The following new and revised medical policies were endorsed at the January 24, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > 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.

 

Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.   

 

Revised Medical Policies effective January 31, 2019

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

  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • DRUG.00088 - Atezolizumab (Tecentriq®)
  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses

 

Revised Medical Policies effective February 27, 2019

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

  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

 

Revised Medical Policies effective February 27, 2019

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

  • ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
  • DME.00025 - Self-Operated Spinal Unloading Devices
  • DRUG.00013 - Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
  • DRUG.00027 - Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
  • DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
  • DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
  • DRUG.00081 - Eteplirsen (Exondys 51®)
  • DRUG.00082 - Daratumumab (DARZALEX®)
  • GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00016 - Gene Expression Profiling for Colorectal Cancer
  • GENE.00034 - SensiGene™ Fetal RHD genotyping
  • GENE.00036 - Genetic Testing for Hereditary Pancreatitis
  • GENE.00037 - Genetic Testing for Macular Degeneration
  • GENE.00039 - Genetic Testing for Frontotemporal Dementia
  • GENE.00046 - Prothrombin G20210A (Factor II) Mutation Testing
  • LAB.00024 - Immune Cell Function Assay
  • LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
  • MED.00002 - Selected Sleep Testing Services
  • MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
  • MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
  • MED.00065 - Hepatic Activation Therapy
  • MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
  • MED.00091 - Rhinophototherapy
  • MED.00092 - Automated Nerve Conduction Testing
  • MED.00097 - Neural Therapy
  • MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
  • MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
  • MED.00122 - Wilderness Programs
  • RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
  • RAD.00053 - Cervical and Thoracic Discography
  • REHAB.00003 - Hippotherapy
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
  • SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
  • SURG.00073 - Epiduroscopy
  • SURG.00079 - Nasal Valve Suspension
  • SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
  • SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
  • SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma
  • SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus
  • SURG.00111 - Axial Lumbar Interbody Fusion
  • SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
  • SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
  • SURG.00123 - Transmyocardial/ perventricular Device Closure of a Ventricular Septal Defect
  • SURG.00138 - Laser Treatment of Onychomycosis
  • SURG.00146 - Extracorporeal Carbon Dioxide Removal
  • THER-RAD.00008 - Neutron Beam Radiotherapy
  • THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
  • TRANS.00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)
  • TRANS.00008 - Liver Transplant
  • TRANS.00009 - Lung and Lobar Transplant
  • TRANS.00010 - Autologous and Allogenic Pancreatic Islet Cell Transplant
  • TRANS.00026 - Heart-Lung Transplantation
  • TRANS.00033 - Heart Transplant

 

Archived Medical Policies effective March 21, 2019

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • SURG.00115 – Keratoprosthesis (Recategorized to CG-SURG-94)
  • SURG.00117 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention (Recategorized to CG-SURG-95)
  • SURG.00136 - Intraocular Telescope (Recategorized to CG-SURG-96)

 

Revised Medical Policy effective August 1, 2019

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

  • TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

 

Revised Medical Policies effective August 1, 2019

(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)

 

New Medical Policy effective August 1, 2019

(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • LAB.00036 - Multiplex Autoantigen Microarray Testing for Diagnosing Systemic Lupus Erythematosus



Featured In:
May 2019 Anthem Connecticut Provider Newsletter