Medicare AdvantageJuly 1, 2019
Medical Policies and Clinical Utilization Management Guidelines update
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
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Updates:
- MED.00110 — Growth Factors, Silver-Based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting was revised to add bioengineered autologous skin-derived products (for example, SkinTE) as investigational and not medically necessary.
- MED.00126 — Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders was revised to add nasal nitric oxide as investigational and not medically necessary in the diagnosis and monitoring of asthma and other respiratory disorders.
- SURG.00037 — Treatment of Varicose Veins (Lower Extremities) was revised to replace “non-surgical management” with “conservative therapy” in the medically necessary criteria and to add sclerotherapy used in conjunction with a balloon catheter (for example, KAVS procedure) as investigational and not medically necessary.
- TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases (Previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications) was revised to expand the scope to address non-FDA-approved uses of mesenchymal stem cell therapy; the position statement has been revised to the following: “Mesenchymal stem cell therapy is considered INV & NMN for the treatment of joint and ligament disorders caused by injury or degeneration as well as autoimmune, inflammatory and degenerative diseases.”
- The following AIM Specialty Healthâ updates took effect on January 24, 2019: Advanced Imaging (imaging of the heart and imaging of the head and neck), Arterial Ultrasound and Joint Surgery.
Medical Policies
On January 24, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).
Publish date |
Medical Policy # |
Medical Policy title |
New or revised |
2/27/2019 |
LAB.00036 |
Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus |
New |
2/27/2019 |
SURG.00011 |
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting |
Revised |
1/31/2019 |
DRUG.00088 |
Atezolizumab (Tecentriq®) |
Revised |
2/27/2019 |
MED.00126 |
Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders |
Revised |
2/27/2019 |
MED.00110 |
Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting |
Revised |
2/27/2019 |
TRANS.00035 |
Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases Previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications |
Revised |
1/31/2019 |
OR-PR.00003 |
Microprocessor Controlled Lower-Limb Prosthesis |
Revised |
1/31/2019 |
DRUG.00071 |
Pembrolizumab (Keytruda®) |
Revised |
2/27/2019 |
SURG.00037 |
Treatment of Varicose Veins (Lower Extremities) |
Revised |
Clinical UM Guidelines
On January 24, 2019, 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 March 28, 2019.
Publish date |
Clinical UM Guideline # |
Clinical UM Guideline title |
New or revised |
1/31/2019 |
CG-ANC-07 |
Inpatient Interfacility Transfers |
New |
1/31/2019 |
CG-DRUG-50 |
Paclitaxel, protein-bound (Abraxane®) |
Revised |
1/31/2019 |
CG-DRUG-99 |
Elotuzumab (Empliciti™) |
Revised |
1/31/2019 |
CG-LAB-09 |
Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain |
Revised |
1/31/2019 |
CG-REHAB-02 |
Outpatient Cardiac Rehabilitation |
Revised |
1/31/2019 |
CG-SURG-27 |
Sex Reassignment Surgery |
Revised |
1/31/2019 |
CG-SURG-83 |
Bariatric Surgery and Other Treatments for Clinically Severe Obesity |
Revised |
2/27/2019 |
CG-DRUG-106 |
Brentuximab Vedotin (Adcetris®) |
Revised |
2/27/2019 |
CG-GENE-05 |
Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy) |
New |
2/27/2019 |
CG-MED-73 |
Hyperbaric Oxygen Therapy (Systemic/Topical) |
Revised |
2/27/2019 |
CG-SURG-77 |
Refractive Surgery |
Revised |
2/27/2019 |
CG-SURG-92 |
Paraesophageal Hernia Repair |
New |
2/27/2019 |
CG-SURG-93 |
Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction |
New |
3/21/2019 |
CG-SURG-94 |
Keratoprosthesis |
New |
3/21/2019 |
CG-SURG-95 |
Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention |
New |
3/21/2019 |
CG-SURG-96 |
Intraocular Telescope |
New |
PUBLICATIONS: July 2019 Anthem Provider News - Georgia
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