Medical Policy and Clinical Guideline updates

The following new revised Medical Policies and Clinical Guidelines, and all other Medical Policies and Clinical Guidelines, are available at https://anthem.com/provider. 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.

New Medical Policies effective October 1, 2025:

• DME.00054 Gait Modulation Systems Using Rhythmic Auditory Stimulation
• MED.00153 Encapsulated Cell Therapy for Degenerative Ocular Disease
• MED.00155 Allogeneic Bone Marrow‑Derived Mesenchymal Stromal Cell Therapy
• SURG.00163 Autologous Cell Sheet‑Based Gene Therapy for Treatment of Dystrophic Epidermolysis Bullosa

Revised Medical Policies effective October 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 and/or investigational:

• SURG.00010 Treatments for Urinary Incontinence
• SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational

Revised Clinical Guideline effective October 1, 2025:

The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG‑MED‑26 Neonatal Levels of Care