Medical policy and clinical guideline updates are available on anthem.com

The following new and revised medical policies and clinical guidelines were endorsed at the February 11, 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. 

 

Revised medical policy effective February 18, 2021

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

• 00121 - Transcatheter Heart Valve Procedures
• 00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

 

Reviewed medical policies effective April 1, 2021

The following medical policies were reviewed and updated with new procedure and/or diagnoses codes.

• 00049 - Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy)
• 00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• 00011 - Analysis of Proteomic Patterns

 

Coding update effective April 1, 2021

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

• OR-PR.00005 – Upper Extremity Myoelectric Orthoses

 

New Medical Policy effective April 1, 2021

The following medical policy is new.

• 00056 - Gene Expression Profiling for Bladder Cancer

 

Revised medical policy effective April 1, 2021

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

• 00087 - Optical Detection for Screening and Identification of Cervical Cancer

 

Reviewed medical policies effective April 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.

• 00007 – Cosmetic and Reconstructive Services: Skin Related
• 00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
• 00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
• 00032 - Automated External Defibrillators for Home Use
• 00041 - Low Intensity Therapeutic Ultrasound
• 00009 - Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
• 00038 - Genetic Testing for Statin-Induced Myopathy
• 00050 - Gene Expression Profiling for Coronary Artery Disease
• 00054 - Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
• 00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
• 00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
• 00025 - Topographic Genotyping
• 00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
• 00024 - Adoptive Immunotherapy and Cellular Therapy
• 00053 - Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
• 00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• 00059 - Idiopathic Environmental Illness (IEI)
• 00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
• 00102 - Ultrafiltration in Decompensated Heart Failure
• 00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
• 00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
• 00111 - Intracardiac Ischemia Monitoring
• 00112 - Autonomic Testing
• 00118 - Continuous Monitoring of Intraocular Pressure
• 00120 - Gene Therapy for Ocular Conditions
• 00125 - Biofeedback and Neurofeedback
• 00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
• OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
• 00001 - Computed Tomography of Detect Coronary Artery Calcification
• 00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
• 00044 - Magnetic Resonance Neurography
• 00052 - Positional MRI
• 00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
• 00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• 00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
• 00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
• 00053 - Unicondylar Interpositional Spacer
• 00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
• 00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
• 00070 - Photocoagulation of Macular Drusen
• 00072 - Lysis of Epidural Adhesions
• 00075 - Intervertebral Stabilization Devices
• 00089 - Self-Expanding Absorptive Sinus Ostial Dilation
• 00096 - Surgical and Ablative Treatments for Chronic Headaches
• 00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
• 00107 - Prostate Saturation Biopsy
• 00113 - Artificial Retinal Devices
• 00124 - Carotid Sinus Baroreceptor Stimulation Devices
• 00127 - Sacroiliac Joint Fusion
• 00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
• 00137 - Focused Microwave Thermotherapy for Breast Cancer
• 00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
• 00143 - Perirectal Spacers for Use During Prostate Radiotherapy
• 00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
• 00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
• 00150 - Leadless Pacemaker
• 00151 - Balloon Dilation of Eustachian Tubes
• 00152- Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
• 00154 - Microsurgical Procedures for the Treatment of Lymphedema
• 00011 - Pancreas Transplant and Pancreas-Kidney Transplant
• 00013 - Small Bowel and Multivisceral Transplant including Small Bowel/Liver
• 00016 - Umbilical Cord Blood Progenitor Cell Transplant
• 00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
• 00028 - Hematopoietic Stem Cell Transplant for Hodgkin’s Disease & Non-Hodgkin’s Lymphoma
• 00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease & Misc. Solid Tumors

 

Archived medical policy effective April 7, 2021

The following medical policy has been archived.

• 00077 - In-Vivo Analysis of Gastrointestinal Lesions

 

Archived medical policy effective April 7, 2021

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

• 00007 - Cardiac Ion Channel Genetic Testing (transitioned to CG-GENE-23)
• 00011 - Gene Expression Profiling for Managing Breast Cancer Treatment (transitioned to CG-GENE-22)
• 00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy) (transitioned to CG-GENE-23)

 

Archived medical policy effective June 25, 2021

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

• 00022 - Lung Volume Reduction Surgery (transitioned to CG-SURG-110)

 

New medical policies effective July 1, 2021

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

• 00038 - Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
• 00039 - Pooled Antibiotic Sensitivity Testing
• 00159 - Focal Laser Ablation for the Treatment of Prostate Cancer
• 00037 - Uterine Transplantation

 

Revised medical policies effective July 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.

• 00008 - Cosmetic and Reconstructive Services of the Head and Neck
• 00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
• 00056 - Gene Expression Profiling for Bladder Cancer

 

Revised clinical guidelines effective February 18, 2021

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

• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
• CG-SURG-27 - Gender Reassignment Surgery

 

Revised clinical guideline effective April 1, 2021

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

• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules

 

Revised clinical guideline effective April 1, 2021

The following adopted guideline was revised and may have word changes or coding updates but had no significant changes to the position or criteria.

• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

 

Archived clinical guidelines effective April 1, 2021

The following adopted guidelines have been archived and their content has been transferred to an existing Clinical UM Guideline.

• CG-GENE-02 - Analysis of RAS Status (transferred to CG-GENE-14)
• CG-GENE-03 - BRAF Mutation Analysis (transferred to CG-GENE-14)
• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions (transferred to CG-GENE-14)
• CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing (transferred to CG-GENE-14)

 

Revised clinical guidelines effective April 7, 2021

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

• CG-MED-26 - Neonatal Levels of Care
• CG-SURG-71 - Reduction Mammoplasty
• CG-SURG-97 - Cardioverter Defibrillators
• CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

 

Reviewed clinical guidelines effective April 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-06 - Pneumatic Compression Devices for Lymphedema
• CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
• CG-GENE-07 - BCR-ABL Mutation Analysis
• CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
• CG-GENE-09 - Genetic Testing for CHARGE Syndrome
• CG-GENE-16 - BRCA Genetic Testing
• CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
• CG-MED-68 - Therapeutic Apheresis
• CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
• CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
• CG-SURG-99 - Panniculectomy and Abdominoplasty
• CG-SURG-104 - Intraoperative Neurophysiological Monitoring
• CG-TRANS-02 - Kidney Transplantation

 

New clinical guidelines effective April 7, 2021

The following guidelines were previously medical policies and have been adopted with no significant changes.

• CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment (previously GENE.00011)
• CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions (previously GENE.00007 and GENE.00017)

 

New clinical guideline effective April 7, 2021

The following guideline is new and has been adopted.

• CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting

 

New clinical guideline effective June 25, 2021

The following guideline was previously a medical policy and has been adopted with have no significant changes.

• CG-SURG-110 - Lung Volume Reduction Surgery (previously SURG.00022)

 

Revised clinical guidelines effective July 1, 2021

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

• CG-GENE-13 - Genetic Testing for Inherited Diseases
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
• CG-SURG-88 - Mastectomy for Gynecomastia
• CG-SURG-97 - Cardioverter Defibrillators
• CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

 

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