State & FederalHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingSeptember 1, 2020

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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit the Medical Policies and Clinical UM Guidelines webpage.

Updates

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

*SURG.00028 – Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- Revised scope of document to only address benign prostatic hyperplasia (BPH)
- Revised medically necessary criteria for transurethral incision of the prostate by adding “prostate volume less the 30 mL”
- Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL and waterjet tissue ablation as medically necessary indication
- Moved transurethral radiofrequency needle ablation from medically necessary to not medically necessary section
- Moved placement of prostatic stents from standalone statement to combined not medically necessary statement
*SURG.00037 – Treatment of Varicose Veins (Lower Extremities)
- Added the anterior accessory great saphenous vein (AAGSV) as medically necessary for ablation techniques when criteria are met
- Added language to the medically necessary criteria for ablation techniques addressing variant anatomy
- Added limits to retreatment to the medically necessary criteria for all procedures
*SURG.00047 – Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- Expanded scope to include gastroparesis
- Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as investigational and not medically necessary
*SURG.00097 – Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
- Expanded scope of document to include vertebral body tethering
- Added vertebral body tethering as investigational and not medically necessary
*CG-LAB-14 – Respiratory Viral Panel Testing in the Outpatient Setting
- Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving 5 targets or less when criteria are met
- Added RVP testing in the outpatient setting using large panels involving 6 or more targets as not medically necessary
*CG-MED-68 – Therapeutic Apheresis
- Added diagnostic criteria to the condition “chronic inflammatory demyelinating polyradiculoneuropathy” (CIDP) when it is treated by plasmapheresis or immunoadsorption

The following AIM Specialty Clinical Appropriateness Guidelines have been approved, to view an AIM guideline, visit the AIM Specialty Health_®** page:

*Joint Surgery
*Advanced Imaging—Vascular Imaging

Medical Policies

On November 7, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

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

Publish date	Medical Policy number	Medical Policy title	New or Revised
12/18/2019	ADMIN.00001	Medical Policy Formation	Revised
11/12/2019	ANC.00009	Cosmetic and Reconstructive Services of the Trunk and Groin	Revised
11/12/2019	BEH.00002	Transcranial Magnetic Stimulation	Revised
02/05/2020	GENE.00025	Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies	Revised
02/05/2020	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	New
12/18/2019	MED.00110	Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting	Revised
02/05/2020	MED.00117	Autologous Cell Therapy for the Treatment of Damaged Myocardium	Revised
11/12/2019	MED.00124	Tisagenlecleucel (Kymriah^®)	Revised
12/18/2019	SURG.00011	Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
11/12/2019	SURG.00023	Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures	Revised
12/18/2019	*SURG.00028	Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) Previous title: Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions	Revised
12/18/2019	SURG.00032	Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention	Revised
12/18/2019	*SURG.00037	Treatment of Varicose Veins (Lower Extremities)	Revised
12/18/2019	*SURG.00047	Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis Previous title: Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia	Revised
12/18/2019	*SURG.00097	Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents Previous title: Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents	Revised
12/18/2019	SURG.00127	Sacroiliac Joint Fusion	Revised
11/12/2019	SURG.00145	Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)	Revised
12/18/2019	TRANS.00033	Heart Transplantation	Revised

Clinical UM Guidelines

On November 7, 2019, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Anthem members on November 25, 2019.

Publish Date	Clinical UM Guideline number	Clinical UM Guideline Title	New or Revised
12/18/2019	CG-ANC-04	Ambulance Services: Air and Water	Revised
12/18/2019	CG-BEH-01	Assessment of Autism Spectrum Disorders and Rett Syndrome Previous title: Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome	Revised
12/18/2019	CG-BEH-02	Adaptive Behavioral Treatment for Autism Spectrum Disorder	Revised
12/18/2019	CG-GENE-12	PIK3CA Mutation Testing for Malignant Conditions Previous title: PIK3CA Mutation Testing	Revised
2/5/2020	CG-GENE-13	Genetic Testing for Inherited Diseases	New
2/5/2020	CG-GENE-14	Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management	New
2/5/2020	CG-GENE-15	Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis	New
2/5/2020	CG-GENE-16	BRCA Testing for Breast and/or Ovarian Cancer Syndrome	New
2/5/2020	CG-GENE-17	RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility	New
2/5/2020	CG-GENE-18	Genetic Testing for TP53 Mutations	New
2/5/2020	CG-GENE-19	Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers	New
2/5/2020	CG-GENE-20	Epidermal Growth Factor Receptor (EGFR) Testing	New
12/18/2019	*CG-LAB-14	Respiratory Viral Panel Testing in the Outpatient Setting	Revised
12/18/2019	CG-MED-42	Maternity Ultrasound in the Outpatient Setting	Revised
12/18/2019	*CG-MED-68	Therapeutic Apheresis	Revised
12/18/2019	CG-MED-71	Chronic Wound Care in the Home or Outpatient Setting Previous title: Wound Care in the Home Setting	Revised
12/18/2019	CG-MED-84	Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting	Revised
12/18/2019	CG-MED-85	Posterior Segment Optical Coherence Tomography	New
12/18/2019	CG-MED-86	Enhanced External Counterpulsation in the Outpatient Setting	New
2/5/2020	CG-MED-87	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	New
12/18/2019	CG-REHAB-02	Outpatient Cardiac Rehabilitation	Revised
12/18/2019	CG-SURG-27	Gender Reassignment Surgery Previous title: Sex Reassignment Surgery	Revised
12/18/2019	CG-SURG-61	Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver Previous title: Cryosurgical Ablation of Solid Tumors Outside the Liver	Revised
12/18/2019	CG-SURG-92	Paraesophageal Hernia Repair	Revised
12/18/2019	CG-SURG-104	Intraoperative Neurophysiological Monitoring	New
2/5/2020	CG-SURG-105	Corneal Collagen Cross-Linking	New
2/5/2020	CG-SURG-106	Venous Angioplasty with or without Stent Placement or Venous Stenting Alone	New

**AIM Specialty Health is a separate company providing utilization review services on behalf of Anthem Blue Cross and Blue Shield.

PUBLICATIONS: September 2020 Anthem Provider News - Indiana

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Medical policies and clinical utilization management guidelines update

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