June 1, 2021
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 note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www.anthem.com/ca/provider/policies/clinical-guidelines/search.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
- Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
- *GENE.00056 - Gene Expression Profiling for Bladder Cancer
- Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary
- *LAB.00038 - Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- Cell-free DNA testing is considered investigational and not medically necessary as a non-invasive method of determining the risk of rejection in kidney transplant recipients
- *LAB.00039 - Pooled Antibiotic Sensitivity Testing
- Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications
- *SURG.00159 - Focal Laser Ablation for the Treatment of Prostate Cancer
- Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer
- *TRANS.00037 - Uterine Transplantation
- Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus
- *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
- *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with based on one of the following cephalometric measurement: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
- *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor GM-CSF) as not medically necessary for all liver-related indications
- *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
- Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
- Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
- Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
- CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
- A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
- CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
- A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
- CG-SURG-110 - Lung Volume Reduction Surgery
- A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021
Medical Policies
On February 11, 2021, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan). These guidelines take effect June 4, 2021.
Publish date |
Medical Policy number |
Medical Policy title |
New or revised |
4/1/2021 |
*GENE.00056 |
Gene Expression Profiling for Bladder Cancer |
New |
4/7/2021 |
*LAB.00038 |
Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection |
New |
4/7/2021 |
*LAB.00039 |
Pooled Antibiotic Sensitivity Testing |
New |
4/7/2021 |
*SURG.00159 |
Focal Laser Ablation for the Treatment of Prostate Cancer |
New |
4/7/2021 |
*TRANS.00037 |
Uterine Transplantation |
New |
4/7/2021 |
*ANC.00008 |
Cosmetic and Reconstructive Services of the Head and Neck |
Revised |
4/7/2021 |
MED.00087 |
Optical Detection for Screening and Identification of Cervical Cancer |
Revised |
2/18/2021 |
SURG.00121 |
Transcatheter Heart Valve Procedures |
Revised |
2/18/2021 |
SURG.00145 |
Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) |
Revised |
Clinical UM Guidelines
On February 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem Blue Cross Cal MediConnect Plan. These guidelines were adopted by the medical operations committee for Anthem Blue Cross Cal MediConnect Plan members on February 25, 2021. These guidelines take effect June 4, 2021.
Publish date |
Clinical UM Guideline number |
Clinical UM Guideline title |
New or revised |
4/7/2021 |
*CG-LAB-17 |
Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting |
New |
2/18/2021 |
CG-GENE-21 |
Cell-Free Fetal DNA-Based Prenatal Testing |
Revised |
4/7/2021 |
CG-MED-26 |
Neonatal Levels of Care |
Revised |
2/18/2021 |
CG-MED-87 |
Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications |
Revised |
4/7/2021 |
*CG-OR-PR-04 |
Cranial Remodeling Bands and Helmets (Cranial Orthotics) |
Revised |
2/18/2021 |
CG-SURG-55 |
Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation |
Revised |
4/7/2021 |
CG-SURG-71 |
Reduction Mammaplasty |
Revised |
4/7/2021 |
*CG-SURG-78 |
Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies |
Revised |
4/7/2021 |
*CG-SURG-82 |
Bone-Anchored and Bone Conduction Hearing Aids |
Revised |
4/7/2021 |
CG-SURG-97 |
Cardioverter Defibrillators |
Revised |
ACAD-NU-0157-21
PUBLICATIONS: June 2021 Anthem Blue Cross Provider News - California
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