July 2024 Provider Newsletter

Contents

AdministrativeCommercialJuly 1, 2024

Drugs and biologic

AdministrativeCommercialJuly 1, 2024

Connecticut fee schedule revision October 2024

AdministrativeCommercialJuly 1, 2024

Important changes to payment structure for PT, OT, and ST

AdministrativeCommercialJuly 1, 2024

Recovery room — facility editing update

AdministrativeCommercialMedicare AdvantageJune 12, 2024

Phoenix Sepsis Criteria for coding and billing pediatric sepsis

AdministrativeCommercialJuly 1, 2024

CAA: Maintain your online provider directory information

Education & TrainingCommercialMedicare AdvantageJuly 1, 2024

July is Disability Awareness Month

Education & TrainingCommercialJune 13, 2024

Faster notification of EDI corrected claims errors

Policy UpdatesMedicare AdvantageJune 3, 2024

Clinical Criteria updates — November 2023

Policy UpdatesMedicare AdvantageJune 4, 2024

Clinical Criteria updates

Policy UpdatesMedicare AdvantageMay 29, 2024

Carelon Medical Benefits Management, Inc. updates

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageJune 27, 2024

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2024

Medical Policy and Clinical Guideline updates

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 30, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Federal Employee Program (FEP)CommercialJuly 1, 2024

Antidepressant Medication Management (AMM)

PharmacyCommercialJuly 1, 2024

Correction: Specialty pharmacy updates — July 2024

PharmacyMedicare AdvantageJune 20, 2024

Anthem expands specialty pharmacy precertification list

Quality ManagementMedicare AdvantageJuly 1, 2024

Understanding your role in the Health Outcomes Survey

CTBCBS-CRCM-061267-24

AdministrativeCommercialJuly 1, 2024

Drugs and biologic

Effective October 1, 2024, Anthem is enhancing its claims editing system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate Federal Drug Administration (FDA) approved indicators for on- and off-label use.

These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with the FDA indicator for on-/off-label use.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record that is relevant to the drug provided.

If you have questions about this notification, contact your contract manager or provider relationship management account representative.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061244-24

AdministrativeCommercialJuly 1, 2024

Timely receipt of other carrier EOB or rejection helps avoid timely filing denials

When working with another carrier, submit documentation from the other carrier when you send the claim to Anthem to help avoid the claim from denying for timely filing. You can submit the documentation and the claim through Availity Essentials using the Claims and Payments application.

If we are the secondary payer, we will need to receive an Explanation of Benefits (EOB) along with the claim submission to determine our payment amount. To avoid a timely filing denial, the documentation must demonstrate that submission to the other insurer was within Anthem’s timely filing limit and must reflect that it was received within the timely filing limit starting from the date of the remittance advice or Explanation of Payments.

If you submit to the other carrier first and receive a rejection, submit the denial letter from the other insurance carrier along with the claim. To avoid a timely filing denial, the denial letter must be dated and printed on letterhead, and the claim and documentation must be submitted to Anthem within the timely filing limit starting from the date of the denial letter.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can delay your receiving payment and can also cause you to miss the timely filing guideline.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Resource

Coordination of benefits — how to avoid timely filing denial

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061117-24

ATTACHMENTS (available on web): Coordination of benefits — how to avoid timely filing denials (pdf - 0.32mb)

AdministrativeCommercialJuly 1, 2024

Connecticut fee schedule revision October 2024

At Anthem, we value our physician partnerships and appreciate the quality care you provide to our members. As part of our continued partnership with you, we are pleased to share that we are updating our commercial fee schedules for Connecticut, which will result in an overall net increase to our physician network fees starting this fall.

Anthem periodically reviews and updates its professional fee schedules to ensure access to high-quality, affordable healthcare for our members. This evaluation includes competitive benchmarking, analysis of CMS physician fee schedule rates and regulations, consideration of changes in care delivery models, and the impact of rate changes on the consumers we serve. Non-MD providers are paid at a percentage of the applicable fee schedule rate based on their level of education, licensure level, and how Medicare pays them.

These changes apply to Century 90 and Century Preferred programs (including PPO, EPO, CDHP products, and State Preferred); BlueCare Health Plan programs (including POE, POS, Prime, and State BlueCare); Pathway Small Group HMO and PPO; and Pathway Individual HMO and PPO products, programs, and benefit plans. Note that these changes do not apply to MediBlue HMO and PPO products, programs, and benefit plans.

The updated fee schedule will take effect October 1, 2024. The full schedule will be available in the Information Center in Availity Essentials starting July 1, 2024. Please refer to this site or contact the Provider Call Center at 800-922-3242 if you have any questions.

We appreciate your partnership and look forward to continuing to work with you to provide the people we mutually serve in Connecticut access to high-quality, affordable healthcare.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CM-061877-24-SRS61877

AdministrativeCommercialJuly 1, 2024

Important changes to payment structure for PT, OT, and ST

This is to inform you of changes to our payment model for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) that we believe will greatly simplify operations between our organizations.

Effective for dates of service on or after October 1, 2024, we will transition from a fee-for-service model to a per-diem (per day), flat-rate system. This means that instead of receiving payments based on each individual service provided, you will now receive up to an $80 daily per diem for those services. This change in methodology does not impact the way claims are submitted to Anthem. You should continue billing claims with the applicable reimbursement codes, modifiers, and units as is done today.

Our new methodology is aimed at providing more predictability and ease of management for both you and our organization. We believe this new model is in line with our continued commitment to providing the best services to our patients and a fair compensation structure for our dedicated professionals.

We want to take this opportunity to thank you for your continued dedication and outstanding care for our members. It is our hope that this new payment model will improve our services and allow us to further enhance the quality of care we provide to our members.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CM-061928-24-SRS61877

AdministrativeCommercialJuly 1, 2024

Recovery room — facility editing update

Effective for all claims received on and after August 1, 2024, Anthem is updating its outpatient facility editing system to deny revenue code 0710 (recovery room services) when billed without revenue code 037X (anesthesia services), on the same claim. Per industry-standard coding resources, including the UB04 editor and the National Uniform Billing Committee (NUBC), “an anesthesia charge (revenue code category 037X) should be billed with a revenue code from category 071X, recovery room charge.”

If you believe you have received a denial in error, follow the Anthem claim dispute process.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061118-24-SRS60998

AdministrativeCommercialMedicare AdvantageJune 12, 2024

Phoenix Sepsis Criteria for coding and billing pediatric sepsis

To ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis for our pediatric members, we review clinical information (including treatment and medical management) and laboratory and diagnostic procedure findings in the medical records submitted for review. To conduct the review accurately and consistently, our review process for pediatric sepsis applies coding and documentation guidelines.

Beginning with admission dates of July 1, 2024, and later for members aged 29 days through 17 years of age, we will also apply the updated and most recent publication of the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force criteria known as the Phoenix Sepsis Criteria, published in the Journal of the American Medical Association (JAMA) in January 2024.

Clinicians and facilities should apply the Phoenix Sepsis Criteria when determining at discharge if the pediatric patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the Phoenix Sepsis Criteria.

Together, we can work towards improved outcomes.

jamanetwork.com/journals/jama/article-abstract/2814297

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CRCM-056018-24-CPN55116

AdministrativeCommercialJuly 1, 2024

CAA: Maintain your online provider directory information

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/provider. Then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your care provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

  • Updating care provider demographic information for all assigned payers in one location.
  • Attesting to and managing current care provider demographic information.
  • Monitoring submitted demographic updates in real-time with a digital dashboard.
  • Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

  • Log on to Availity.com to learn about and attend one of our training opportunities.
  • On Availity.com, you can view the Availity PDM quick start guide.
  • Roster Automation Standard Template and Roster Automation Rules of Engagement training:
    • Listen to our recorded webinar on Availity.com.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your care providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060917-24-SRS60902

Digital SolutionsMedicare AdvantageJuly 1, 2024

Admission, discharge, and transfer information is now available for Medicare Advantage members

If you and your organization are focused on promoting evidence-based medicine and clinical quality performance, our Alerts Hub clinical notification tool, accessed through Availity Essentials, can help drive your success. 

Our clinical notification application, Alerts Hub, offers admission, discharge, and transfer (ADT) notifications for Medicare Advantage members. For those members, Alerts Hub offers a simple way to view a list of patients who have been admitted to the hospital or visited the emergency room. 

Discover what users across the country already know.

Alerts Hub offers timely, actionable information to help your organization reach out to patients who can benefit from transitions in care planning or other interventions following inpatient or emergency care.

Viewing and responding to ADT notifications with outreach to patients can help drive your organizations’ clinical quality and cost of care performance in value-based care arrangements —More importantly, it helps drive better outcomes for your patients.

Get started today.

We are committed to finding solutions that help our care provider partners offer quality services to our members. To access Alerts Hub, log on to Availity Essentials, select Payer Spaces, then select Alerts Hub. New users will need to register and set preferences. Registered users will receive daily notification emails with a summary of relevant alerts and a reminder to view details in Alerts Hub. Be sure to check your junk or spam folders if you aren’t receiving messages in your inbox.

Need more help? The Availity Custom Learning Center offers a range of training materials that can help you get up to speed quickly so that you can take advantage of all Alerts Hub has to offer.

Contact us.

Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-060650-24-CPN59897

Digital SolutionsCommercialJune 20, 2024

Digital-only authorization case status notification coming to you

In our previous communications, we shared information about using the Authorizations and Referrals application on Availity Essentials to receive digital notifications for your authorization cases and related decision letters, and we introduced the Preference Center for Authorization and Referrals where you can select your preferred method of communication. We are excited to announce that we launched the Preference Center for Authorization and Referrals in April and will start using your preferences there in July.

Here is a quick recap on how to receive digital notifications and set your preferred communication method for the status of your authorization cases.

Use the Authorizations and Referrals application for digital notifications:

  • Retrieve cases submitted digitally and non-digitally by your organization through Auth/Referral Inquiry; use the Pin to Dashboard feature to keep these cases on the Auth/Referral Dashboard, saving you from repeating the search in the future.
  • Find the most recent statuses of cases submitted by your organization on the Auth/Referral Dashboard — Select View Details in the Actions menu for case details, including decision letters. For pinned cases, select the case card to get the latest status and case details.

Access the Preference Center and set your preferences:

  • After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile.
  • Select your organization and then set your communication preference (your default is Digital Access (Default) or if you prefer to receive paper surface mail, you can select Digital + Mail) for Authorization and Referrals:  
    • Adjust the preference for the tax IDs and NPIs of your organization to fit your business needs.
    • You can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs.

Manage preferences (Availity administrators)

Availity Administrators can learn more about managing preferences related to Authorization Decision letters. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters.

With your help, we can continually build towards a future of shared success.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060250-24-CPN60234

Education & TrainingCommercialMedicare AdvantageJuly 1, 2024

July is Disability Awareness Month

We hope you are finding our monthly observance articles helpful and informative. We will continue to feature these monthly articles to keep you informed about our resources that are here to support you in caring for all of our members.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers.

In recognition of July as Disability Awareness Month, and to commemorate the signing of the Americans with Disabilities Act (ADA) in 1990 that promotes equal rights and accessibility for people with disabilities, we are introducing three eLearning resources and tools on My Diverse Patients. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address disparities. Availability of multiple free continuing medical education (CME) courses with CMEs are offered through the American Academy of Family Physicians (AAFP).

For the month of July, our featured eLearning Resources & Tools are:

  • Health Equity Framework for People with Disabilities:
    • This policy brief provides the rationale for the need for an all-of-government approach to achieve health equity in the United States and its territories for the largest unrecognized minority group in this country — the over 61 million people with disabilities — and sets forth a framework to achieve health equity for all people with disabilities. Disability is a natural part of the human condition, which occurs across all ages, genders, races, ethnicities, languages, and social groups.
  • Health Equity for People with Disabilities:
    • The CDC’s Division of Human Development and Disability (DHDD) works to promote health and reduce health inequities for people with disabilities of all ages so they can participate fully in all aspects of their communities throughout their lives and have the opportunity to achieve all they set out to do.
  • Connections Between Health Equity and Disability:
    • When it comes to healthcare, significant disparities abound between people with disabilities and able-bodied people. From physical barriers and discrimination to financial hurdles and a lack of available resources, access to healthcare is alarmingly inequitable for people with disabilities around the world.

We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-ALL-CRCM-060725-24-CPN60345

Education & TrainingCommercialJune 13, 2024

Faster notification of EDI corrected claims errors

For those providers and their corresponding vendors (either billing services or clearinghouses) who submit corrected claims through EDI, we’re enhancing the 277CA to notify you of submission errors discovered during our claims processing. Although you’ll continue to receive physical mail notifications related to claims processing issues, the 277CA notifications can expedite the turnaround time by highlighting submission issues upfront.

Now, the 277CA will also communicate the following messages:

  • Tax ID and NPI are not registered.
  • Billed place of treatment doesn’t correspond with the place of service.
  • Rendering provider isn’t valid for the service date.
  • Billing NPI doesn’t align with the claim’s tax ID.

Despite the addition of this new feature, there will be no reductions in the services we already provide. Our hope is that this change will augment the speed and communication of our service.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060850-24-CPN59863

Education & TrainingCommercialMarch 12, 2024

Important reminder: The correct original claim number must be included if submitting a corrected claim

When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim.

  1. For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:
    1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
    2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.
  1. For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:
    1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
    2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.

We’ve also developed a training video that can help you reduce duplicate claims along with a training guide called Making the Claims Process Work for You to help you properly submit a corrected claim. Access the video and download the guide here. Provider information is required to view this training; however, you will only be prompted to enter this information the first time viewing this training.

If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-049145-23-CPN48099, MULTI-BCBS-CM-061597-24-CPN61590

Policy UpdatesMedicare AdvantageJune 3, 2024

Clinical Criteria updates — November 2023

Summary: On February 24, 2023, September 11, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective Date

Clinical Criteria Number

Clinical Criteria Title

New or Revised

September 5, 2024

*CC-0252

Adzynma (ADAMTS13, recombinant-krhn)

New

September 5, 2024

*CC-0253

Aphexda (motixafortide)

New

September 5, 2024

*CC-0254

Zilbysq (zilucoplan)

New

September 5, 2024

CC-0130

Imfinzi (durvalumab)

Revised

September 5, 2024

CC-0223

Imjudo (tremelimumab-actl)

Revised

September 5, 2024

*CC-0059

Selected Injectable NK-1 Antiemetic Agents

Revised

September 5, 2024

CC-0074

Akynzeo (fosnetupitant and palonosetron) for injection

Revised

September 5, 2024

*CC-0065

Agents for Hemophilia A and von Willebrand Disease

Revised

September 5, 2024

CC-0124

Keytruda (pembrolizumab)

Revised

September 5, 2024

CC-0150

Kymriah (tisagenlecleucel)

Revised

September 5, 2024

CC-0187

Breyanzi (lisocabtagene maraleucel)

Revised

September 5, 2024

CC-0133

Aliqopa (copanlisib)

Revised

September 5, 2024

CC-0205

Fyarro (sirolimus albumin bound)

Revised

September 5, 2024

CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

September 5, 2024

*CC-0226

Elahere (mirvetuximab)

Revised

September 5, 2024

CC-0125

Opdivo (nivolumab)

Revised

September 5, 2024

CC-0058

Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents

Revised

September 5, 2024

*CC-0009

Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis

Revised

September 5, 2024

*CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Revised

September 5, 2024

*CC-0011

Ocrevus (ocrelizumab)

Revised

September 5, 2024

*CC-0174

Kesimpta (ofatumumab)

Revised

September 5, 2024

*CC-0020

Natalizumab Agents (Tysabri, Tyruko)

Revised

September 5, 2024

*CC-0032

Botulinum Toxin

Revised

September 5, 2024

*CC-0068

Growth Hormone

Revised

September 5, 2024

*CC-0173

Enspryng (satralizumab-mwge)

Revised

September 5, 2024

*CC-0170

Uplizna (inebilizumab-cdon)

Revised

September 5, 2024

*CC-0199

Empaveli (pegcetacoplan)

Revised

September 5, 2024

*CC-0041

Complement Inhibitors

Revised

September 5, 2024

*CC-0071

Entyvio (vedolizumab)

Revised

September 5, 2024

*CC-0064

Interleukin-1 Inhibitors

Revised

September 5, 2024

*CC-0042

Monoclonal Antibodies to Interleukin-17

Revised

September 5, 2024

*CC-0066

Monoclonal Antibodies to Interleukin-6

Revised

September 5, 2024

*CC-0050

Monoclonal Antibodies to Interleukin-23

Revised

September 5, 2024

*CC-0078

Orencia (abatacept)

Revised

September 5, 2024

*CC-0063

Ustekinumab Agents

Revised

September 5, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

September 5, 2024

CC-0003

Immunoglobulins

Revised

September 5, 2024

*CC-0002

Colony Stimulating Factor Agents

Revised

September 5, 2024

CC-0247

Beyfortus (nirsevimab)

Revised

September 5, 2024

CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors

Revised

September 5, 2024

CC-0010

Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors

Revised

September 5, 2024

CC-0209

Leqvio (inclisiran)

Revised

September 5, 2024

*CC-0182

Iron Agents

Revised

September 5, 2024

*CC-0086

Spravato (esketamine) Nasal Spray

Revised

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CR-050488-24-CPN49884

Policy UpdatesMedicare AdvantageJune 4, 2024

Clinical Criteria updates

Effective September 5, 2024

Summary

On November 17, 2023, and March 21, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

  • The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
  • This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date

Clinical Criteria number

Clinical Criteria title

New or revised

September 5, 2024

*CC-0261

Winrevair (sotatercept-csrk)

New

September 5, 2024

*CC-0125

Opdivo (nivolumab)

Revised

September 5, 2024

*CC-0003

Immunoglobulins

Revised

September 5, 2024

CC-0033

Xolair (omalizumab)

Revised

September 5, 2024

*CC-0062

Tumor Necrosis Factor Antagonists

Revised

September 5, 2024

CC-0121

Gazyva (obinutuzumab)

Revised

September 5, 2024

CC-0201

Rybrevant (amivantamab-ymjw)

Revised

September 5, 2024

*CC-0251

Ycanth (cantharidin)

Revised

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CR-059943-24-CPN59599

Policy UpdatesMedicare AdvantageMay 29, 2024

Carelon Medical Benefits Management, Inc. updates

This article was updated as of August 23, 2024.

Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

  • Site of Care Guidelines:
    • Site of Care for Advanced Imaging
    • Rehabilitative Site of Care
    • Surgical Site of Care

Please share this notice with other members of your practice and office staff.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CR-055357-24-CPN54514, MULTI-ALL-CDCR-066460-24

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageJune 27, 2024

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology:

  • Brain Imaging:
    • Added indications for MRI and amyloid beta PET imaging in Alzheimer disease to address patients considering or receiving lecanemab
  • Spine Imaging:
    • Changed Perioperative and Periprocedural Imaging to Postoperative and Postprocedural Imaging; pre-procedure requests should be reviewed based on more specific indication
  • Extremity Imaging:
    • Separated criteria for osteomyelitis and septic arthritis into separate indications; US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication
  • Vascular Imaging:
    • CTA/MRA Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
    • Lower Extremity PAD: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with ACR Appropriateness Criteria
    • Suboptimal imaging option downgrades/removals in Brain, Head and Neck, and Abdomen/Pelvis

Cardiovascular:

  • Imaging of the Heart:
    • Resting Transthoracic Echocardiography (TTE)
    • Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
    • Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant
  • Cardiac Resynchronization Therapy:
    • Exclusion added for Wireless CRT
  • Diagnostic Coronary Angiography:
    • Criteria reaffirmed — no changes
  • Endovascular Revascularization:
    • Added indication for endovascular venous arterialization of the tibial or peroneal veins
    • Exclusions added for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
    • Also exclusion added for atherectomy (clarification)
  • Implantable Cardioverter Defibrillators:
    • Transvenous ICD placement
    • Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies
  • Percutaneous Coronary Intervention:
    • Exclusion added for percutaneous transluminal coronary lithotripsy
  • Permanent Implantable Pacemakers:
    • Device replacement
    • Added criteria for permanent implantable pacemaker device replacement
    • Single chamber leadless pacemakers
    • Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
    • Exclusion added for right atrial single chamber leadless pacemakers
    • Dual chamber leadless pacemakers
    • Exclusion added for dual chamber leadless pacemakers

Genetic Testing:

  • Chromosomal Microarray Analysis:
    • Clarified recommendations for Genetic Counseling
    • Clarified requirements for postnatal evaluation of individuals with:
    • Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
    • Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
    • Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound
  • Pharmacogenomic Testing:
    • Added APOE testing
  • Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing:
    • Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications), and moved these tests to exclusions as they are considered not medically necessary
    • Retitled guideline to Predictive and Prognostic Polygenic Testing to address this change in scope.
  • Somatic Testing of Solid Tumors:
    • Breast Cancer
    • Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer
  • Whole Exome and Whole Genome Sequencing:
    • Expanded WES criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications.
    • Clarified well-delineated genetic syndrome in criterion for multiple anomalies
    • Clarified Genetic Counseling details for WES

MSK:

  • Sacroiliac Joint Fusion:
    • New medical necessity criteria for open SI joint fusion
    • As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum
    • As an adjunct to the medical treatment of sacroiliac joint infection/sepsis (for example, osteomyelitis, pyogenic sacroiliitis)
    • For severe traumatic injuries associated with pelvic ring disruption (for example, pelvic ring fractures, acetabular fracture, spinopelvic dissociation)
    • During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium as part of medically necessary lumbar spine fusion procedures
    • Open SI joint fusion is not medically necessary for poorly defined low back pain and sacral insufficiency fractures.
  • Spine Surgery:
    • Lumbar Discectomy, Foraminotomy, and Laminotomy
    • Added exclusion for annular closure device
    • Lumbar Laminectomy
    • Expanded timeframe for imaging lumbar disc herniation (9 months) and lumbar spinal stenosis (12 months)

Radiation Oncology:

  • Removed criteria for hyperthermia
  • Clarified inclusion criteria of the RTOG 1112 protocol.

Sleep Disorder Management:

  • Expanded definitions and terminology
  • Expanded documentation of hypoventilation
  • Expanded criteria for home and in-lab sleep studies
  • Added contraindication to APAP titration for use of supplemental oxygen
  • Removed home sleep apnea testing (HSAT) as an option in medical necessity of MSLT/MWT for suspected narcolepsy
  • Management of OSA using Implanted Hypoglossal Nerve Stimulators — Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by FDA
  • Miscellaneous Devices section added: electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of high-quality evidence

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

  • Access Carelon Medical Benefits Management’s provider portal 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.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CRCM-059470-24-CPN58860

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2024

Medical Policy and Clinical Guideline updates

The following new and revised Medical Policies were endorsed at the May 9, 2024, Medical Policy and Technology Assessment Committee (MPTAC) meeting. These policies and all of Anthem’s Medical Policies and Clinical Guidelines are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View 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® or FEP), visit Medical Policies & Utilization Management Guidelines (fepblue.org).

Medical Policy updates

New Medical Policy effective October 1, 2024

The following policy is new:

  • RAD.00069 Absolute Quantitation of Myocardial Blood Flow Measurement

Revised Medical Policies effective October 1, 2024

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:

  • MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
  • SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061523-24

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 30, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Effective August 30, 2024

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider > Providers > Policies, Guidelines & Manuals.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • MED.00146 - Gene Therapy for Sickle Cell Disease
    • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease
  • RAD.00068 - Myocardial Strain Imaging
    • Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications
  • SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
    • Reformatted Position Statement and added headers
    • Reformatted Medically Necessary statements to move target treatment areas into criteria
    • Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
    • Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
    • Reformatted Medically Necessary statements for epilepsy
    • Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
    • Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
    • Revised and reformatted Investigational & Not Medically Necessary statements
  • SURG.00097 - Scoliosis Surgery
    • Revision to Position Statement formatting
    • Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement
  • SURG.00142 - Genicular Procedures for Treatment of Knee Pain
    • Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
    • Revised title
    • Added genicular artery embolization to the scope of document
    • Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary
  • CG-DME-42 - Continuous Glucose Monitoring Devices
    • Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
    • Revised title
    • Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
    • Revised existing Medically Necessary and Not Medically Necessary statements
  • CG-DME-52 - Continuous Passive Motion Devices in the Home Setting
    • Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications
  • CG-MED-94 - Vestibular Function Testing
    • Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing
  • CG-SURG-09 - Temporomandibular Disorders
    • Revised formatting of Medically Necessary statement
    • Revised surgical procedures criteria
    • Added MIRO Therapy to Not Medically Necessary statement
  • CG-SURG-70 - Gastric Electrical Stimulation
    • Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 30, 2024.

Publish date

Medical Policy number

Medical Policy title

New or revised

1/3/2024

LAB.00026

Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer

Previously titled: Systems Pathology Testing for Prostate Cancer

Revised

1/3/2024

LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

Revised

1/3/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Conversion new

1/3/2024

MED.00057

MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Revised

1/18/2024

*MED.00146

Gene Therapy for Sickle Cell Disease

New

1/3/2024

*RAD.00068

Myocardial Strain Imaging

New

1/3/2024

SURG.00010

Treatments for Urinary Incontinence

Revised

12/28/2023

*SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

Revised

12/28/2023

*SURG.00097

Scoliosis Surgery

Revised

1/3/2024

*SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Revised

1/3/2024

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Revised

Clinical UM Guidelines

On November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on January 4, 2024. These guidelines take effect August 30, 2024.

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

1/3/2024

*CG-DME-42

Continuous Glucose Monitoring Devices

Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps

Revised

1/3/2024

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

1/3/2024

CG-DME-50

Automated Insulin Delivery Systems

Conversion new

1/3/2024

CG-DME-51

External Insulin Pumps

Conversion new

1/3/2024

*CG-DME-52

Continuous Passive Motion Devices in the Home Setting

New

1/3/2024

CG-LAB-25

Outpatient Glycated Hemoglobin and Protein Testing

Revised

1/3/2024

CG-MED-92

Foot Care Services

Revised

1/3/2024

*CG-MED-94

Vestibular Function Testing

New

1/3/2024

*CG-SURG-09

Temporomandibular Disorders

Revised

12/28/2023

*CG-SURG-70

Gastric Electrical Stimulation

Revised

1/3/2024

CG-SURG-94

Keratoprosthesis

Revised

12/28/2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

Revised

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CR-056158-24-CPN54635

Prior AuthorizationCommercialJuly 1, 2024

Precertification list change notification July 1, 2024

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity (Availity.com) or call Anthem’s

Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider. 

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-DME-06

Compression Devices for Lymphedema

E0678

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0679

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0680

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0681

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0682

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33276

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33277

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33278

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33279

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33280

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33281

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33287

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33288

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93150

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93151

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93152

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93153

10/1/2024

CG-SURG-83

Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0813T

10/1/2024

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

A4540

10/1/2024

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

E0732

10/1/2024

DME.00042

Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

E0530

10/1/2024

DME.00043

Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

E0492

10/1/2024

DME.00043

Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

E0493

10/1/2024

DME.00046

Intermittent Abdominal Pressure Ventilation Devices

A4468

10/1/2024

DME.00049

External Upper Limb Stimulation for the Treatment of Tremors

A4542

10/1/2024

DME.00049

External Upper Limb Stimulation for the Treatment of Tremors

E0734

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0423U

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0434U

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0438U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81457

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81458

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81459

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81462

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81463

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81464

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0422U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0424U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0425U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0426U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0428U

10/1/2024

GENE.00056

Gene Expression Profiling for Bladder Cancer

0420U

10/1/2024

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0435U

10/1/2024

LAB.00016

Fecal Analysis in the Diagnosis of Intestinal Disorders

0430U

10/1/2024

LAB.00019

Proprietary Algorithms for Liver Fibrosis

Previously titled: Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

81517

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0112U

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0152U

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0323U

10/1/2024

MED.00130

Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring

E0746

10/1/2024

RAD.00068

Myocardial Strain Imaging

C9762

10/1/2024

RAD.00068

Myocardial Strain Imaging

C9763

10/1/2024

SURG.00007

Vagus Nerve Stimulation

E0735

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4279

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4287

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4288

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4289

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4290

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4291

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4292

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4293

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4294

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4295

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4296

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4297

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4298

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4299

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4300

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4301

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4302

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4303

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4304

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

61889

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

61891

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

C1778

10/1/2024

SURG.00045

Extracorporeal Shock Wave Therapy

0864T

10/1/2024

SURG.00077

Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques

58580

10/1/2024

SURG.00097

Scoliosis Surgery

22836

10/1/2024

SURG.00097

Scoliosis Surgery

22837

10/1/2024

SURG.00097

Scoliosis Surgery

22838

10/1/2024

SURG.00097

Scoliosis Surgery

0790T

10/1/2024

SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

37242

10/1/2024

SURG.00150

Leadless Pacemaker

0823T

10/1/2024

SURG.00150

Leadless Pacemaker

0824T

10/1/2024

SURG.00150

Leadless Pacemaker

0825T

10/1/2024

SURG.00150

Leadless Pacemaker

0826T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0861T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0862T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0863T

10/1/2024

SURG.00157

Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

31242

10/1/2024

SURG.00157

Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

31243

10/1/2024

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

64596

10/1/2024

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

64597

10/1/2024

UM AROW# A2024M1436

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CM-058786-24-CPN57724

Prior AuthorizationCommercialMay 7, 2024

Anthem Precertification List Change Notification for July 1, 2024

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity at Availity.com or call Anthem’s Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0786T

October 1, 2024

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0787T

October 1, 2024

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0816T

October 1, 2024

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0817T

October 1, 2024

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0818T

October 1, 2024

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0819T

October 1, 2024

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CM-056901-24-SRS56901

Prior AuthorizationCommercialJune 19, 2024

Carelon Medical Benefits Management, Inc. genetic testing code updates

Effective for dates of service on and after September 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

CPT® code

Description

81457

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability

81458

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability

81459

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

81462

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements

81463

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability

81464

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

0420U

Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma

0422U

Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate

0423U

Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition

0424U

Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer

0425U

Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings)

0426U

Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis

0428U

Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden

0434U

Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes

0438U

Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

  • Access the ProviderPortalSM for Carelon Medical Benefits Management 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 Availity.com.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-059592-24-CPN59056

Prior AuthorizationCommercialJuly 1, 2024

Program implementation announcement: Authorizations for post-acute care services by Carelon Medical Benefits Management, Inc.

On December 1, 2023, we announced a delay in the implementation of the prior authorization program for Post-Acute Care (PAC) services administered by Carelon Medical Benefits Management, Inc., formerly Carelon Post Acute Solutions, LLC. It was further announced that a notification would be published at least 30 days prior to implementation of the program. The confirmed new program implementation date is August 1, 2024.

For services beginning on August 1, 2024, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) for members of most commercial plans will be reviewed by Carelon Medical Benefits Management. The goal of this program is to support members through their recovery process in the most appropriate environment. 

With this program implementation, Anthem will transition to Carelon Medical Benefits Management Clinical Appropriateness Guidelines. The guidelines can be accessed here.

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, Carelon Post Acute Solutions will begin receiving requests on July 29, 2024, for members whose anticipated discharge date is on or after August 1, 2024. 

Providers are encouraged to request authorization using NexLync. Go to the Carelon Post Acute Solutions website to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. 

If you have questions or are unable to use the above link or website, call the Carelon Provider Call Center at 833-431-0780 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit providers.carelonmedicalbenefitsmanagement.com/postacute or email PACprovider_relations@carelon.com.

Through our efforts, we can help our care provider partners deliver high quality, equitable healthcare.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-ALL-CM-055900-24

Reimbursement PoliciesCommercialJuly 1, 2024

Reimbursement policy update: Incident to Services — Professional

Beginning with dates of service on or after October 1, 2024, Anthem will update the Incident to Service — Professional policy. The intent of the policy is to identify the reimbursement guidelines for incident to services.

This reimbursement policy identifies the following two different types of incidents:

  • Incident to Billing: When Incident to billing services are rendered and billed in accordance with this policy, the incident to services are eligible for reimbursement based on a 15% reduction of the maximum allowance of the applicable supervising provider’s fee schedule.
  • Incident to Services or Supplies: Incident to services or supplies that are essential to the performance of professional service are considered bundled in the primary service and are not allowed for separate reimbursement.

The Related Coding section of the policy includes Modifier SA which must be appended when the supervising physician is billing on behalf of non-physician practitioner (NPP) for non-surgical services.

The policy has been renamed to Incident to Services and Billing — Professional to define incident to services from incident to billing guidelines. 

For specific policy details, visit the reimbursement policy page at Anthem.com/provider.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061323-24-CPN61066

Reimbursement PoliciesCommercialJuly 1, 2024

New reimbursement policy: Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility

Beginning with dates of service on or after October 1, 2024, Anthem will implement a new reimbursement policy titled Diagnostic Radiopharmaceuticals and Contrast Materials —Professional and Facility.

Under this policy, when radiopharmaceuticals and contrast materials are billed by the facility, such services are not reimbursed as they are considered included in the facility fee. In addition, the following statement was removed from the Place of Service — Professional reimbursement policy and added to this policy:

The health plan does not allow separate reimbursement for diagnostic radiopharmaceutical and contrast materials by professional providers when reported in a facility place of service.

The Related Coding section contains specific codes with guidelines for both professional and facility providers.

For specific policy details, visit the reimbursement policy page at anthem.com/provider.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061235-24

Reimbursement PoliciesCommercialJuly 1, 2024

Reimbursement policy update: Frequency Editing — Professional

Beginning with dates of service on or after October 1, 2024, Anthem will update the Related Coding section of the Frequency Editing — Professional reimbursement policy.

This policy identifies reimbursement for a procedure or service that is billed for a single member, on a single date of service by the same provider and/or provider group, up to the maximum number of units allowed. In addition to using claims processing logic to determine when the use of multiple units is appropriate, we use the nomenclature for a particular CPT® or HCPCS level II code, the CMS’s medically unlikely edits (MUEs) designation, industry standards, or the ability to clinically perform or report a specific service more than one time on a single date of service or within a specific date span per member, per provider in making these determinations.

In the Related Coding section of the policy, the following updates will be made:

CPT maximum frequency code list:

  • Remove 36415 and 36416 (refer to laboratory and venipuncture C-10001)
  • Remove 96158-96159, 96164-96165 (refer to health and behavioral assessment/intervention C-11003)
  • Delete 76942, 77002, 77003, 77012, 77021, 77338, 77600, 77605, 80320-80377, 81479, 86160, 87483, 87491, 87591, 88305, 87529, 90378, 92250, 92273, 92274, 92326, 93325, 95925, 95926, 95938, 95927, 95928, 95929, 95939, 96900, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 93792, and 93793

HCPCS maximum frequency code list:

  • Remove S9529 (refer to laboratory and venipuncture C-10001)
  • Remove G0480, G0481, G0482, and G0483 (refer to drug screen testing — professional C-12004)
  • Remove C9257, G0480, G0481, G0482, and G0483
  • Add A4238, A4239, A6520-A6529, A6552-A6589, A6593-A6610, and Q0509

For specific policy details, visit the reimbursement policy page at anthem.com/provider.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061232-24

Federal Employee Program (FEP)CommercialJuly 1, 2024

Antidepressant Medication Management (AMM)

The National Committee Quality Assurance (NCQA) develops and collects HEDIS® measurements to set performance and drive improvement in quality-of-care outcomes.

The Federal Employee Program® (FEP) for Anthem is continuously working to improve clinical quality of care and performance outcomes. To comply with the NCQA standards and improve HEDIS AMM performance rate, FEP takes this opportunity to remind providers to document every service rendered in an accurate, timely manner and use the appropriate ICD-10-CM, CPT®, and HCPCS codes when billing services rendered for patients who are receiving antidepressant medications. Below is a description of the AMM measure, why it is important, exclusions, and helpful tips (such as medical records documentation and best practices).

HEDIS AMM measure description

This HEDIS measure evaluates the percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported:

  • Effective acute phase treatment: the percentage of members who remained on antidepressant medication for at least 85 days (12 weeks)
  • Effective continuation phase treatment: the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

Members with any diagnosis of major depression who are seen in any of the care settings are included in the AMM measure.

Place of services

  • Outpatient visit
  • Telehealth visit
  • ED visit
  • Acute or nonacute inpatient stay
  • Intensive outpatient encounter or partial hospitalization
  • Community mental health center
  • E-Visit or virtual check-in (online assessment)

Why is the HEDIS AMM measure important?

Major depression is a serious mental illness with a significant burden of symptoms and the most common psychiatric disorder in individuals who die from suicide.1 Integrating the right antidepressant medication with appropriate behavioral therapy leads to positive benefits and outcomes for members. Compliance with antidepressant medication is an essential component in treatment guidelines for major depression.2

Exclusions

Enrollees who did not have an encounter with a diagnosis of major depression during the 121-day period from 60 days prior to the index prescription start date (IPSD) through the IPSD and the 60 days after the IPSD

Common behavioral health codes used with any diagnosis of major depression that trigger patients into the HEDIS AMM measure are:

Description

Behavioral health codes (ICD-10-CM, CPT, HCPCS, POS)

Major depression

ICD-10-CM: F32.0–F32.4, F32.9, F33.0–F33.3, F33.41, F33.42, F33.9. F34.1

BH outpatient visit

CPT: 98960–98962, 99078, 99202–99205, 99211–99215, 99242–99245,
99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99492–99494, 99510

HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013 - H2020, T1015

Place of service (POS)

POS: 02, 10, 52, 53

Telehealth visit

POS: 10

CPT: 98966–98968, 99441–99443

ED visit

CPT: 99281–99285

E-visit or virtual check-in (online assessment)

CPT: 98970–98972, 98980, 98981, 99421–99423, 99457, 99458

HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

Helpful tips

Medical record documentation:

  • Diagnosis of major depression
  • Date of services
  • Date of dispensing
  • Evidence of antidepressant medication prescription

Best practices:

  • Educate members that most antidepressants take four to six weeks to work.
  • Encourage members to continue any prescribed medication even if they feel better. Inform them of the danger of discontinuing suddenly. If they take the medication for less than six months, they are at a higher risk of recurrence.
  • Assess members within 30 days from when the prescription is first filled for any side effects and their response to treatment.
  • When patients are making a follow-up visit, educate and encourage patients to bring their discharge instructions and medications list to their first appointment.
  • Coordinate care between behavioral health and primary care physicians by sharing progress notes and updates.
  • Educate members on what to do in an emergency, such as when having suicidal thoughts.
  • Focus on member preferences for treatment, allowing the member to take ownership of their health and treatment plan.

  1. https://pubmed.ncbi.nlm.nih.gov/23411024: Accessed January 21, 2020.
  2. https://ncqa.org/hedis/measures/antidepressant-medication-management

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060942-24

PharmacyCommercialJuly 1, 2024

Correction: Specialty pharmacy updates — July 2024

This article was updated on October 9, 2024, to remove Ilumya as non-preferred from the step therapy requirements section below. Ilumya is not being added to the step therapy program at this time.

Specialty pharmacy updates for Anthem are listed below.

Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request PA review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our PA review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

Clinical Criteria

Drug

HCPCS or CPT® Code(s)

CC-0003*

Alyglo (immune globulin intravenous, human-stwk)

J1599

CC-0062

Simlandi (adalimumab-ryvk)

J3590

CC-0261

Winrevair (sotatercept-csrk)

C9399, J3590

* Oncology use is managed by Carelon Medical Benefits Management.

Note: PA requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria

Status

Drug

HCPCS or CPT Code(s)

CC-0003

Non-preferred

Alyglo (immune globulin intravenous, human-stwk)

J1599

CC-0062

Non-preferred

Cimzia (certolizumab pegol)

J0717

CC-0042

Non-preferred

Cosentyx intravenous (secukinumab)

C9399, J3490, J3590, C9166

CC-0050

Non-preferred

Omvoh (mirkizumab-mrkz)

C9168, J3590

Quantity limit updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Clinical Criteria

Drug

HCPCS or CPT Code(s)

CC-0062

Simlandi (adalimumab-ryvk)

J3590

CC-0261

Winrevair (sotatercept-csrk)

C9399, J3590

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-060687-24-CPN60563, MULTI-BCBS-CM-069897-24

PharmacyMedicare AdvantageJune 20, 2024

Anthem expands specialty pharmacy precertification list

Effective for dates of service on and after October 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules. They must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

HCPCS codes

Medicare Part B drugs

J3490, J3590

Amtagvi (lifleucel)

J3490, J3590

iDoseTR (travoprost implant)

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-058746-24-CPN58434

Quality ManagementMedicare AdvantageJuly 1, 2024

Understanding your role in the Health Outcomes Survey

The Centers for Medicare & Medicaid Services (CMS) Health Outcomes Survey (HOS) gathers patient-reported health outcomes from members enrolled in Medicare Advantage plans to support quality improvement activities and improve the overall health of members.

Increased awareness of all HOS measures can help guide your provider interactions with your patients and positively impact HOS results and can help impact your Star rating.

Refer to attachment to view full details

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-055932-24-CPN55629

ATTACHMENTS (available on web): Understanding your role in the Health Outcomes Survey (pdf - 0.88mb)