The following new and revised medical policies were endorsed at the November 7, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > select state > scroll down and select ‘See Policies and 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 December 18, 2019

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

  • CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions


Revised clinical guidelines effective December 18, 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-ANC-04 - Ambulance Services; Air and Water
  • CG-ANC-07 - Inpatient Interfacility Transfers
  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-BEH-14 - Intensive In-Home Behavioral Health Services
  • CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
  • CG-DME-10 - Durable Medical Equipment
  • CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)
  • CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
  • CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
  • CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
  • CG-LAB-13 - Skin Nerve Fiber Density Testing
  • CG-MED-19 - Custodial Care
  • CG-MED-23 - Home Health
  • CG-MED-26 - Neonatal Levels of Care
  • CG-MED-38 - Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
  • CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
  • CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
  • CG-OR.PR-05 - Myoelectric Upper Extremity Prosthetic Devices
  • CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-27 - Gender Reassignment Surgery
  • CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
  • CG-SURG-71 - Reduction Mammoplasty
  • CG-SURG-72 - Endothelial Keratoplasty
  • CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
  • CG-SURG-77 - Refractive Surgery
  • CG-SURG-94 - Keratoprosthesis
  • CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
  • CG-SURG-96 - Intraocular Telescope
  • CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-Coronary)


Archived clinical guideline effective December 18, 2019

(The following adopted clinical guideline has been archived and its content has been transferred to an existing Clinical UM Guideline.)

  • CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver (combined with CG-SURG-61)


Revised clinical guidelines effective January 1, 2020

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

  • CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-REHAB-11 - Cognitive Rehabilitation
  • CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection


Adopted clinical guidelines effective February 5, 2020 

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

  • CG-GENE-13 - Genetic Testing for Inherited Diseases (previously GENE.00012 and GENE.00043)
  • CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
  • CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis (previously GENE.00028)
  • CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome (previously GENE.00029)
  • CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility (previously GENE.00030)
  • CG-GENE-18 - Genetic Testing for TP53 Mutations (previously GENE.00035)
  • CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers (previously GENE.00045)
  • CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing (previously GENE.00006)
  • CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications (previously RAD.00023)
  • CG-SURG-105 - Corneal Collagen Cross-Linking (previously MED.00109)
  • CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (previously SURG.00122)


Revised clinical guideline effective May 1, 2020

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

  • CG-GENE-13 - Genetic Testing for Inherited Diseases
  • CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
  • CG-MED-68 - Therapeutic Apheresis


Featured In:
February 2020 Anthem Connecticut Provider News