The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 13, 2020 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.


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


NOTE: *Precertification required




Effective Date

CG-MED-55 Level of Care: Advanced Radiologic Imaging

New Title: Site of Care: Advanced Radiologic Imaging


CG-MED-83 Level of Care: Specialty Pharmaceuticals

New Title: Site of Care: Specialty Pharmaceuticals


*CG-SURG-27 Gender Reassignment Surgery

Added CPT codes 54400, 54401, 54405, 55899 (NOC), C1813, C2622, L8699 for penile prosthesis insertion as part of phalloplasty with medical necessity (MN) criteria


CG-SURG-52 Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

New Title: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services


GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

• Removed MN criteria for non-small cell lung cancer (NSCLC) for tumor burden assessment

• Added molecular profile ng as MN for unresectable or metastatic solid tumors when criteria are met

Specific PLA codes 0037U and 0048U will now pend for all solid tumor diagnoses for review of MN criteria (was just NSCLC), and added 0211U effective 10/01/20 to also pend;

also added PLA panel codes 0212U-0217U (effective 10/01/2020) and 81448 (previously addressed in GENE.00033) considered INV&NMN (Investigational and not medically necessary)


SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

New Title: Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques

Expanded scope of document to include transcervical image guided techniques

• Added radiofrequency ablation using a transcervical approach in combination with imaging guidance as a treatment of uterine fibroids as INV&NMN

• Added existing CPT Category III code 0404T and associated ICD-10-PCS codes for transcervical RF ablation, considered INV&NMN


*SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)

Previous title: Occipital Nerve and Supraorbital Nerve Stimulation

• Revised scope of document to address implanted nerve stimulation devices and related procedures

• Added implantation of a trigeminal nerve stimulation device (and related procedures) as INV&NMN for all indications

Added existing codes 61885, 64568, 64569, C1767, C1778 for cranial nerve stimulator implantation (when specified as trigeminal stimulation); added ICD-10-CM codes R51.0-R51.9 replacing R51 effective 10/01/20




Featured In:
October 2020 Anthem Provider News - Indiana