Provider News ConnecticutAugust 2019 Anthem Connecticut Provider NewsAs part of our commitment to provider collaboration, Anthem is introducing a new program to reduce the administrative burden associated with current prior authorization (PA) processes for providers who are contracted with Anthem in Connecticut. The Prior Auth Pass Program allows providers who meet program requirements to waive prior authorization for select outpatient medical procedures that generally have high rates of PA requests and approvals.
For providers that meet all program criteria and agree to participate in the Prior Auth Pass Program, the provider will no longer need to submit a request for a PA decision for a predetermined list of common medical procedures. They will simply verify that the patient is an Anthem member* receiving services in Connecticut and then provide the eligible service.
Current criteria for participation in Anthem’s Prior Auth Pass Program are as follows:
- Participation in the Cooperative Care value-based program, which includes meaningful shared risk for their Commercial patient population.
- Demonstration of historically high prior authorization approval rates of 90% or greater for program procedure codes.
- Commitment to Anthem’s back-end monitoring process to manage under- and over-utilization.
- Having technical system capabilities in place to allow for timely adoption and implementation.
For questions about fulfilling the criteria and participating in the Prior Auth Pass Program, please contact CTNetworkManagement-SM@anthem.com.
*Exceptions: BlueCard Host members, Federal Employee Program members, New York State and New York City employees. Effective November 1, 2019, the following MCG care guideline 23rd edition customization will be implemented for chemotherapy, inpatient & surgical care (W0162) for adult patients. This customization provides specific criteria and guidance on the following:
- Revised clinical indications for admission and added examples for:
- o Aggressive hydration needs that cannot be managed in an infusion center
- o Prolonged marrow suppression
- Added regimens that cannot be managed as an outpatient with examples
Visit our website to view the summary of MCG 23RD edition customizations.
For questions, please contact the provider service number on the back of the member's ID card. We have launched a new page on our Provider website to access Provider Manuals. This page delivers a more streamlined and easier user experience to access both current and archived Manuals (if applicable), as well as the BlueCard Manual. The new page can be found at anthem.com/provider, then scroll down to ‘Enjoy Easy Access to Policies and Guidelines.’ Select ‘See Policies and Guidelines’. On the Policies and Guidelines landing page, you’ll find a link to the Provider Manuals page. Fee Schedule information is proprietary to Anthem Blue Cross and Blue Shield (Anthem) under the terms and conditions of your participation Agreement (the Agreement) with Anthem. The Agreement sets forth restrictions against the disclosure of proprietary information. Those restrictions include the disclosure of proprietary information such as fee schedule information to third-parties (e.g., consultants, lenders, legal advisors, and business advisors). Absent Anthem’s written consent, those restrictions apply to all third-parties that conduct business on behalf of Anthem’s participating providers.
Exceptions to those restrictions, as set forth in the Agreement, include: i) disclosure as required or permitted by applicable law or regulatory requirements; and/or ii) disclosure as consented to by Anthem.
In the case of permitted disclosures, all third-parties are subject to the confidentiality requirements as set forth in your participation Agreement.
Please refer to your participation Agreement to ensure you understand all restrictions and exceptions.
Disclosure of confidential and proprietary information, in violation of the terms of the Agreement, is subject to penalty.
The following new and revised medical policies were endorsed at the June 6, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > scroll down and select ‘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.
Transitioned medical policies effective June 10, 2019
[The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.]
- DRUG.00046 - Ipilimumab (Yervoy®) [transitioned to ING-CC-0119 Yervoy (ipilimumab)]
- DRUG.00053 - Carfilzomib (Kyprolis®) [transitioned to ING-CC-0120 Kyprolis (carfilzomib)]
- DRUG.00063 - Ofatumumab (Arzerra®) [transitioned to ING-CC-0122 Arzerra (ofatumumab)]
- DRUG.00067 - Ramucirumab (Cyramza®) [transitioned to ING-CC-0123 Cyramza (ramucirumab)
- DRUG.00071 - Pembrolizumab (Keytruda®) [transitioned to ING-CC-0124 Keytruda (pembrolizumab)]
- DRUG.00075 - Nivolumab (Opdivo®) [transitioned to ING-CC-0125 Opdivo (nivolumab)]
- DRUG.00107 - Avelumab (Bavencio®) [transitioned to ING-CC-0129 Bavencio (avelumab)]
Revised medical policies effective June 13, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
New medical policy effective June 13, 2019
(The policy below is new and determined to not have significant change.)
- MED.00129 - Gene Therapy for Spinal Muscular Atrophy
Revised medical policies effective June 27, 2019
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00062 - Obinutuzumab (Gazyva®)
- GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
Revised medical policies effective June 27, 2019
(The following policies were reviewed and had procedure code/diagnoses code updates, but had no significant changes to the policy position or criteria.)
- GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies
- GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
- SURG.00010 - Treatments for Urinary Incontinence
- SURG.00121 - Transcatheter Heart Valves Procedures
Revised medical policies effective June 27, 2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
Revised medical policy effective July 10, 2019
(The following policy were revised to expand medical necessity indications or criteria.)
- MED.00109 - Corneal Collagen Cross-Linking
Revised medical policies effective July 10, 2019
(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)
- ADMIN.00002 - Preventive Health Guidelines
- ADMIN.00004 - Medical Necessity Criteria
- ADMIN.00005 - Investigational Criteria
- ADMIN.00007 - Immunizations
- ANC.00006 - Biomagnetic Therapy
- ANC.00007 - Cosmetic and Reconstructive Services; Skin Related
- DME.00024 - Transtympanic Micropressure for the Treatment of Meniere's Disease
- DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
- DME.00034 - Standing Frames
- DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
- DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
- GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
- GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
- GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
- GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
- LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
- LAB.00031 - Advanced Lipoprotein Testing
- LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- MED.00098 - Hyperoxemic Reperfusion Therapy
- MED.00106 - Sipuleucel-T (Provenge®)
- MED.00123 - Axicabtagene ciloleucel (Yescarta®)
- MED.00124 - Tisagenlecleucel (Kymriah®)
- MED.00127 - Chelation Therapy
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
- RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
- SURG.00005 - Partial Left Ventriculectomy
- SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
- SURG.00076 - Nerve Graft After Prostatectomy
- SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
- SURG.00084 - Implantable Middle Ear Hearing Aids
- SURG.00105 - Bicmpartmental Knee Arthroplasty
- SURG.00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
- SURG.00118 - Bronchail Termoplasty
- SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
- SURG.00126 - Irreversible Electroporation
- SURG.00134 - Interspinous Process Fixation Devices
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
Transitioned medical policies effective September 1, 2019
(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- DRUG.00062 - Obinutuzumab (Gazyva®) [transitioned to ING-CC-0121 Gazyva (obinutuzumab)]
- DRUG.00076 - Blinatumomab (Blincyto®) [transitioned to ING-CC-0126 Blincyto (blinatumomab)
- DRUG.00082 - Daratumumab (DARZALEX®) [transitioned to ING-CC-0127 Darzalex (daratumumab)]
- DRUG.00088 - Atezolizumab (Tecentriq®) [transitioned to ING-CC-0128 Tecentriq (atezolizumab)]
- DRUG.00109 - Durvalumab (Imfinzi®) [transitioned to ING-CC-0130 Imfinzi (durvalumab)]
- DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®) [transitioned to ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)]
- DRUG.00118 - Copanlisib (Aliqopa®) [transitioned to ING-CC-0133 Aliqopa (copanlisib)]
- MED.00106 - Sipuleucel-T (Provenge®) [transitioned to ING-CC-0134 Provenge (Sipuleucel-T)]
Revised medical policy effective September 4, 2019
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- GENE.00010 - Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status [Note: Genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved into a separate clinical utilization management guideline, CG-GENE-11: Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status.]
Archived medical policies effective September 4, 2019
(These policies are now Anthem Clinical Guidelines.)
- GENE.00021 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies (transitioned to CG-GENE-10)
- SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus (transitioned to CG-SURG-101)
- SURG.00133 - Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy (transitioned to CG-SURG-102)
Revised medical policies effective November 1, 2019
(The following policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
- LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
- LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer Test
- OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
- SURG.00045 - Extracorporeal Shock Wave Therapy
- SURG.00120 - Internal Rib Fixation Systems
New medical policies effective November 1, 2019
(The policies below are new and determined to not have significant change.
- GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
- SURG.00153 - Cardiac Contractility Modulation Therapy
The following new and revised medical policies were endorsed at the June 6, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem clinical guidelines, are available at anthem.com/provider > scroll down and select ‘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.
Transitioned clinical guidelines effective June 10, 2019
(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- CG-DRUG-38 - Pemetrexed Disodium (Alimta®) [transitioned to ING-CC-0094 Alimta (pemetrexed)]
- CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase) [transitioned to ING-CC-0096 Asparagine Specific Enzymes]
- CG-DRUG-63 - Levoleucovorin Products [transitioned to ING-CC-0104 Levoleucovorin Agents]
- CG-DRUG-66 - Panitumumab (Vectibix®) [transitioned to ING-CC-0105 Vectibix (panitumumab)]
- CG-DRUG-72 - Pertuzumab (Perjeta®) [transitioned to ING-CC-0110 Perjeta (pertuzumab)]
- CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®) [transitioned to ING-CC-0115 Kadcyla (ado-trastuzumab)]
- CG-DRUG-98 - Bendamustine Hydrochloride [transitioned to ING-CC-0116 Bendamustine agents]
- CG-DRUG-106 - Brentuximab Vedotin (Adcetris®) [transitioned to ING-CC-0092 Adcetris (brentuximab)]
Revised clinical guideline effective July 10, 2019
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
Revised clinical guidelines effective July 10, 2019
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DME-45 - Ultrasound Bone Growth Stimulation
- CG-GENE-02 - Analysis of KRAS Status
- CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
- CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
- CG-MED-77 - SPECT/CT Fusion Imaging
- CG-MED-83 - Level of Care: Specialty Pharmaceuticals
- CG-REHAB-11 - Cognitive Rehabilitation
- CG-SURG-05 - Maze Procedure
- CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- CG-SURG-12 - Penile Prosthesis Implantation
- CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
- CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
- CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
- CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
- CG-SURG-85 - Hip Resurfacing
- CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
- CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
- CG-SURG-88 - Mastectomy for Gynecomastia
- CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
- CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Transitioned clinical guideline effective August 1, 2019
(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- CG-DRUG-76 - Plerixafor Injection (Mozobil™) [Transitioned to ING-CC-0089 Mozobil (plerixafor)]
Transitioned clinical guidelines effective September 1, 2019
(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use [transitioned to ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use]
- CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection [transitioned to ING-CC-0098 Doxorubicin Hydrochloride Liposome]
- CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®) [transitioned to ING-CC-0099 Abraxane (paclitaxel protein-bound)]
- CG-DRUG-51 - Romidepsin (Istodax®) [transitioned to ING-CC-0100 Istodax (romidepsin)]
- CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration [transitioned to ING-CC-0136 Dose, frequency, and route of administration]
- CG-DRUG-62 - Fulvestrant (FASLODEX®) [transitioned to ING-CC-0103 Faslodex (fulvestrant)]tCG-DRUG-67 - Cetuximab (Erbitux®) [transitioned to ING-CC-0106 Erbitux (cetuximab)]
- CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications [transitioned to ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications (Avastin, Mvasi)]
- CG-DRUG-70 - Eribulin mesylate (Halaven®) [transitioned to ING-CC-0108 Halaven (eribulin)]
- CG-DRUG-71 - Ziv-aflibercept (Zaltrap®) [transitioned to ING-CC-0109 Zaltrap (ziv-aflibercept)]
- CG-DRUG-75 - Romiplostim (Nplate®) [transitioned to ING-CC-0111 Nplate (romiplostim)]
- CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)[transitioned to ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)]
- CG-DRUG-80 - Cabazitaxel (Jevtana®) [transitioned to ING-CC-0114 Jevtana (cabazitaxel)]
- CG-DRUG-99 - Elotuzumab (Empliciti™) [transitioned to ING-CC-0117 Empliciti (elotuzumab)]
- CG-DRUG-100 - Interferon gamma-1b (Actimmune®) [transitioned to ING-CC-0085 Actimmune (interferon gamma-1B)]
- CG-DRUG-101 - Ixabepilone (Ixempra®) [transitioned to ING-CC-0090 Ixempra (ixabepilone)]
- CG-DRUG-102 - Olaratumab (Lartruvo™) [transitioned to ING-CC-0091 Lartruvo (olaratumab)]
- CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) [transitioned to ING-CC-0131 Besponsa (inotuzumab ozogamicin)]
- CG-MED-67 - Melanoma Vaccines [transitioned to ING-CC-0135 Melanoma Vaccines]
- CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [transitioned to ING-CC-0118 Radioimmunotherapy: Zevalin; azedra; Lutathera]
Adopted clinical guidelines effective September 4, 2019
(The following guidelines were previously medical policies and have been adopted with no significant changes.)
- CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies (converted from GENE.00021)
- CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status (content previously addressed in GENE.00010)
- CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus (converted from SURG.00106)
Revised clinical guideline effective November 1, 2019
(The guideline listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)
- CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
Transitioned clinical guideline effective November 1, 2019
(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- CG-DRUG-79 - Siltuximab (Sylvant®) [transitioned to ING-CC-0113 Sylvant (siltuximab)]
Below are clinical criteria that were endorsed at the May 17, 2019 clinical criteria meeting. To access the clinical criteria information please click here.
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.
Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Revised clinical criteria effective June 10, 2019
The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
CG-DRUG-106
|
ING-CC-0092
|
Adcetris (brentuximab)
|
Adcetris
|
J9042
|
CG-DRUG-38
|
ING-CC-0094
|
Alimta (pemetrexed)
|
Alimta
|
J9305
|
CG-DRUG-42
|
ING-CC-0096
|
Asparagine Specific Enzymes
|
Erwinaze, Asparaginase, Oncaspar
|
J9019, J9020, J9266
|
CG-DRUG-63
|
ING-CC-0104
|
Leucovorin and Levoleucovorin agents
|
Fusilev, Khapzory
|
J0641, C9043, J3490
|
CG-DRUG-66
|
ING-CC-0105
|
Vectibix (panitumumab)
|
Vectibix
|
J9303
|
CG-DRUG-72
|
ING-CC-0110
|
Perjeta (pertuzumab)
|
Perjeta
|
J9306
|
CG-DRUG-96
|
ING-CC-0115
|
Kadcyla (ado-trastuzumab)
|
Kadcyla
|
J9354
|
CG-DRUG-98
|
ING-CC-0116
|
Bendamustine agents
|
Bendeka, Treanda, Belrapzo
|
J9034, J9033, C9042, J9999
|
DRUG.00046
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Yervoy
|
J9228
|
DRUG.00053
|
ING-CC-0120
|
Kyprolis (carfilzomib)
|
Kyprolis
|
J9047
|
DRUG.00063
|
ING-CC-0122
|
Arzerra (ofatumumab)
|
Arzerra
|
J9302
|
DRUG.00067
|
ING-CC-0123
|
Cyramza (ramucirumab)
|
Cyramza
|
J9308
|
DRUG.00071
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Keytruda
|
J9271
|
DRUG.00075
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Opdivo
|
J9299
|
DRUG.00107
|
ING-CC-0129
|
Bavencio (avelumab)
|
Bavencio
|
J9023
|
Revised clinical criteria effective September 1, 2019
The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
CG-DRUG-100
|
ING-CC-0085
|
Actimmune (interferon gamma-1B)
|
Actimmune
|
J9216
|
CG-DRUG-101
|
ING-CC-0090
|
Ixempra (ixabepilone)
|
Ixempra
|
J9207
|
CG-DRUG-102
|
ING-CC-0091
|
Lartruvo (olaratumab)
|
Lartruvo
|
J9285
|
CG-DRUG-49
|
ING-CC-0098
|
Doxorubicin Hydrochloride Liposome
|
Lipodox, Doxorubicin hydrochloride liposomal, Doxil
|
Q2049, Q2050
|
CG-DRUG-50
|
ING-CC-0099
|
Abraxane (paclitaxel protein-bound)
|
Abraxane
|
J9264
|
CG-DRUG-51
|
ING-CC-0100
|
Istodax (romidepsin)
|
Istodax
|
J9315
|
CG-DRUG-62
|
ING-CC-0103
|
Faslodex (fulvestrant)
|
Faslodex
|
J9395
|
CG-DRUG-67
|
ING-CC-0106
|
Erbitux (cetuximab)
|
Erbitux
|
J9055
|
CG-DRUG-68
|
ING-CC-0107
|
Bevacizumab agents (Avastin, Mvasi)
|
Avastin, Mvasi
|
J9035, Q5107
|
CG-DRUG-70
|
ING-CC-0108
|
Halaven (eribulin)
|
Halaven
|
J9179
|
CG-DRUG-71
|
ING-CC-0109
|
Zaltrap (ziv-aflibercept)
|
Zaltrap
|
J9400
|
CG-DRUG-75
|
ING-CC-0111
|
Nplate (romiplostim)
|
Nplate
|
J2796
|
CG-DRUG-77
|
ING-CC-0112
|
Xofigo (Radium Ra 223 Dichloride)
|
Xofigo
|
A9606, 79101
|
CG-DRUG-80
|
ING-CC-0114
|
Jevtana (cabazitaxel)
|
Jevtana
|
J9043
|
CG-DRUG-99
|
ING-CC-0117
|
Empliciti (elotuzumab)
|
Empliciti
|
J9176
|
CG-THER-RAD-03
|
ING-CC-0118
|
Radioimmunotherapy: Zevalin; azedra; Lutathera
|
Zevalin, Azedra, Lutathera
|
79403, A9543, 79101, A9699, C9408, A9513
|
DRUG.00062
|
ING-CC-0121
|
Gazyva (obinutuzumab)
|
Gazyva
|
J9301
|
DRUG.00076
|
ING-CC-0126
|
Blincyto (blinatumomab)
|
Blincyto
|
J9039
|
DRUG.00082
|
ING-CC-0127
|
Darzalex (daratumumab)
|
Darzalex
|
J9145
|
DRUG.00088
|
ING-CC-0128
|
Tecentriq (atezolizumab)
|
Tecentriq
|
J9022
|
DRUG.00109
|
ING-CC-0130
|
Imfinzi (durvalumab)
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Imfinzi
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J9173
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CG-DRUG-113
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ING-CC-0131
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Besponsa (inotuzumab ozogamicin)
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Besponsa
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J9229
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DRUG.00112
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ING-CC-0132
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Mylotarg (gemtuzumab ozogamicin)
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Mylotarg
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J9203
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DRUG.00118
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ING-CC-0133
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Aliqopa (copanlisib)
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Aliqopa
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J9057
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MED.00106
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ING-CC-0134
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Provenge (Sipuleucel-T)
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Provenge
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Q2043
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CG-MED-67
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ING-CC-0135
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Melanoma Vaccines
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Imlygic
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J9325, J3590
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CG-DRUG-53
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ING-CC-0136
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Drug dosage, frequency, and route of administration
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N/A
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N/A
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CG-DRUG-01
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ING-CC-0141
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Off-Label Drug and Approved Orphan Drug Use
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N/A
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N/A
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Revised clinical criteria effective November 1, 2019
The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]
New clinical criteria effective November 1, 2019
The following clinical criteria are new.
- ING-CC-0137 Cablivi (caplacizumab-yhdp)
- ING-CC-0138 Asparlas (calaspargase pegol-mknl)
- ING-CC-0139 Evenity (romosozumab-aqqg)
- ING-CC-0140 Zulresso (brexanolone)
Bundled, Beginning with dates of service on or after November 1, 2019, new Interprofessional CPT codes 99451 and 99452 are not eligible for reimbursement when they are reported with another service or reported as a stand-alone service. These codes have been added to policy section 1 of the Bundled Services and Supplies reimbursement policy. Our Frequency Editing policy applies frequency maximums per day and/or per date span within the same grouping which may be based on the CMS’s MUEs, industry standards, and/or code description. Beginning with dates of service November 1, 2019, maximum units per day may be based on claims data analysis. Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.
Oncologic Imaging Guideline contains updates to the following:
- Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary/cancers not otherwise specified,
- Added new sections on hepatobiliary cancer and suspected metastases
- Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
- Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”
Vascular Imaging Guideline contains updates to the following:
- Brain, head and neck: aneurysm - intracranial, aneurysm - extracranial, arteriovenous malformation (AVM) and fistula (AVF), fibromuscular dysplasia, hemorrhage - intracranial, stenosis or occlusion - extracranial, stenosis or occlusion - intracranial, stroke and venous thrombosis or compression - intracranial
- Chest: acute aortic syndrome, aortic aneurysm, pulmonary artery hypertension
- Abdomen and pelvis: acute aortic syndrome, aneurysm of the abdominal aorta or iliac arteries, hematoma/hemorrhage within the abdomen or unexplained hypotension, renal artery stenosis (RAS)/renovascular hypertension, venous thrombosis or compression – intracranial, stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- Upper extremity: peripheral arterial disease, venous thrombosis or occlusion
- Lower extremity: added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
- Added arterial ultrasound guideline content
- Aligned peripheral arterial ultrasound with advanced vascular imaging criteria
Imaging of the Heart Guideline contains updates to the following:
- Blood pool imaging: changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
- Cardiac CT: quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.
Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 866-714-1107, Monday - Friday, 8:00 a.m. - 5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Radiation Oncology: Proton Beam Therapy Clinical Appropriateness Guideline.
- Sinonasal cancer: Added criteria and diagnosis codes for locally advanced sinonasal cancer when tumor involves base of skull and proton beam therapy is needed to spare orbit, optic nerve, optic chiasm, or brainstem
- Ocular Melanoma: Removed tumor size restrictions for treating melanoma of the uveal tract
- Pediatric tumors: Clarified proton beam therapy appropriate for all pediatric tumors requiring radiation therapy
Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 866-714-1107, Monday - Friday, 8:00 a.m. - 5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Effective for dates of service on and after July 14, 2019, the following updates will apply to the AIM Advanced Oncologic Imaging Clinical Appropriateness Guideline.
Added criteria for the appropriate use of PET-CT with the radiotracers Axumin and 11-Choline, establishing the position of this test in the care continuum for prostate cancer primarily related to biochemical recurrence
Added criteria for the appropriate use of PET-CT with the radiotracer DOTA-TATE, establishing the position of this test in the care continuum for neuroendocrine tumors
Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 866-714-1107, Monday - Friday, 8:00 a.m. - 5:00 p.m.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Effective for dates of service on and after November 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria will be included in our pre-service clinical review process.
Please note: inclusion of NDC code on claims will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.
Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Medical Policy or Clinical UM Guideline
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HCPCS or CPT Codes
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NDC Codes
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Drug
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ING-CC-0050
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J3490
J3590
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00074-2042-01
00074-2042-02
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Skyrizi™
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In the June 2019 issue of Provider News we announced the transition of the medical non-oncology specialty drug review process from AIM Specialty Health® (AIM) to Anthem’s medical specialty drug review team, effective June 15, 2019. Here’s a reminder of the changes.
What has changed?
- Beginning June 15, 2019, for all new specialty drug review requests and reauthorization specialty drug review requests that were previously performed by AIM, providers need to contact Anthem’s medical specialty drug review team:
- by phone at 833-293-0659 or
- by fax at 888-223-0550
- All inquiries about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration are being managed by Anthem’s medical specialty drug review team.
What has not changed?
- AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
- Specialty drug review processes not previously done by AIM remain unchanged.
- Clinical criteria for medical non-oncology specialty drugs continues to reside on the clinical criteria page on anthem.com.
- Post service clinical coverage reviews and grievance and appeals process and teams have not changed.
Here is a summary of the medical specialty drug changes beginning June 15, 2019:
Action
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Contact
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Submit a new prior authorization request for a medical specialty drug review
Submit a reauthorization request for a medical specialty drug review previously performed by AIM
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Call Anthem at 833-293-0659 or
Fax Anthem at 888-223-0550
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Inquire about an existing request (initially submitted to AIM or Anthem, peer-to-peer review, or reconsideration
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Call Anthem at 833-293-0659
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For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions and other requirements, restrictions or limitations that apply to certain drugs, visit anthem.com/pharmacyinformation.
- To locate the commercial drug list, select ‘Click here to access your drug list’.
- To locate the Marketplace Select Formulary and pharmacy information, scroll down to ‘Select Drug Lists’, then select the applicable state’s drug list link.
The commercial and marketplace drug lists are reviewed and updates are posted to the website quarterly (the first of the month for January, April, July and October).
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. This drug list is also reviewed and updated regularly as needed. Enhancements have been made to the Availity Portal that will now allow you to access more service types when using the Eligibility and Benefits Inquiry tool, and will also allow us to share even more valuable information with you electronically.
You may have already noticed new additions to service types, including:
- Medically related transportation
- Long-term care
- Acupuncture
- Respite care
- Dermatology
- Sleep study therapy (found under diagnostic medical)
- Allergy testing
Note, although there is an extensive list of available benefit types available when submitting an eligibility and benefits request, these types do vary by payer.
Here are some important points to remember when selecting service types:
- The benefit/service type field is populated with the last benefit type you selected. If you don’t see a specific benefit in the results, submit a new request and select the specific benefit type/service code.
- You have the ability to inquire about 50 patients at one time using the Add Multiple Patients feature.
Anthem Medicare Advantage allows reimbursement for presumptive and definitive drug screening services (policy 19-001). In certain circumstances, we allow reimbursement for presumptive drug testing by instrumented chemistry analyzers and definitive drug screening services for the same member provided on the same day by a reference laboratory.
Definitive drug testing may be done to confirm the results of a negative presumptive test or to identify substances when there is no presumptive test available. Provider’s documentation and member’s medical records should reflect that the test was properly ordered and support that the order was based on the result of the presumptive test.
In the event a reference lab (POS = 81) performs both presumptive and definitive tests on the same date of service, records should reflect that the ordering/treating provider issued a subsequent order for definitive testing based on the results of the presumptive tests.
For additional information, refer to the Drug Screen Testing reimbursement policy at www.anthem.com/medicareprovider.
Currently, providers submit various pre-service requests to AIM Specialty Health® (AIM). As part of our ongoing quality improvement efforts for outpatient diagnostic imaging services, cardiac procedures and sleep studies, AIM may request documentation to support the clinical appropriateness of certain requests.
When requested, providers should verify information by submitting documentation from the medical record and/or participating in a pre-service consultation with an AIM physician reviewer. If medical necessity is not supported, the request may be denied as not medically necessary.
Should you have any questions, please call the Provider Services number on the back of the member ID card.
We offer special needs plans (SNPs) to people eligible for either Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNPs include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums. As you are aware, CMS regulations protect SNP members from balance billing.
Providers who are contracted for SNPs are required to take annual training to stay current on plan benefits and requirements, including coordination-of-care and model-of-care elements. Providers contracted for our SNPs received notices in the first quarter of 2019 containing information for online, self-paced training through our training site hosted by SkillSoft. Each provider contracted for our SNPs is required to complete this annual training and select the attestation stating they have completed the training. Attestations can be completed by individual providers or at the group level with one signature.
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