The following new and revised clinical guidelines were endorsed at the May 3, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meetings. These, and all Anthem medical policies, are available at Medical Policies and Clinical UM Guidelines.


If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.


Revised clinical guideline effective May 10, 2018

(The following guideline was expanded medical necessity indications or criteria.)


CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)


Revised clinical guidelines effective June 6, 2018

(The following guidelines were expanded medical necessity indications or criteria.)


CG-DRUG-62- Fulvestrant (FASLODEX®)

CG-DRUG-73 - Denosumab (Prolia®, Xgeva®)

CG-DRUG-78 - Antihemophilic Factor and Clotting Factors


Revised clinical guidelines effective June 6, 2018   

(The following guidelines were reviewed and had no significant changes to the position or criteria.)


CG-DRUG-05 - Recombinant Erythropoietin Products

CG-DRUG-08 - Enzyme Replacement Therapy for Gaucher Disease

CG-DRUG-09 - Immune Globulin (Ig) Therapy

CG-DRUG-16 - White Blood Cell Growth Factors

CG-DRUG-25 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection

CG-DRUG-51 - Romidepsin (Istodax®)

CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration

CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders

CG-REHAB-05 - Occupational Therapy

CG-SURG-30 - Tonsillectomy for Children with or without Adenoidectomy


New and adopted clinical guidelines effective June 28, 2018

(The following guidelines were previously medical policies and have been adopted. No significant changes were made.)


CG-DME-44 - Electric Tumor Treatment Field (TTF)

CG-DRUG-67 - Cetuximab (Erbitux®)

CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications

CG-DRUG-95 - Belatacept (Nulojix®)

CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®)

CG-DRUG-97 - Rilonacept (Arcalyst®)

CG-DRUG-98 - Bendamustine Hydrochloride

CG-DRUG-99 - Elotuzumab (Empliciti™)

CG-DRUG-100 - Interferon gamma-1b (Actimmune®)

CG-DRUG-101 - Ixabepilone (Ixempra®)

CG-DRUG-102 - Olaratumab (Lartruvo™)

CG-MED-72 - Hyperthermia for Cancer Therapy

CG-SURG-76 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

CG-SURG-77 - Refractive Surgery

CG-SURG-78 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

CG-SURG-79 - Implantable Infusion Pumps

CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors


Revised clinical guideline effective November 1, 2018

(The following guideline below might result in services that were previously covered now being considered not medically necessary.)


CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)


Featured In:
August 2018 Anthem Connecticut Provider Newsletter