The following new and revised medical policies were endorsed at the June 6, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > 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 > Benefit Plans > Brochures and Forms > Medical Policies.   


Transitioned medical policies effective June 10, 2019

[The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.]

  • DRUG.00046 - Ipilimumab (Yervoy®) [transitioned to ING-CC-0119 Yervoy (ipilimumab)]
  • DRUG.00053 - Carfilzomib (Kyprolis®) [transitioned to ING-CC-0120 Kyprolis (carfilzomib)]
  • DRUG.00063 - Ofatumumab (Arzerra®) [transitioned to ING-CC-0122 Arzerra (ofatumumab)]
  • DRUG.00067 - Ramucirumab (Cyramza®) [transitioned to ING-CC-0123 Cyramza (ramucirumab)
  • DRUG.00071 - Pembrolizumab (Keytruda®) [transitioned to ING-CC-0124 Keytruda (pembrolizumab)]
  • DRUG.00075 - Nivolumab (Opdivo®) [transitioned to ING-CC-0125 Opdivo (nivolumab)]
  • DRUG.00107 - Avelumab (Bavencio®) [transitioned to ING-CC-0129 Bavencio (avelumab)]


Revised medical policies effective June 13, 2019

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

  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions 


New medical policy effective June 13, 2019

(The policy below is new and determined to not have significant change.)

  • MED.00129 - Gene Therapy for Spinal Muscular Atrophy


Revised medical policies effective June 27, 2019

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

  • DRUG.00062 - Obinutuzumab (Gazyva®)
  • GENE.00044 - Analysis of PIK3CA Status in Tumor Cells


Revised medical policies effective June 27, 2019

(The following policies were reviewed and had procedure code/diagnoses code updates, but had no significant changes to the policy position or criteria.)

  • GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies
  • GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
  • SURG.00010 - Treatments for Urinary Incontinence
  • SURG.00121 - Transcatheter Heart Valves Procedures


Revised medical policies effective June 27, 2019

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

  • GENE.00001 - Genetic Testing for Cancer Susceptibility
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
  • LAB.00011 - Analysis of Proteomic Patterns
  • LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer


Revised medical policy effective July 10, 2019

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

  • MED.00109 - Corneal Collagen Cross-Linking


Revised medical policies effective July 10, 2019

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

  • ADMIN.00002 - Preventive Health Guidelines
  • ADMIN.00004 - Medical Necessity Criteria
  • ADMIN.00005 - Investigational Criteria
  • ADMIN.00007 - Immunizations
  • ANC.00006 - Biomagnetic Therapy
  • ANC.00007 - Cosmetic and Reconstructive Services; Skin Related
  • DME.00024 - Transtympanic Micropressure for the Treatment of Meniere's Disease
  • DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
  • DME.00034 - Standing Frames
  • DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
  • DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
  • GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
  • GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
  • GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
  • GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
  • LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
  • LAB.00031 - Advanced Lipoprotein Testing
  • LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
  • MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
  • MED.00098 - Hyperoxemic Reperfusion Therapy
  • MED.00106 - Sipuleucel-T (Provenge®)
  • MED.00123 - Axicabtagene ciloleucel (Yescarta®)
  • MED.00124 - Tisagenlecleucel (Kymriah®)
  • MED.00127 - Chelation Therapy
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
  • RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
  • SURG.00005 - Partial Left Ventriculectomy
  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
  • SURG.00076 - Nerve Graft After Prostatectomy
  • SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
  • SURG.00084 - Implantable Middle Ear Hearing Aids
  • SURG.00105 - Bicmpartmental Knee Arthroplasty
  • SURG.00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
  • SURG.00118 - Bronchail Termoplasty
  • SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
  • SURG.00126 - Irreversible Electroporation
  • SURG.00134 - Interspinous Process Fixation Devices
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
  • SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders


Transitioned medical policies effective September 1, 2019

(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • DRUG.00062 - Obinutuzumab (Gazyva®) [transitioned to ING-CC-0121 Gazyva (obinutuzumab)]
  • DRUG.00076 - Blinatumomab (Blincyto®) [transitioned to ING-CC-0126 Blincyto (blinatumomab)
  • DRUG.00082 - Daratumumab (DARZALEX®) [transitioned to ING-CC-0127 Darzalex (daratumumab)]
  • DRUG.00088 - Atezolizumab (Tecentriq®) [transitioned to ING-CC-0128 Tecentriq (atezolizumab)]
  • DRUG.00109 - Durvalumab (Imfinzi®) [transitioned to ING-CC-0130 Imfinzi (durvalumab)]
  • DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®) [transitioned to ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)]
  • DRUG.00118 - Copanlisib (Aliqopa®) [transitioned to ING-CC-0133 Aliqopa (copanlisib)]
  • MED.00106 - Sipuleucel-T (Provenge®) [transitioned to ING-CC-0134 Provenge (Sipuleucel-T)]


Revised medical policy effective September 4, 2019

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

  • GENE.00010 - Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status [Note: Genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved into a separate clinical utilization management guideline, CG-GENE-11: Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status.]


Archived medical policies effective September 4, 2019

(These policies are now Anthem Clinical Guidelines.)

  • GENE.00021 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies (transitioned to CG-GENE-10)
  • SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus (transitioned to CG-SURG-101)
  • SURG.00133 - Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy (transitioned to CG-SURG-102)


Revised medical policies effective November 1, 2019

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

  • DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
  • LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer Test
  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
  • SURG.00045 - Extracorporeal Shock Wave Therapy
  • SURG.00120 - Internal Rib Fixation Systems


New medical policies effective November 1, 2019

(The policies below are new and determined to not have significant change.

  • GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
  • SURG.00153 - Cardiac Contractility Modulation Therapy

Featured In:
August 2019 Anthem Connecticut Provider News