The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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.

 

Note:

  • Effective November 1, 2018, MCG Health Care Guidelines® will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).
  • Additionally, effective November 1, 2018, AIM Specialty Health Proton Beam Therapy will be used for clinical reviews.

 

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

 

To search for specific policies or guidelines, visit http://www.anthem.com/cptsearch_shared.html.

 

Medical Policies

On May 3, 2018, 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 number



Medical Policy
title


New or revised

6/6/2018

DRUG.00098

Lutetium Lu 177 dotatate (Lutathera®)

New

6/6/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

5/10/2018

DRUG.00047

Brentuximab Vedotin (Adcetris®)

Revised

5/10/2018

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

6/6/2018

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

6/6/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

5/10/2018

DRUG.00076

Blinatumomab (Blincyto®)

Revised

6/6/2018

DRUG.00111

Monoclonal Antibodies to Interleukin-23

Revised

5/10/2018

SURG.00026

Deep Brain, Cortical and Cerebellar Stimulation

Revised

 

Clinical UM Guidelines

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 


Publish date

Clinical UM Guideline number


Clinical UM Guideline
title


New or revised

6/6/2018

CG-LAB-12 

Testing for Oral and Esophageal Cancer

New

6/6/2018

CG-MED-71

Wound Care in the Home Setting

New

6/28/2018

CG-DME-44

Electric Tumor Treatment Field (TTF)

New

6/28/2018

CG-DRUG-67

Cetuximab (Erbitux®)

New

6/28/2018

CG-DRUG-94

Rituximab (Rituxan®) for Nononcologic Indications

New

6/28/2018

CG-DRUG-95

Belatacept (Nulojix®)

New

6/28/2018

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

New

6/28/2018

CG-DRUG-97

Rilonacept (Arcalyst®)

New

6/28/2018

CG-DRUG-98

Bendamustine Hydrochloride

New

6/28/2018

CG-DRUG-99

Elotuzumab (Empliciti™)

New

6/28/2018

CG-DRUG-100

Interferon gamma-1b (Actimmune®)

New

6/28/2018

CG-DRUG-101

Ixabepilone (Ixempra®)

New

6/28/2018

CG-DRUG-102

Olaratumab (Lartruvo™)

New

6/28/2018

CG-MED-72

Hyperthermia for Cancer Therapy

New

6/28/2018

CG-SURG-76

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

New

6/28/2018

CG-SURG-77

Refractive Surgery

New

6/28/2018

CG-SURG-78

Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

New

6/28/2018

CG-SURG-79

Implantable Infusion Pumps

New

6/28/2018

CG-SURG-80

Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors

New

5/10/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

6/6/2018

CG-DRUG-60

Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications

Revised

6/6/2018

CG-DRUG-62

Fulvestrant (FASLODEX®)

Revised

6/6/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

 

 



Featured In:
December 2018 Anthem Indiana Provider Newsletter