The following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > 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 November 15, 2018

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

  • CG-DRUG-88 - Dupilumab (Dupixent®)

 

Revised clinical guidelines effective December 12, 2018

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

  • CG-DRUG-62 - Fulvestrant (FASLODEX®)
  • CG-DRUG-63 - Levoleucovorin Products
  • CG-DRUG-65 - Tumor Necrosis Factor Antagonists
  • CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
  • CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
  • CG-GENE-03 - BRAF Mutation Analysis
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

 

Revised clinical guidelines effective December 12, 2018

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

  • CG-DRUG-38 - Pemetrexed (Alimta®)
  • CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
  • CG-DRUG-44 - Pegloticase (Krystexxa®)
  • CG-DRUG-45 - Octreotide Acetate (Sandostatin, Sandostatin LAR)
  • CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
  • CG-DRUG-64 - FDA-Approved Biosimilar Products
  • CG-DRUG-66 - Panitumumab (Vectibix®)
  • CG-DRUG-70 - Eribulin mesylate (Halaven®)
  • CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
  • CG-DRUG-75 - Romiplostim (Nplate®)
  • CG-DRUG-76 - Plerixafor Injection (Mozobil™)
  • CG-DRUG-79 - Siltuximab (Sylvant®)
  • CG-DRUG-80 - Cabazitaxel (Jevtana)
  • CG-DRUG-87 - Vedolizumab (Entyvio®)
  • CG-MED-19 - Custodial Care
  • CG-MED-26 - Neonatal Levels of Care
  • CG-MED-67 - Melanoma Vaccines
  • CG-MED-68 - Therapeutic Apheresis
  • CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
  • CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

 

Revised clinical guideline effective December 12, 2018

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

  • CG-DRUG-16 - White Blood Cell Growth Factors

 

Revised clinical guidelines effective December 27, 2018

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

  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
  • CG-DRUG-29 - Hyaluronan Injections
  • CG-DRUG-61 - Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
  • CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions
  • CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Archived clinical guideline effective January 1, 2019

(The following adopted guideline has been archived and has been replaced by AIM guidelines.)

  • CG-SURG-60 - Cervical Total Disc Arthroplasty

 

Revised clinical guidelines effective January 1, 2019

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

  • CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
  • CG-MED-65 - Manipulation Under Anesthesia

 

Adopted clinical guidelines effective January 3, 2019

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

  • CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
  • CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion

 

Revised clinical guidelines effective April 1, 2019

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
  • CG-GENE-01 - Janus Kinase 2 (JAK2) V617F and JAK2 exon 12 Gene Mutation Assays
  • CG-SURG-27 - Sex Reassignment Surgery
  • CG-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver



Featured In:
January 2019 Anthem Connecticut Provider Newsletter