CommercialSeptember 28, 2018
Medical Policy and Clinical Guidelines Updates
The following new and revised medical policies were endorsed at the July 26, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers, scroll down and select Find Resources for Indiana, then from the Indiana Provider Home Page, select Medical Policies and Clinical UM Guidelines.
These medical policies were converted to clinical guidelines and became effective on September 20, 2018.
New Clinical Guideline |
Content Moved From Clinical Guideline and/or Medical Policy |
CG-DME-45 Ultrasound Bone Growth Stimulation |
Content moved from DME.00027 No change to position statement → clinical indications |
CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) |
Content moved from MED.00005 No change to position statement → clinical indications |
CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry |
Content moved from MED.00051 No change to position statement → clinical indications |
CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome |
Content moved from MED.00107 No change to position statement → clinical indications |
CG-MED-76 Magnetic Source Imaging and Magnetoencephalography |
Content moved from RAD.00019 No change to position statement → clinical indications |
CG-MED-77 SPECT/CT Fusion Imaging |
Content moved from RAD.00042 No change to position statement → clinical indications |
CG-REHAB-11 Cognitive Rehabilitation |
Content moved from MED.00081 Removed "Note" in Clinical Indications referring to CG-REHAB-09 Acute Inpatient Rehabilitation |
CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants |
Content moved from SURG.00014 No change to position statement → clinical indications |
CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids |
Content moved from SURG.00020 No change to position statement → clinical indications |
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery |
Content moved from SURG.00049 No change to position statement → clinical indications |
CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring |
Content moved from SURG.00074 Revised title - Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring No change to position statement → clinical indications |
CG-SURG-88 Mastectomy for Gynecomastia |
Content moved from SURG.00085 No change to position statement → clinical indications |
CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia |
Content moved from SURG.00090 No change to position statement → clinical indications |
CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation |
Content moved from TRANS.00018 No change to position statement → clinical indications |
These medical policies were converted to clinical guidelines and will become effective on October 31, 2018
New Clinical Guideline |
Content Moved From Clinical Guideline and/or Medical Policy |
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity |
Content moved from SURG.00024 No change to position statement → clinical indications |
CG-SURG-85 Hip Resurfacing |
Content moved from SURG.00051 No change to position statement → clinical indications |
CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection |
Content moved from SURG.00054 No change to position statement → clinical indications |
This new medical policy will be implemented on January 1, 2019.
New Medical Policy |
Content |
GENE.00049 Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) |
MPTAC approved this new medical policy which reflects the following: The use of a circulating tumor DNA (ctDNA) test for the diagnosis or treatment of cancer is considered investigational and not medically necessary (INV&NMN) for all indications |
This medical policy has been revised and will be effective January1, 2019.
New Medical Policy |
Content |
ANC.00007 Cosmetic and Reconstructive Services: Skin Related |
MPTAC approved revision of policy which reflects the following: • Added microneedling (also known as percutaneous collagen induction therapy or skin needling) as COS&NMN for all indications |
This medical policy is archived effective September 1, 2018.
GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance
PUBLICATIONS: October 2018 Anthem Indiana Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/indiana/articles/medical-policy-and-clinical-guidelines-updates-571
Or scan this QR code with your phone