The following new and revised medical policies and clinical guidelines were endorsed at the May 13, 2021, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.' 

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines. 

 

Medical policy updates

 

Revised medical policies effective May 20, 2021

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

  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
  • 00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • 00143 - Perirectal Spacers for Use During Prostate Radiotherapy
  • 00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease and Miscellaneous Solid Tumors

 

Reviewed medical policy effective July 1, 2021

The following medical policy was reviewed and updated with new procedure and/or diagnoses codes.

  • 00098 - Hyperoxemic Reperfusion Therapy

 

Coding update effective July 1, 2021

The following policy was updated with new procedure and/or diagnosis codes.

  • 00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents

 

Revised medical policies effective July 7, 2021

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

  • 00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
  • 00095 - Viscocanalosomy and Canaloplasty

 

Reviewed medical policies effective July 7, 2021

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

  • 00002 - Preventive Health Guidelines
  • 00004 - Medical Necessity Criteria
  • 00005 - Investigational Criteria
  • 00007 - Immunizations
  • 00006 - Biomagnetic Therapy
  • 00007 - Cosmetic and Reconstructive Services; Skin Related
  • 00024 - Transtympanic Micropressure
  • 00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
  • 00037 - Cooling Devices and Combined Cooling/Heating Devices
  • 00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • 00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
  • 00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
  • 00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
  • 00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
  • 00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
  • 00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
  • 00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
  • 00031 - Advanced Lipoprotein Testing
  • 00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
  • 00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
  • 00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
  • 00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications
  • 00127 - Chelation Therapy
  • 00131 - Electronic Home Visual Field Monitoring
  • 00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
  • 00133 - Ingestion Event Sensors
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
  • 00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
  • 00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
  • 00005 - Partial Left Ventriculectomy
  • 00007 - Vagus Nerve Stimulation
  • 00010 - Treatments for Urinary Incontinence
  • 00045 - Extracorporeal Shock Wave Therapy
  • 00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • 00071 - Percutaneous and Endoscopic Spinal Surgery
  • 00076 - Nerve Graft After Prostatectomy
  • 00084 - Implantable Middle Ear Hearing Aids
  • 00105 - Bicmpartmental Knee Arthroplasty
  • 00111 - Axial Lumbar Interbody
  • 00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
  • 00118 - Bronchail Termoplasty
  • 00120 - Internal Rib Fixation Systems
  • 00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
  • 00126 - Irreversible Electroporation
  • 00134 - Interspinous Process Fixation Devices
  • 00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • 00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • 00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
  • 00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
  • THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
  • 00035 - Other Stem Cell Therapy

 

Archived medical policy effective July 7, 2021

The following medical policy has been archived and transitioned as an AIM Guideline.

  • 00001 - Computed Tomography to Detect Coronary Artery Calcification

 

Archived medical policies effective July 7, 2021

The following medical policies have been archived and transitioned to a Clinical UM Guideline.

  • 00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting (recategorized to CG-DME-48)
  • 00034 - Standing Frames (recategorized to CG-DME-49)

 

Archived medical policies effective June 7, 2021

The following medical policies have been archived and transitioned to an existing Clinical UM Guideline.

  • 00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome (combined into CG-GENE-13)
  • 00046 - Prothrombin (Factor II) Mutation Testing (combined into CG-GENE-13)

 

Archived medical policy effective September 12, 2021

The following medical policy has been archived and it21s content was transitioned to either a Clinical UM Guideline or an AIM Guideline.

  • 00127 - Sacroiliac Joint Fusion (Recategorize "open" to CG-SURG-111. Transition "min invasive" to AIM)

 

New medical policies effective October 1, 2021

The following policies are new and may result in services previously covered now being considered either not medically necessary and/or investigational.

  • 00057 - Gene Expression Profiling for Idiopathic Pulmonary Fibrosis
  • 00041 - Machine Learning Derived Probability Score for Rapid Kidney Function Decline
  • 00137 - Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

 

Revised medical policies effective October 1, 2021

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

  • 00012 - Intrapulmonary Percussive Ventilation Devices
  • 00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
  • 00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
  • 00155 - Cryoneurolysis
  • 00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

 

Clinical guideline updates

 

Revised clinical guideline effective May 20, 2021

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

  • CG-SURG-27 - Gender Affirming Surgery

 

Revised clinical guideline effective July 1, 2021

The following adopted guideline was updated with new procedure and/or diagnoses codes.

  • CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Archived clinical guideline effective July 7, 2021

The following adopted guideline has been archived.

  • CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

 

Revised clinical guidelines effective July 7, 2021

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

  • CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
  • CG-GENE-13 - Genetic Testing for Inherited Diseases
  • CG-SURG-12 - Penile Prosthesis Implantation

 

Reviewed clinical guidelines effective July 7, 2021

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

  • CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
  • CG-DME-45 - Ultrasound Bone Growth Stimulation
  • CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
  • CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
  • CG-MED-76 - Magnetic Source Imaging and Magneto-encephalography
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
  • CG-SURG-05 - Maze Procedure
  • CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
  • CG-SURG-71 - Reduction Mammoplasty
  • CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
  • CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
  • CG-SURG-85 - Hip Resurfacing
  • CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
  • CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
  • CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
  • CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised clinical guidelines effective October 1, 2021

The following adopted guidelines were revised and might result in services previously covered, but now being considered not medically necessary.

  • CG-SURG-12 - Penile Prosthesis Implantation
  • CG-SURG-27 - Gender Affirming Surgery
  • CG-SURG-59 - Vena Cava Filters

 

New clinical guideline effective November 1, 2021

The following guideline is new and has been adopted.

  • CG-MED-89 - Home Parenteral Nutrition

 

1206-0721-PN-NE



Featured In:
July 2021 Connecticut Provider News