Policy Updates Medical Policy & Clinical GuidelinesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 21, 2025

Clinical Utilization Management Criteria update

The following updates have been made to the Clinical Utilization Management Criteria:

  • CG‑SURG‑93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction will be discontinued and archived April 1, 2025.
  • Effective April 1, 2025, the Carelon Medical Benefit Management, Inc. guideline below will be used to review the CPT® codes noted in the following grid.

Clinical Criteria link

Clinical Criteria title

CPT codes

Dialysis Access Evaluations

Angio Evaluation of Dialysis Access Circuit and Endovascular Intervention for Dialysis Access Circuit Dysfunction

36901, 36902, 36903, 36905, 36906, 36907, 36908

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

Use the precertification lookup tool to search codes to determine if preapproval is required and which guideline is used for the case review. To access the tool, visit https://providers.anthem.com/indiana-provider/home and select the Precertification lookup tool under the Claims drop-down.

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

For help with questions about the Clinical Utilization Management Criteria updates, 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 – 833-569-4739

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-077489-25