Medical Policy and Clinical Guideline updates 

The following new and revised Medical Policies and Clinical Guidelines were endorsed at the August 10, 2023, Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem Blue Cross and Blue Shield’s Medical Policies and Clinical Guidelines, are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines. 

To view Medical Policies and Clinical 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), visit fepblue.org > Policies & Guidelines.  

Medical Policy updates

New Medical Policies effective January 1, 2024

The following policies are new:

• MED.00144 Gene Therapy for Duchenne Muscular Dystrophy
• MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation
• TRANS.00041 Molecular Microscope^® Diagnostic System (MMDx) Kidney

Revised Medical Policies effective January 1, 2024

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:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• LAB.00011 Selected Protein Biomarker Algorithmic Assays
• LAB.00028 Blood-Based Biomarker Tests for Multiple Sclerosis
• LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00071 Percutaneous and Endoscopic Spinal Surgery
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

Clinical Guideline updates

Revised Clinical Guidelines effective January 1, 2024

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-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity