Provider News GeorgiaOctober 2019 Provider NewsExciting new changes are on the horizon for the public provider site at anthem.com. These next wave of updates include:
- A new Contact Us page that gives providers easy access to important contact information
- A redesigned Medicare Advantage page with an improved, effortless user experience
- A new Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)
Below is a preview of the new Contact Us and Medicare Advantage page:
Matrix Mobile Bus
As we continue our efforts to help ensure our members enrolled in Affordable Care Act (ACA) compliant plans have their chronic conditions assessed and documented each year, Anthem is engaging Matrix to help encourage members – on our behalf – to schedule a mobile health clinic assessment. A vendor, Matrix operates the largest fleet of mobile medical centers nationwide and has conducted more than 1,000,000 patient assessments since 1998 – providing convenient access to comprehensive health assessments.
The mobile clinic provides members with additional options to help them close any gaps in care that they may have. In late July, Matrix began reaching out to members on our behalf by letter and phone. Our outreach efforts will continue until the end of this year.
Matrix works with hospitals and health plans like Anthem to deliver preventive health testing to the communities Matrix serves. Each mobile clinic has a reception area and private screening rooms. Matrix also helps members with scheduling follow-up appointments with their PCPs at the end of the assessments and forwards the PCPs a copy of any results from the health assessment.
Matrix In-Home Assessments
Matrix will perform in-home assessments where possible. The in-home assessments offer a board-certified nurse practitioner (NP) to come to a member’s home to provide a general exam, suggestions for important screenings or other tests, a full review of the medicines they take, answers to health-related questions & a personal health summary detailing their health information. A copy of the assessment will be sent to members’ PCPs to ensure continuity of care.
The overall goals of the mobile clinic program and the in-home program are to provide convenient, comprehensive appointments that are designed to complement the care provided by our network of physicians. These mobile clinic or in-home visits do not replace any active treatment plans members currently have with their physicians and are not considered wellness visits or a substitute for members’ annual physical examinations.
We’re including information about the program in this edition of Provider News should patients contact you about the program. Please refer members directly to Matrix if they have questions or need more information:
- Mobile Bus: 888-822-3247
- In-Home: 855-403-0967
Continuing our 2019 CRA updates, Anthem requests your assistance with respect to accurately reporting our member’s health status to CMS.
2019 Retrospective Chart Request
Retrospective medical chart collection begins in November and it is the most significant and largest volume of our requests. We appreciate your collaboration as we work through the requests and submit to your medical records department in a timely manner.
Electronic options for chart collections
We have 4 electronic options for chart collections to choose from: 1.) Remote/Direct Anthem Access; 2.) Electronic Medical Record (EMR) Interoperability with 4 EMR systems; 3.) Inovalon virtual visit or onsite; 4.) Secure FTP. Submitting medical charts can be time consuming for your staff. Utilizing an electronic option can alleviate the constraints on your staff’s resources and time.
The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system (Option 1), so that we may retrieve the records ourselves. Our team has collaborated with several Providers and Facilities to have direct access to their EMR systems to collect the charts. This allows for no vendor interventions and fewer handoffs of the records. To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI.
If you are interested in any of these electronic options, or you would like to grant Anthem medical coders direct access to your EMR system, please contact our Commercial Risk Adjustment Representative who supports your area:
- CA, CO, NV - Socorro.Carrasco@anthem.com
- IN, MO, WI, OH, KY – Kris.Raymond@anthem.com
- NY, ME, NH, CT, GA, VA - Alicia.Estrada@anthem.com
Thank you for your continued efforts with our CRA Program, and your help in expediting chart collection requests. The Anthem Blue Cross and Blue Shield Service Benefit Plan®, also known as Federal Employee Program®, FEP®, would like to share information about the turnaround times for urgent or non-urgent precertification requests.
Anthem FEP follows the National Committee for Quality Assurance (NCQA) standards for turnaround time for urgent or non-urgent precertification requests which are outlined below:
- Urgent concurrent - 24 hours (1 day)
- Urgent preservice - 72 hours (3 days)
- Non-urgent preservice - 15 calendar days
- Post-service - 30 calendar days
In addition, Anthem FEP offers an advanced benefit determination (ABD) for elective services.
This precertification service is offered as a courtesy. If you would like more information regarding the ABD review process or have additional questions, please contact FEP Utilization Management at 800-860-2156, 8:00 a.m. – 7:00 p.m., Monday-Friday. This is a one week observance that gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has many tools for providers on their website. Posters, prescriptions pads, social media posts, patient education pieces, sticker and counter clings, and more can be found on the CDC website.
During U.S. Antibiotic Awareness Week and throughout the year, the CDC promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use. Be Antibiotics Aware has resources to help healthcare professionals (in outpatient and inpatient settings) educate patients and families about antibiotic use and risks for potential side effects. For more information visit the CDC website. Beginning with dates of service on or after January 1, 2020, reimbursement for observation services will be limited to 24 hours. For more information about this policy, visit the Reimbursement Policy page on the anthem.com/provider website.
Beginning with dates of service on or after January 1 2020, services reported by a professional provider with a place of service School (03) will be eligible for non-office place of service reimbursement. Anthem announced in July that the AIM Rehabilitative Program was delayed. The AIM Rehabilitative program for Anthem’s Commercial Membership is scheduled to relaunch November 1st. Requests may be submitted beginning October 21st via the AIM ProviderPortal. Processes have been put in place to allow providers to continue to provide treatment and allow claims to process. Claims that were denied for no authorization in error after July 1, 2019 for no prior authorization are being reprocessed. Coverage for PT/ST/OT visits with dates of service July 1, 2019 and thereafter will not require a prior authorization until November 1st. The OrthoNet program is no longer active in applicable markets.
Anthem invites you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the capabilities of the AIM ProviderPortalSM. Visit the AIM Rehabilitation microsite to register for an upcoming training session. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/provider and select “ Pharmacy Information”. The commercial and marketplace drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
Click the following links for the Federal Employee Program formulary Basic Option and Standard Options. These drug lists are also reviewed and updated regularly as needed.
Effective with dates of service on and after October 1, 2019, and in accordance with Anthem’s Pharmacy and Therapeutic (P&T) process, Anthem will update its commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.
To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.
Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).
To view a summary of changes, open the PDF attached to this article titled “8.1.19 and 10.1.19 Summary_of_formulary_changes”. The July 2019 edition of Provider News notified providers that certain Federal Employee Program® (FEP) plans (member IDs beginning with an “R”) utilize a prior approval process for specific specialty drugs and site of care. The prior approval process identifies members who meet appropriate site-of-care criteria and encourages ordering providers and members to consider using a lower level of care option for specific specialty drugs. There is no claim penalty for site of care under the current prior approval process. FEP will continue to use this process through December 31, 2019.
Effective with dates of service on or after January 1, 2020, Anthem FEP will implement a specialty pharmacy prior authorization review process for specific specialty drugs. The prior authorization review will include site-of-care criteria for outpatient hospital-based settings. As a result of this change, services provided on and after January 1, 2020, without a prior authorization will be denied.
FEP will continue to review Federal Employee Program medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.
What’s new beginning with dates of service on or after January 1, 2020?
- Prior to administering the drugs noted below in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. Anthem FEP will begin accepting prior authorization requests on December 18, 2019 for dates of service on and after January 1, 2020. Request prior authorization review by calling the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
- Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review.
- A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
- In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.
- If the prior authorization is denied for either the drug not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
- Services provided on or after January 1, 2020, without prior authorization will result in a denial of claims payment.
Drugs requiring medical necessity and site-of-care review:
Drug
|
Code
|
FEP Medical Policy
|
(Orencia)
|
J0129
|
5.70.18
|
(Benlysta)
|
J0490
|
5.99.01
|
(Privigen)
|
J1459
|
5.20.03
|
(Cuvitru)
|
J1555
|
5.20.08
|
(Bivigam)
|
J1556
|
5.20.03
|
(Gammaplex)
|
J1557
|
5.20.03
|
(Hizentra)
|
J1559
|
5.20.08
|
(Gamunex-c/Gammaked)
|
J1561
|
5.20.03-IV
|
(Gamunex-c/Gammaked)
|
J1561
|
5.20.08-Subq
|
(Carimune)
|
J1566
|
5.20.03
|
(Octagam)
|
J1568
|
5.20.03
|
(Gammagard liquid)
|
J1569
|
5.20.03-IV
|
(Gammagard liquid)
|
J1569
|
5.20.08-Subq
|
(Flebogamma)
|
J1572
|
5.20.03
|
(HyQvia)
|
J1575
|
5.20.08
|
(Panzyga)
|
J1599
|
5.20.03
|
(Simponi Aria)
|
J1602
|
5.70.51
|
(Remicade)
|
J1745
|
5.50.02
|
(Tysabri)
|
J2323
|
5.60.13
|
(Entyvio)
|
J3380
|
5.50.12
|
(Inflectra)
|
Q5103
|
5.50.02
|
(Renflexis)
|
Q5104
|
5.50.02
|
(Ixifi)
|
Q5109
|
5.50.02
|
These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
In the February and May editions of Provider News, we shared that the following clinical criteria will be effective May 1, 2019 for the non-oncology uses of these drugs. We will now also begin the medical step therapy review process for oncology uses of these drugs starting October 1, 2019.
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the attached PDF reference document titled, “Biosimilar Drugs – What are they?”
The clinical criteria information is available on our website.
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code
|
NDC Code
|
ING-CC-0002
|
Preferred Agent
|
Zarxio®
|
Q5101
|
61314-0304-01
61314-0304-10
61314-0312-01
61314-0312-10
61314-0318-01
61314-0318-10
61314-0326-01
61314-0326-10
|
ING-CC-0002
|
Non-Preferred Agent
|
Neupogen®
|
J1442
|
55513-0530-01
55513-0530-10
55513-0546-01
55513-0546-10
55513-0924-01
55513-0924-10
55513-0924-91
55513-0209-01
55513-0209-10
55513-0209-91
|
ING-CC-0002
|
Non-Preferred Agent
|
Granix®
|
J1447
|
63459-0910-11
63459-0910-12
63459-0910-15
63459-0910-17
63459-0910-36
63459-0912-11
63459-0912-12
63459-0912-15
63459-0912-17
63459-0912-36
|
ING-CC-0002
|
Non-Preferred Agent
|
Nivestym™
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
Medicare Advantage
Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following codes:
- 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
- 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
- 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
- 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
- 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
- 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
- 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
- 33271 — Insertion of subcutaneous implantable defibrillator electrode
- 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
- 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
- 81219 — CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9
- 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
- 81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
- 81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
- 81304 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants
- 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81400 — Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
- 81401 — Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
- 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81407 — Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
- 81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
- 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
- C9043 — Injection, levoleucovorin, 1 mg
- C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
- D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
- D9920 — or management, by report
- J9999 — Not otherwise classified, antineoplastic drugs
- S3850 — Genetic testing for sickle cell anemia
To request PA, you may use one of the following methods:
- Web: Availity.com
- Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.
Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and noncontracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements. Medicare Advantage
On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.
For questions or additional information, please send us an email. Medicare Advantage
On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 833-293-0661. Medicare Advantage
The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory Compliance team developed the following two provider trainings. This update outlines the training series:
Medicare risk adjustment and documentation guidance (general)
When — offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 at 1 to 2 p.m. Eastern time
Learning objective — this training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.
Credit — this activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.
If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions.
Medicare risk adjustment, documentation and coding guidance
(condition specific)
When — offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from noon to 1 p.m. Eastern time
Learning objective — this is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
Credit — this live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.
For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:
- Red flag HCCs, part one — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.
- Red Flag HCCs, part two — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.
- Opioids and more: substance abuse and dependence — Recording will play upon registration.
- Acute, chronic and status conditions — Recording will play upon registration.
- Diabetes mellitus and other metabolic disorders — September 25, 2019. Register.
- Behavioral health — November 27, 2019. Register.
Medicare Advantage
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: 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 the provider website at anthem.com/medicareprovider.
Notes/updates
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:
- * DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
- * LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
- * LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
- * OR-PR.00003:
- Clarified medically necessary position statement criteria 2 through 4
- Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
- * SURG.00011:
- Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
- Added new products to investigational and not medically necessary statement
- * SURG.00045:
- Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
- Revised title
- * SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications
- The following AIM Specialty Health® updates were approved on June 6, 2019:
- Advanced imaging:
- Imaging of the heart
- Oncologic imaging
- Vascular imaging
- Proton beam therapy
- Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)
Medical Policies
On June 6, 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
|
June 13, 2019
|
MED.00129
|
Gene Therapy for Spinal Muscular Atrophy
|
New
|
June 13, 2019
|
GENE.00029
|
Genetic Testing for Breast and/or Ovarian Cancer Syndrome
|
Revised
|
June 13, 2019
|
* SURG.00011
|
Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
June 13, 2019
|
SURG.00023
|
Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
|
Revised
|
June 13, 2019
|
SURG.00028
|
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
|
Revised
|
June 27, 2019
|
GENE.00025
|
Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
|
Revised
|
June 27, 2019
|
DRUG.00046
|
Ipilimumab (Yervoy®)
|
Revised
|
June 27, 2019
|
DRUG.00053
|
Carfilzomib (Kyprolis®)
|
Revised
|
June 27, 2019
|
DRUG.00062
|
Obinutuzumab (Gazyva®)
|
Revised
|
June 27, 2019
|
DRUG.00067
|
Ramucirumab (Cyramza®)
|
Revised
|
June 27, 2019
|
DRUG.00071
|
Pembrolizumab (Keytruda®)
|
Revised
|
June 27, 2019
|
DRUG.00075
|
Nivolumab (Opdivo®)
|
Revised
|
June 27, 2019
|
DRUG.00107
|
Avelumab (Bavencio®)
|
Revised
|
June 27, 2019
|
GENE.00044
|
Analysis of PIK3CA Status in Tumor Cells
|
Revised
|
June 27, 2019
|
* SURG.00121
|
Transcatheter Heart Valve Procedures
|
Revised
|
June 27, 2019
|
GENE.00001
|
Genetic Testing for Cancer Susceptibility
|
Revised
|
June 27, 2019
|
GENE.00043
|
Genetic Testing of an Individual’s Genome for Inherited Diseases
|
Revised
|
June 27, 2019
|
LAB.00011
|
Analysis of Proteomic Patterns
|
Revised
|
June 27, 2019
|
LAB.00015
|
Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
|
Revised
|
July 10, 2019
|
GENE.00051
|
Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
|
New
|
July 10, 2019
|
SURG.00153
|
Cardiac Contractility Modulation Therapy
|
New
|
July 10, 2019
|
* DME.00037
|
Cooling Devices and Combined Cooling/Heating Devices
|
Revised
|
July 10, 2019
|
DME.00038
|
Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
|
Revised
|
July 10, 2019
|
GENE.00011
|
Gene Expression Profiling for Managing Breast Cancer Treatment
|
Revised
|
July 10, 2019
|
* LAB.00027
|
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
Revised
|
July 10, 2019
|
* LAB.00033
|
Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
|
Revised
|
July 10, 2019
|
MED.00109
|
Corneal Collagen Cross-Linking
|
Revised
|
July 10, 2019
|
* OR-PR.00003
|
Microprocessor Controlled Lower Limb Prosthesis
|
Revised
|
July 10, 2019
|
SURG.00005
|
Partial Left Ventriculectomy
|
Revised
|
July 10, 2019
|
* SURG.00045
|
Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions
|
Revised
|
July 10, 2019
|
SURG.00120
|
Internal Rib Fixation Systems
|
Revised
|
September 4, 2019
|
GENE.00010
|
Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
Revised
|
Clinical UM Guidelines
On June 6, 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 July 5, 2019.
Publish date
|
Clinical UM Guideline #
|
Clinical UM Guideline title
|
New or revised
|
June 27, 2019
|
CG-SURG-97
|
Cardioverter Defibrillators
|
New
|
June 27, 2019
|
CG-DRUG-98
|
Bendamustine Hydrochloride
|
Revised
|
June 27, 2019
|
CG-LAB-09
|
Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
|
Revised
|
June 27, 2019
|
CG-LAB-14
|
Respiratory Viral Panel Testing in the Outpatient Setting
|
Revised
|
July 10, 2019
|
CG-SURG-100
|
Laser Trabeculoplasty and Laser Peripheral Iridotomy
|
New
|
July 10, 2019
|
CG-ADMIN-01
|
Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
|
Revised
|
July 10, 2019
|
CG-ANC-06
|
Ambulance Services: Ground; Non-Emergent
|
Revised
|
July 10, 2019
|
CG-DME-03
|
Neuromuscular Stimulation in the Treatment of Muscle Atrophy
|
Revised
|
July 10, 2019
|
CG-DME-07
|
Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
|
Revised
|
July 10, 2019
|
CG-DME-08
|
Infant Home Apnea Monitors
|
Revised
|
July 10, 2019
|
CG-DME-39
|
Dynamic Low-Load Prolonged-Duration Stretch Devices
|
Revised
|
July 10, 2019
|
CG-DME-42
|
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
|
Revised
|
July 10, 2019
|
CG-DME-45
|
Ultrasound Bone Growth Stimulation
|
Revised
|
July 10, 2019
|
CG-MED-41
|
Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
|
Revised
|
July 10, 2019
|
CG-MED-49
|
Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
|
Revised
|
July 10, 2019
|
CG-MED-57
|
Cardiac Stress Testing with Electrocardiogram
|
Revised
|
July 10, 2019
|
CG-MED-59
|
Upper Gastrointestinal Endoscopy in Adults
|
Revised
|
July 10, 2019
|
CG-SURG-11
|
Surgical Treatment for Dupuytren's Contracture
|
Revised
|
July 10, 2019
|
CG-SURG-17
|
Trigger Point Injections
|
Revised
|
July 10, 2019
|
CG-SURG-35
|
Intracytoplasmic Sperm Injection (ICSI)
|
Revised
|
July 10, 2019
|
CG-SURG-49
|
Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
|
Revised
|
July 10, 2019
|
CG-SURG-81
|
Cochlear Implants and Auditory Brainstem Implants
|
Revised
|
July 10, 2019
|
CG-SURG-85
|
Hip Resurfacing
|
Revised
|
July 10, 2019
|
CG-SURG-93
|
Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
|
Revised
|
September 4, 2019
|
CG-GENE-11
|
Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
New
|
September 4, 2019
|
CG-GENE-10
|
Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
|
New
|
September 4, 2019
|
CG-SURG-101
|
Ablative Techniques as a Treatment for Barrett’s Esophagus
|
New
|
September 4, 2019
|
CG-SURG-102
|
Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
|
New
|
Medicare Advantage
Aspire Health* for Medicare members in need of telephonic palliative care
The Aspire Telehealth Palliative Care program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on:
- Helping patients understand their diagnosis.
- Facilitating conversations with patients and their families around their goals of care.
- Ensuring patients receive care aligned with their goals and values.
The program begins with an initial 30 to 60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need. Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed. Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6 to 8 months with some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to hospice when appropriate.
More information is available at aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 844-232-0500.
* Aspire Health is an independent company providing telephonic palliative care on behalf of Anthem Blue Cross and Blue Shield. |