The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on May 14, 2020 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.


Below are new medical policies and/or clinical guidelines.

NOTE: *Precertification required




Effective Date

DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

• Electronic positional therapy devices are considered investigational/not medically necessary (INV&NMN) in the treatment of obstructive sleep apnea

Code K1001 (effective 01/01/20) for OSA positional devices will be considered INV&NMN for all indications


MED.00131 Electronic Home Visual Field Monitoring

• The use of electronic home visual field monitoring is considered INV&NMN for all indications

Existing codes 0378T, 0379T will be considered INV&NMN for all indications


*MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

New criteria

• Outlines the MN, REC, and COS&NMN indications for autologous fat grafting

Criteria moved from existing medical policies (ANC.00007 & MED.00110) with no change to criteria

• Autologous adipose-derived regenerative cell therapy (for example, Lipogems) is considered INV&NMN for all indications

• Outlines the MN, REC, and COS&NMN indications for injectable soft tissue fillers

  - Added codes 15771, 15772, 15773, 15774 (effective 01/01/20) for injectable autologous fat grafts to be reviewed for MN, REC, and COS&NMN indications;

  - Added codes 31574, C1878, L8607 for soft tissue (vocal cord) bulking agents to be reviewed for MN criteria (previously addressed in SURG.00011);

- Transitioned codes from ANC.00007 for dermal fillers and from MED.00110 for regenerative therapy unchanged


MED.00133 Ingestion Event Monitors

• Ingestion event monitors are considered INV&NMN for medication monitoring and adherence and for all other indications


*THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

• The use of electrophysiology-guided noninvasive stereotactic cardiac radioablation is considered INV&NMN as a treatment modality for all indications, including drug and ablation refractory ventricular tachycardia and cardiomyopathy related to premature ventricular contractions

- Existing codes 77373, 77435 for stereotactic body radiation therapy will be considered INV&NMN for specified cardiac diagnoses; no specific codes for treatment planning, listed 77299, 77399 NOC



The previously adopted clinical guidelines or medical policies have changes noted below.

NOTE: *Precertification required




Effective date

*CG-GENE-02 Analysis of RAS Status

• Clarified scope of document includes HRAS

• Added HRAS as NMN.

Added Tier 2 genetic codes 81403, 81404 to pend; when specified as HRAS considered NMN; removed associated code 88363 (not specific)


CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

Revised the MN statement to state:

• Transcatheter radiofrequency ablation or cryoablation of arrhythmogenic foci in the pulmonary veins is considered MN as a treatment of symptomatic individuals with one of the following:

   - Recurrent (2 or more episodes) paroxysmal (terminates spontaneously or with intervention within 7 days of onset) atrial fibrillation as an alternative to medical therapy; or

   - Persistent (sustained greater than 7 days) atrial fibrillation when refractory or intolerant to one or more antiarrhythmic drugs (or has a contraindication to all appropriate antiarrhythmic drug therapy)


DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

• Added transcutaneous electrical modulation pain reprocessing as INV&NMN for all indications including, but not limited to, treatment of acute and chronic pain

• Reordered statements in alphabetical order

- Added existing Category III code 0278T for pain reprocessing (Scrambler) therapy, considered INV&NMN


MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

• Added reflectance confocal microscopy for the evaluation of skin lesions as NMN in all cases

• Removed Cosmetic  (COS) &NMN statement

- Added existing CPT codes 96931, 96932, 96933, 96934, 96935, 96936 for reflectance confocal microscopy for skin lesions, considered NMN



The following Anthem Blue Cross and Blue Shield clinical guideline will be adopted as a prior authorization requirement for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

NOTE *Precertification required




Effective Date

* CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

This document addresses the use of moderate to deep anesthesia services utilized in the facility setting when used to treat individuals undergoing dental procedures. This excludes the office setting.


Codes applicable:


CPT: 00170, 41899,  99151, 99152, 99153, 99155, 99156, 99157, CPT Physical Status Modifiers: P1, P2, P3, P4


HCPCS: D9222, D9223


ICD-10 DX: K00.0-K00.9, K01.0-K01.1, K02.3-K02.9, K03.0-K03.9, K04.0-K04.99, K08.0-K08.119, M26.70-M26.79, M26.81-M26.82




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August 2020 Anthem Provider News - Indiana