobile Device-Based Health Management Applications |
New |
|
7/1/2020 |
*CG-SURG-107 |
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) |
New |
|
4/15/2020 |
*CG-SURG-108 |
Stereotactic Radiofrequency Pallidotomy |
New |
|
7/8/2020 |
*CG-DME-46 |
Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting |
Revised |
|
7/8/2020 |
*CG-DME-47 |
Noninvasive Home Ventilator Therapy for Respiratory Failure |
Revised |
|
7/8/2020 |
*CG-GENE-02 |
Analysis of RAS Status |
Revised |
|
5/21/2020 |
CG-MED-44 |
Holter Monitors |
Revised |
|
7/8/2020 |
*CG-MED-64 |
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) |
Revised |
|
7/8/2020 |
*CG-MED-68 |
Therapeutic Apheresis |
Revised |
|
5/21/2020 |
CG-MED-74 |
Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry |
Revised |
|
5/21/2020 |
CG-MED-77 |
SPECT/CT Fusion Imaging |
Revised |
|
5/21/2020 |
CG-SURG-98 |
Prostate Biopsy using MRI Fusion Techniques |
Revised |
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