Policy Updates Medical Policy & Clinical GuidelinesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingMarch 7, 2024

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search

Notes/Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

  • CG-SURG-95 – Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention; Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention:
    • Revised title
    • Added Medically Necessary criteria for temporary SNS for urinary and fecal conditions
    • Reformatted Medically Necessary criteria for permanent SNS for urinary and fecal conditions
    • Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices
    • CG-SURG-95 will be used only for repair or replacement, not initial placement

Clinical UM Guidelines

On May 11, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members on June 22, 2023. These guidelines take effect April 26, 2024.

Publish Date

Clinical UM Guideline Number

Clinical UM Guideline Title

New or Revised

6/28/2023

*CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

Revised

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-044160-23-CPN4370

PUBLICATIONS: April 2024 Provider Newsletter