The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

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

 

To view a guideline, visit the Medical Policies and Clinical UM Guidelines webpage.

 

Updates

 

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

  • *SURG.00028 – Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
    • Revised scope of document to only address benign prostatic hyperplasia (BPH)
    • Revised medically necessary criteria for transurethral incision of the prostate by adding “prostate volume less the 30 mL”
    • Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL and waterjet tissue ablation as medically necessary indication
    • Moved transurethral radiofrequency needle ablation from medically necessary to not medically necessary section
    • Moved placement of prostatic stents from standalone statement to combined not medically necessary statement
  • *SURG.00037 – Treatment of Varicose Veins (Lower Extremities)
    • Added the anterior accessory great saphenous vein (AAGSV) as medically necessary for ablation techniques when criteria are met
    • Added language to the medically necessary criteria for ablation techniques addressing variant anatomy
    • Added limits to retreatment to the medically necessary criteria for all procedures
  • *SURG.00047 – Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
    • Expanded scope to include gastroparesis
    • Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as investigational and not medically necessary
  • *SURG.00097 – Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
    • Expanded scope of document to include vertebral body tethering
    • Added vertebral body tethering as investigational and not medically necessary
  • *CG-LAB-14 – Respiratory Viral Panel Testing in the Outpatient Setting
    • Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving 5 targets or less when criteria are met
    • Added RVP testing in the outpatient setting using large panels involving 6 or more targets as not medically necessary
  • *CG-MED-68 – Therapeutic Apheresis
    • Added diagnostic criteria to the condition “chronic inflammatory demyelinating polyradiculoneuropathy” (CIDP) when it is treated by plasmapheresis or immunoadsorption

 

The following AIM Specialty Clinical Appropriateness Guidelines have been approved, to view an AIM guideline, visit the AIM Specialty Health®** page:

  • *Joint Surgery
  • *Advanced Imaging—Vascular Imaging

 

Medical Policies

 

On November 7, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

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

 

Publish date

Medical Policy number

Medical Policy title

New or Revised

12/18/2019

ADMIN.00001

Medical Policy Formation

Revised

11/12/2019

ANC.00009

Cosmetic and Reconstructive Services of the Trunk and Groin

Revised

11/12/2019

BEH.00002

Transcranial Magnetic Stimulation

Revised

02/05/2020

GENE.00025

Proteogenomic Testing for the Evaluation of Malignancies

Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies

Revised

02/05/2020

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

New

12/18/2019

MED.00110

Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

Revised

02/05/2020

MED.00117

Autologous Cell Therapy for the Treatment of Damaged Myocardium

Revised

11/12/2019

MED.00124

Tisagenlecleucel (Kymriah®)

Revised

12/18/2019

SURG.00011

Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Revised

11/12/2019

SURG.00023

Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

12/18/2019

*SURG.00028

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

Previous title: Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

Revised

12/18/2019

SURG.00032

Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

Revised

12/18/2019

*SURG.00037

Treatment of Varicose Veins (Lower Extremities)

Revised

12/18/2019

*SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

Previous title: Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia

Revised

12/18/2019

*SURG.00097

Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents

Previous title: Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents

Revised

12/18/2019

SURG.00127

Sacroiliac Joint Fusion

Revised

11/12/2019

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

Revised

12/18/2019

TRANS.00033

Heart Transplantation

Revised

 

 

Clinical UM Guidelines

 

On November 7, 2019, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Anthem members on November 25, 2019.

 

Publish Date

Clinical UM Guideline number

Clinical UM Guideline Title

New or Revised

12/18/2019

CG-ANC-04

Ambulance Services: Air and Water

Revised

12/18/2019

CG-BEH-01

Assessment of Autism Spectrum Disorders and Rett Syndrome

Previous title: Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome

Revised

12/18/2019

CG-BEH-02

Adaptive Behavioral Treatment for Autism Spectrum Disorder

Revised

12/18/2019

CG-GENE-12

PIK3CA Mutation Testing for Malignant Conditions

Previous title: PIK3CA Mutation Testing

Revised

2/5/2020

CG-GENE-13

Genetic Testing for Inherited Diseases

New

2/5/2020

CG-GENE-14

Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

New

2/5/2020

CG-GENE-15

Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis

New

2/5/2020

CG-GENE-16

BRCA Testing for Breast and/or Ovarian Cancer Syndrome

New

2/5/2020

CG-GENE-17

RET Proto-oncogene Testing   for Endocrine Gland Cancer Susceptibility

New

2/5/2020

CG-GENE-18

Genetic Testing for TP53 Mutations

New

2/5/2020

CG-GENE-19

Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

New

2/5/2020

CG-GENE-20

Epidermal Growth Factor Receptor (EGFR) Testing

New

12/18/2019

*CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

Revised

12/18/2019

CG-MED-42

Maternity Ultrasound in the Outpatient Setting

Revised

12/18/2019

*CG-MED-68

Therapeutic Apheresis

Revised

12/18/2019

CG-MED-71

Chronic Wound Care in the Home or Outpatient Setting

Previous title: Wound Care in the Home Setting

Revised

12/18/2019

CG-MED-84

Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

Revised

12/18/2019

CG-MED-85

Posterior Segment Optical Coherence Tomography

New

12/18/2019

CG-MED-86

Enhanced External Counterpulsation in the Outpatient Setting

New

2/5/2020

CG-MED-87

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

New

12/18/2019

CG-REHAB-02

Outpatient Cardiac Rehabilitation

Revised

12/18/2019

CG-SURG-27

Gender Reassignment Surgery

Previous title: Sex Reassignment Surgery

Revised

12/18/2019

CG-SURG-61

Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver

Previous title: Cryosurgical Ablation of Solid Tumors Outside the Liver

Revised

12/18/2019

CG-SURG-92

Paraesophageal Hernia Repair

Revised

12/18/2019

CG-SURG-104

Intraoperative Neurophysiological Monitoring

New

2/5/2020

CG-SURG-105

Corneal Collagen Cross-Linking

New

2/5/2020

CG-SURG-106

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

New

 

**AIM Specialty Health is a separate company providing utilization review services on behalf of Anthem Blue Cross and Blue Shield.



Featured In:
September 2020 Anthem Provider News - Indiana