The following new and revised medical policies were endorsed at the August 22, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > select state > scroll down and select Review Policies > then select View Medical Policies & 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 September 25, 2019

(The following guideline was revised to expand medical necessity indications or criteria.)

CG-MED-68 - Therapeutic Apheresis


 Revised clinical guidelines effective September 25, 2019

(The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use

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

CG-GENE-03 - BRAF Mutation Analysis

CG-MED-63 - Treatment of Hyperhidrosis

CG-MED-65 - Manipulation under Anesthesia

CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue

CG-REHAB-04 - Physical Therapy

CG-REHAB-05 - Occupational Therapy

CG-REHAB-06 - Speech-Language Pathology Services

CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services

CG-REHAB-08 - Private Duty Nursing

CG-SURG-28 - Transcatheter Uterine Artery Embolization

CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

CG-SURG-59 - Vena Cava Filters

CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

CG-SURG-79 - Implantable Infusion Pumps


Revised clinical guidelines effective October 1, 2019

(The following guidelines were updated with new procedure and/or diagnosis codes.)

CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

CG-SURG-09 - Temporomandibular Disorders

CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

CG-SURG-97 - Cardioverter Defibrillators


Adopted clinical guideline effective November 12, 2019

(The following guideline was previously a medical policy and has been adopted with no significant changes.)

CG-GENE-12 - PIK3CA Mutation Testing [previously GENE.00044]


Unadopted clinical guidelines effective November 12, 2019

(The criteria in the following guidelines will no longer be applied to any member claims.)

CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies [Combined with CG-SURG-80 and CG-THER-RAD-04]

CG-MED-39 - Bone Mineral Density Testing Measurement [combined with RAD.00004]


Archived clinical guidelines effective November 20, 2019

(The following adopted clinical guidelines have been archived and its content has been transferred to existing Clinical UM Guidelines.)

CG-SURG-80: Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Content transitioned  to CG-SURG-78]

CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors [Content transitioned to CG-SURG-78]


Revised clinical guidelines effective February 1, 2020

(The following guidelines listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

CG-ANC-07 - Inpatient Interfacility Transfers

CG-GENE-02 - Analysis of RAS Status

CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Featured In:
November 2019 Anthem Connecticut Provider News