Medical Policy and Clinical Guideline updates

The following new and revised Medical Policies and Clinical Guidelines and other Anthem Medical Policies and Clinical Guidelines are available at https://anthem.com. Select For Providers. Select your state. Under the Resources heading, select 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 https://fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policies effective August 1, 2025:

• DME.00053 Home Video‑Assisted Robotic Rehabilitation Systems
• MED.00151 Gene Therapy for Aromatic L‑Amino Acid Decarboxylase Deficiency
• MED.00152 Outpatient Intravenous Insulin Therapy
• SURG.00165 Histotripsy

Revised Medical Policies effective August 1, 2025

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 or investigational:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications
• SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
• SURG.00155 Cryosurgery of Peripheral Nerves
• TRANS.00033 Heart Transplantation

Clinical Guideline updates

Revised Clinical Guidelines effective August 1, 2025

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‑SURG‑119 Treatment of Varicose Veins Lower Extremities
• CG‑SURG‑123 Autologous Fat Grafting and Injectable Soft Tissue Fillers