Medicare Advantage

 

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.

 

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

 

To view a guideline, visit anthem.com/search.html.

 

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

 



Featured In:
July 2019 Anthem Provider News - Georgia