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