Due to coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. These coding updates may result in a “not medically necessary” determination.


Effective May 1, 2019, we implemented coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.


Clinical Criteria Document Number

Clinical Criteria Name


Alpha-1 Proteinase Inhibitor Therapy


You can go online to access the Clinical Criteria information.


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July 2019 Anthem Provider News - Indiana