Policy Updates Medical Policy & Clinical GuidelinesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingNovember 4, 2024

Clinical Utilization Management Criteria update

The Clinical Utilization Management Criteria updates are as follows for Anthem:

  • CG-SURG-120 Vagus Nerve Stimulation has replaced SURG.00007 when requesting prior authorization (PA) for replacements only.
  • CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations has replaced SURG.00036

All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows care providers to search codes by the specific line of business to determine if PA is required and which guideline is used for the case review. To access the PA lookup tool, visit providers.anthem.com/in and select the precertification lookup tool under the Claims drop-down.

Contracted care providers can also access the care provider lookup tool via Availity Essentials. Visit https://Availity.com, select Payer Spaces, and then select the precertification lookup tool tile.

For assistance with questions regarding the PA requirement change, call Provider Services at one of the phone numbers listed below:

  • Hoosier Healthwise — 866-408-6132
  • Healthy Indiana Plan — 844-533-1995
  • Hoosier Care Connect — 844-284-1798
  • Indiana PathWays for Aging – 833-412-4405

Criteria link

Criteria title

CPT® codes

CG-SURG-120 Vagus Nerve Stimulation

Vagus Nerve Stimulation

61885, 64569, L8679, L8680, L8685, L8686

CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations

Fetal Surgery for Prenatally Diagnosed Malformations

59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

INBCBS-CD-058883-24