Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Quarter 1, 2024. 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 and select Change State and pick appropriate state. Then Providers > Policies, Guidelines & Manuals.

Notes/Updates:

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

• LAB.00039 - Combined Pathogen Identification and Drug Resistance Testing; Previously Titled: Pooled Antibiotic Sensitivity Testing

• Revised title
• Revised Position Statement to address “combined pathogen identification and drug resistance” testing

• OR-PR.00008 - Osseointegrated Limb Prostheses
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
  • Revised Medically Necessary criteria for basivertebral nerve ablation (BVNA)
• SURG.00162 - Implantable Shock Absorber for Treatment of Knee Osteoarthritis
  • Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered Investigational & Not Medically Necessary
• CG-DME-53 - Biomechanical Footwear Therapy
  • Biomechanical footwear therapy is considered Not Medically Necessary for all indications
• CG-LAB-32 - Cancer Antigen 125 Testing
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the tumor marker cancer antigen 125 (CA-125) testing
• CG-MED-94 - Vestibular Function Testing
  • Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests
• CG-MED-96 - Prefabricated External Infant Ear Molding Systems
  • Outlines the Medically Necessary, Reconstructive and Cosmetic & Not Medically Necessary criteria for the use of prefabricated external infant ear molding systems to treat external ear malformations and deformations

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 8, 2024.

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare members on March 28, 2024. These guidelines take effect August 8, 2024.