Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageMay 30, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Effective August 30, 2024

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider > Providers > Policies, Guidelines & Manuals.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • MED.00146 - Gene Therapy for Sickle Cell Disease
    • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease
  • RAD.00068 - Myocardial Strain Imaging
    • Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications
  • SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
    • Reformatted Position Statement and added headers
    • Reformatted Medically Necessary statements to move target treatment areas into criteria
    • Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
    • Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
    • Reformatted Medically Necessary statements for epilepsy
    • Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
    • Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
    • Revised and reformatted Investigational & Not Medically Necessary statements
  • SURG.00097 - Scoliosis Surgery
    • Revision to Position Statement formatting
    • Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement
  • SURG.00142 - Genicular Procedures for Treatment of Knee Pain
    • Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
    • Revised title
    • Added genicular artery embolization to the scope of document
    • Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary
  • CG-DME-42 - Continuous Glucose Monitoring Devices
    • Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
    • Revised title
    • Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
    • Revised existing Medically Necessary and Not Medically Necessary statements
  • CG-DME-52 - Continuous Passive Motion Devices in the Home Setting
    • Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications
  • CG-MED-94 - Vestibular Function Testing
    • Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing
  • CG-SURG-09 - Temporomandibular Disorders
    • Revised formatting of Medically Necessary statement
    • Revised surgical procedures criteria
    • Added MIRO Therapy to Not Medically Necessary statement
  • CG-SURG-70 - Gastric Electrical Stimulation
    • Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 30, 2024.

Publish date

Medical Policy number

Medical Policy title

New or revised

1/3/2024

LAB.00026

Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer

Previously titled: Systems Pathology Testing for Prostate Cancer

Revised

1/3/2024

LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

Revised

1/3/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Conversion new

1/3/2024

MED.00057

MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Revised

1/18/2024

*MED.00146

Gene Therapy for Sickle Cell Disease

New

1/3/2024

*RAD.00068

Myocardial Strain Imaging

New

1/3/2024

SURG.00010

Treatments for Urinary Incontinence

Revised

12/28/2023

*SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

Revised

12/28/2023

*SURG.00097

Scoliosis Surgery

Revised

1/3/2024

*SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Revised

1/3/2024

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Revised

Clinical UM Guidelines

On November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on January 4, 2024. These guidelines take effect August 30, 2024.

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

1/3/2024

*CG-DME-42

Continuous Glucose Monitoring Devices

Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps

Revised

1/3/2024

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

1/3/2024

CG-DME-50

Automated Insulin Delivery Systems

Conversion new

1/3/2024

CG-DME-51

External Insulin Pumps

Conversion new

1/3/2024

*CG-DME-52

Continuous Passive Motion Devices in the Home Setting

New

1/3/2024

CG-LAB-25

Outpatient Glycated Hemoglobin and Protein Testing

Revised

1/3/2024

CG-MED-92

Foot Care Services

Revised

1/3/2024

*CG-MED-94

Vestibular Function Testing

New

1/3/2024

*CG-SURG-09

Temporomandibular Disorders

Revised

12/28/2023

*CG-SURG-70

Gastric Electrical Stimulation

Revised

1/3/2024

CG-SURG-94

Keratoprosthesis

Revised

12/28/2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

Revised

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PUBLICATIONS: July 2024 Provider Newsletter