Products & ProgramsMedicare AdvantageAugust 28, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs

Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments — helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to Carelon Medical Benefits Management programs, including cardiology, radiation oncology, radiology, musculoskeletal, sleep, surgical, and additional outpatient services.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on CMS guidance, including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in the Medical Policies and Clinical Guidelines of Anthem listed in the table below. These Clinical Guidelines can be found at Availity.com.

Detailed prior authorization (PA) requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted care providers should call Provider Services at the phone number on the back of the member’s ID card for PA requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting PA requests September 23, 2024, for dates of service on or after October 1, 2024. For procedures scheduled to begin on or after October 1, 2024, care providers must contact Carelon Medical Benefits Management to obtain PA for the nonemergency modalities below. Refer to the Clinical Guidelines on the microsite resource pages for complete code lists.

Program

Services

Medical Policies or
Clinical Guidelines

Cardiovascular

  • OP cardiac hemodynamic monitoring w/wireless sensor for heart failure management
  • Non-invasive heart failure & arrhythmia monitoring system
  • Vascular-carotid sinus device (effective March 1, 2025)
  • MED.00115
  • MED.00134
  • SURG.00124 (effective March 1, 2025)

Additional outpatient utilization management

  • Therapeutic apheresis
  • Hyperbaric oxygen therapy
  • Physiologic record of tremor
  • Home enteral and parenteral nutrition
  • Ambulance services
  • Virtual reality-assisted therapy systems
  • Home visual field monitor
  • Colonic irrigation
  • Automated evacuation of meibomian gland
  • Prothrombin time self-monitoring devices
  • CG-MED-68
  • MED.00101
  • CG-MED-08
  • CG-MED-89
  • CG-DME-30
  • CG-MED-73
  • DME.00048
  • DME.00048
  • MED.00103
  • MED.00131
  • MED.00141
  • CG-ANC-06
  • CG-SURG-08
  • SURG.00052
  • SURG.00158
  • SURG.00112

Musculoskeletal

  • Peripheral nerve blocks for Tx of neuropathic pain
  • Implant of nerve stim. devices
  • Percutaneous vertebral disc and vertebral endplate procedures
  • CG-SURG-08
  • SURG.00052
  • SURG.00158
  • SURG.00026
  • SURG.00112

Surgical

  • Surg. Tx of hyperhidrosis
  • Skin related cosmetic and reconstructive services
  • Cochlear and auditory brainstem implants
  • Implantable hearing aids
  • Surg. Tx for OSA and snoring
  • Drug-eluting devices to maintain sinus ostial patency
  • Minimally invasive Tx of posterior nasal nerve for rhinitis
  • Temporomandibular disorders
  • Nasal valve repair
  • Gastric electrical stim.
  • Penile prosthesis implantation
  • Diaphragmatic/phrenic nerve stim. and pacing systems
  • Radiofrequency ablation of renal sympathetic nerves
  • Respiratory assist devices
  • Tonsillectomy/adenoidectomy
  • Uterine fibroid ablation
  • Sacral nerve stim. Tx of neurogenic bladder secondary to spinal cord injury
  • Vagus nerve stim.
  • Ablation for solid tumors outside the liver
  • Intraocular telescope
  • Automated evacuation of meibomian gland
  • Intraocular anterior segment aqueous drainage devices
  • Extracorporeal shock wave therapy
  • Implant of nerve stim. devices
  • Implanted artificial iris devices
  • Implantable infusion pumps
  • Tx for urinary and fecal incontinence
  • Panniculectomy and abdominoplasty
  • Regenerative cell therapy and soft tissue
  • Augmentation
  • Products for wound healing and soft tissue grafting
  • Surg. and ablative Tx for chronic headaches
  • Intraoperative assess. of surgical margins during breast-conserving surg.
  • Mandibular/maxillary surg.
  • SURG.00045
  • SURG.00112
  • CMS criteria only
  • SURG.00129
  • SURG.00047
  • ANC.00007
  • CG-MED-79
  • CG-SURG-08
  • CG-SURG-09
  • CG-SURG-116
  • CG-SURG-118
  • CG-SURG-12
  • CG-SURG-120
  • CG-SURG-30
  • CG-SURG-36
  • CG-SURG-61
  • CG-SURG-70
  • CG-SURG-79
  • CG-SURG-81
  • CG-SURG-82
  • CG-SURG-84
  • CG-SURG-95
  • CG-SURG-96
  • CG-SURG-99
  • MED.00103
  • MED.00132
  • MED.00132
  • SURG.00010
  • SURG.00011
  • SURG.00077
  • SURG.00079
  • SURG.00096
  • SURG.00129
  • SURG.00132
  • SURG.00135
  • SURG.00139
  • SURG.00156
  • SURG.00157

Sleep

  • Electronic positional devices for Tx of OSA
  • Neuromuscular electrical training for Tx of OSA
  • Respiratory assist device
  • DME.00042
  • DME.00043
  • SURG.00007
  • CMS criteria

To determine if PA is needed for a member on or after October 1, 2024, call Provider Services using the phone number on the back of the member’s ID card. Care providers using the interactive care reviewer (ICR) tool on Availity.com for PA requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept PA requests for services administered by Carelon Medical Benefits Management).

How to place a review request

Care providers may place a PA request online to Carelon Medical Benefits Management by way of providerportal.com, which is available 24/7 and which processes requests in real time using Clinical Criteria.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, surgical, and programs, visit:

Our website helps you access information and tools, such as order entry checklists, Clinical Guidelines, and answers to frequently asked questions.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Carelon Insights, Inc. provides payment integrity services on behalf of the health plan.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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.

MULTI-BCBS-CR-066953-24-CPN66900