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

The following new and revised medical policies and clinical guidelines were endorsed at the March 22, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > Select a state > Find Resources for [state] > Medical Policies and Clinical UM Guidelines.

 

If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.

 

Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.

 

Revised medical policies effective March 29, 2018

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

 

DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility

SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke

 

New medical policy effective March 29, 2018

(The policy below is new and determined to not have significant change.)

 

MED.00120 - Voretigene neparvovec (Luxturna™)

 

Revised medical policies effective April 25, 2018   

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

 

DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting

RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer

SURG.00121 - Transcatheter Heart Valve Procedures

 

Revised medical policies effective April 25, 2018      

(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)

 

ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck

DME.00032 - Automated External Defibrillators for Home Use

DRUG.00086 - Mecasermin (Increlex®)

DRUG.00108 - Edaravone (Radicava®)

GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

MED.00007 - Prolotherapy for Joint and Ligamentous Conditions

MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State

MED.00059 - Idiopathic Environmental Illness (IEI)

MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)

RAD.00012 - Ultrasound for the Evaluation of Paranasal Sinuses

RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

RAD.00044 - Magnetic Resonance Neurography

RAD.00052 - Positional MRI

REHAB.00003 - Hippotherapy

SURG.00033 - Cardioverter Defibrillators

SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons

SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions

SURG.00048 - Panniculectomy and Abdominoplasty

SURG.00053 - Unicondylar Interpositional Spacer

SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence

SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses

SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

SURG.00066 - Percutaneous Neurolysis for Chronic Neck and Back Pain

SURG.00070 - Photocoagulation of Macular Drusen

SURG.00073 - Epiduroscopy

SURG.00079 - Nasal Valve Suspension

SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches

SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma

SURG.00111 - Axial Lumbar Interbody Fusion

SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

SURG.00150 - Leadless Pacemaker

TRANS.00008 - Liver Transplantation

TRANS.00009 - Lung and Lobar Transplantation

TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation

TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation

TRANS.00026 - Heart/Lung Transplantation

TRANS.00033 - Heart Transplantation

 

Archived medical policy effective June 22, 2018

(This policy is now an Anthem Clinical Guideline.)

 

DRUG.00092 - Buprenorphine Implant (Probuphine®)

 

Archived medical policies effective June 28, 2018

(These polices are now Anthem Clinical Guidelines.)

 

BEH-00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

DRUG.00028 - Intravitreal Treatment for Retinal Vascular Conditions

DRUG.00032 - Intravitreal Corticosteroid Implants

DRUG.00072 - Alpha-1 Proteinase Inhibitor Therapy

DRUG.00101 - Sarilumab (Kevzara®)

LAB.00020 - Skin Nerve Fiber Density Testing

MED.00076 - Inhaled Nitric Oxide

RAD.00030 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

SURG.00081 - Total Ankle Replacement

SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation

SURG.00110 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions

THER-RAD.00003 - Intravascular Brachytherapy (Coronary and Non-Coronary

 

Archived medical policy effective October 31, 2018

(This policy is now an MCG Behavioral Health Clinical Guideline.) 

 

BEH.00001 - Opioid Antagonists under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification

 

Revised medical policies effective September 1, 2018

(The following policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

 

DRUG.00003 - Chelation Therapy

OR.PR.00003 - Microprocessor Controlled Lower Limb Prostheses

SURG.00037 - Treatment of Varicose Veins (Lower Extremity)

SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

New medical policy effective September 1, 2018

(The policy below is new and may result in services previously covered now being considered either not medically necessary and/or investigational)

 

SURG.00151 - Balloon Dilation of Eustachian Tubes

 

Revised clinical guidelines effective April 25, 2018   

(The following guidelines were revised and had no significant changes to the position or criteria.)

 

CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder

CG-BEH-03 - Psychiatric Disorder Treatment

CG-BEH-07 - Psychological Testing

CG-DRUG-27 - Clostridial Collagenase Histolyticum Injection

CG-DRUG-57 - Idursulfase (Elaprase®)

CG-MED-55 - Level of Care: Advanced Radiologic Imaging

CG-MED-68 - Therapeutic Apheresis

CG-SURG-09 - Temporomandibular Disorders

CG-SURG-27 - Sex Reassignment Surgery

CG-TRANS-02 - Kidney Transplantation

 

New and adopted clinical guidelines effective June 22, 2018

(The following guidelines were previously medical policies and have been adopted. No significant changes were made.)

 

CG-DRUG-89 - Implantable and Extended-Release Buprenorphine-Containing Products  

CG-DRUG-92 - Alpha-1 Proteinase Inhibitor Therapy

 

New and adopted clinical guidelines effective June 28, 2018

(The following guidelines were previously medical policies and have been adopted. No significant changes were made.)

 

CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions

CG-DRUG-91 - Intravitreal Corticosteroid Implants

CG-DRUG-93 - Sarilumab (Kevzara®)

CG-LAB-13 - Skin Nerve Fiber Density Testing

CG-MED-69 - Inhaled Nitric Oxide

CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

CG-SURG 73 - Self-Expanding Absorptive Sinus Ostial Dilation

CG-SURG-74 - Total Ankle Replacement

CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions

CG-THER-RAD.07 - Intravascular Brachytherapy (Coronary and Non-Coronary

 

Revised clinical guidelines effective September 1, 2018

(The following guidelines might result in services that were previously covered now being considered not medically necessary.)

 

CG-DME-06 - Pneumatic Compression Devices for Lymphedema

CG-REHAB-04 - Physical Therapy

CG-REHAB-05 - Occupational Therapy

 

Adopted clinical guideline effective September 1, 2018

(The following guideline was adopted and might result in services that were previously covered now being considered not medically necessary.)

 

CG-DRUG-44 - Pegloticase (Krystexxa®)

 

Archived clinical guidelines effective October 31, 2018

(These guidelines are now MCG Behavioral Health Clinical Guidelines.) 

 

CG-BEH-03 - Psychiatric Disorder Treatment

CG-BEH-04 - Substance-Related and Addictive Disorder Treatment

CG-BEH-05 - Eating and Feeding Disorder Treatment

CG-BEH-07 - Psychological Testing

CG-MED-23 - Home Health