The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note that 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 anthem.com/provider/policies/clinical-guidelines/search/

 

Notes/updates:

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

  • *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
    • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
  • *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
    • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and
    • anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
  • *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
    • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
    • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
    • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
  • *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
    • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
  • *CG-LAB-15 – Red Blood Cell Folic Acid Testing
    • RBC folic acid testing is considered not medically necessary in all cases
  • *CG-LAB-16 – Serum Amylase Testing
    • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
  • *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
    • Added the Afirma Xpression Atlas as not medically necessary
  • 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
    • A new Medical Policy was created from content contained in DME.00011.
    • There are no changes to the policy content.
    • Publish date is December 16, 2020.
  • CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
    • A new Clinical Guideline was created from content contained in GENE.00026.
    • There are no changes to the guideline content.
    • Publish date is December 16, 2020.

 

Medical Policies

On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect March 8, 2021.

 

Policies 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

12/16/2020

*GENE.00055

Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

New

12/16/2020

*LAB.00037

Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

New

11/12/2020

ANC.00009

Cosmetic and Reconstructive Services of the Trunk and Groin

Revised

12/16/2020

*DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Revised

11/12/2020

GENE.00052

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

Revised

11/12/2020

MED.00129

Gene Therapy for Spinal Muscular Atrophy

Revised

12/16/2020

SURG.00011

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

Revised

12/16/2020

*SURG.00062

Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Revised

 

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.

 

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

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

12/16/2020

*CG-LAB-15

Red Blood Cell Folic Acid Testing

New

12/16/2020

*CG-LAB-16

Serum Amylase Testing

New

11/12/2020

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

12/16/2020

*CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

Revised

12/16/2020

CG-GENE-18

Genetic Testing for TP53 Mutations

Revised

12/16/2020

CG-GENE-20

Epidermal Growth Factor Receptor (EGFR) Testing

Revised

11/12/2020

CG-MED-87

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

 

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March 2021 Anthem Provider News - Indiana