Policy UpdatesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingFebruary 12, 2024

Lab testing reminder

Background

Anthem follows MCG Care Guidelines for the following lab tests.

You can view appropriate Clinical Utilization Management Guidelines (CUMGs) here.

Update

In compliance with MCG Care Guidelines, only medically necessary lab testing will be covered. Effective March 1, 2024, coverage for these labs will be denied unless medically necessary:

Clinical UM Guideline number/title

Clinical indications for medical necessity

MCD ENT — CG-Lab-29: Gamma Glutamyl Transferase Testing

GGT testing using blood is considered medically necessary for any of the following indications:

  1. To differentiate between sources of elevated alkaline phosphatase activity; or
  2. To evaluate liver function, injury, or disease in individuals with at least one of the following:
    1. Known or suspected hepatobiliary disease; or
    2. Alcohol use disorder; or
    3. Substance use disorder; or
    4. Therapy with medication that has potentially toxic effects on the liver; or
    5. Exposure to hepatotoxins; or
    6. Infections that may cause liver injury (for example, viral hepatitis, amoebiasis, tuberculosis, and similar infections); or
    7. Pancreatic disease; or
    8. Gastrointestinal disease; or
    9. Liver transplantation; or
    10. Primary or secondary malignant neoplasms; or
    11. Diseases or conditions known to have liver involvement (for example, diabetes mellitus, sarcoidosis, amyloidosis, disorders of iron and mineral metabolism, lupus, hypertension, heart failure).

MCD ENT — CG‑Lab‑30: Outpatient Laboratory-based Blood Glucose Testing

Medically necessary

Blood glucose testing is considered medically necessary for individuals who meet any of the following criteria (A through Q):

  1. Signs or symptoms of either of the following:
    1. Hypoglycemia; or
    2. Hyperglycemia; or
  2. Overweight or obesity* of any age; or
  3. From a population with a high prevalence of diabetes mellitus**; or
  4. Impaired fasting glucose has been found on other testing; or
  5. Pregnant and considered to be at high risk for type 2 diabetes mellitus; or
  6. Prior testing at least 3 months previously showed abnormal blood glucose results; or
  7. Insulin resistance syndrome; or
  8. Carbohydrate intolerance; or
  9. Hypoglycemia disorders, such as nesidioblastosis or insulinoma; or
  10. Catabolic or malnutrition states; or
  11. Tuberculosis; or
  12. Unexplained chronic or recurrent infection; or
  13. Alcohol use disorder; or
  14. Coronary artery disease; or
  15. Unexplained skin conditions (including pruritis, local skin infections, ulceration and gangrene without an established cause); or
  16. Chronic glucocorticoid therapy; or
  17. To evaluate glycemic status for individuals with established diabetes mellitus, prediabetes, or a history of gestational diabetes when done no more often than the following test frequencies:

1. Up to once yearly for individuals with prediabetes; or

2. Up to two times per year for individuals with diabetes mellitus who are meeting treatment goals; or

3. Within the first year postpartum and then up to once yearly for individuals who have had gestational diabetes.

Notes:
See the Discussion section below for more information about:
*ADA, ACOG, and USPSTF recommendations about individuals who have overweight or obesity concerns; and
**Populations with high prevalence of diabetes mellitus.

What if I have questions?

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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, and Hoosier Care Connect 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-048162-23-CPN47422

PUBLICATIONS: March 2024 Provider Newsletter