We annually update our provider manuals to ensure care provider partners have the latest information for collaboration. Serving as a comprehensive reference, the manual is reviewed each year to incorporate changes in processes and policies. It includes essential details for both professional and hospital/facility providers. The next update will be available on our website on May 1, 2025, and will take effect on August 1, 2025.

To view the updated manual, please visit anthem.com. Select For Providers, then Indiana, then Access the commercial provider site, then Review Policies, scroll to the Provider Manual area, and select Download the Manual to view and/or download the provider manual as well as the BlueCard and Medicare Advantage manuals.

Archived copies of the professional and hospital/facility manual will remain available at the same location.

INBCBS-CM-082722-25

AdministrativeCommercialMay 1, 2025

Wellness visits may increase appointment scheduling For members enrolled in an ACA plan

Annual wellness and well-woman visits are covered with no member cost-sharing when provided by in-network providers for our members with Affordable Care Act (ACA)compliant plans. Individual and small group plan members are encouraged to schedule these visits within the first 90 days of their plan starting or renewing, so your practice may see an increase in requests, especially at the beginning of the second and fourth quarters.

Providers can perform the annual wellness or well‑woman visit, even if it has been less than one calendar year since the last wellness visit. We ask that your practice be flexible in accommodating members wanting to schedule their visits earlier than they may have previously. The wellness or well‑woman visit claim will be processed as a preventive care service covered with no member cost share.

Please note that this benefit may not apply to all health plans. You should continue to verify eligibility and benefits for all members in Availity Essentials (https://Availity.com) before providing services or receiving member copayments, deductibles, or coinsurance.

MULTI-BCBS-CM-079025-24-CPN73418

Behavioral HealthHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingMay 1, 2025

FDA lifts risk evaluation and mitigation strategy reporting requirements for Clozapine

At a glance:

The Food and Drug Administration (FDA) removed Clozapine from the risk evaluation and mitigation strategy (REMS) program, enhancing access while maintaining monitoring through label‑recommended white blood cell (WBC) and absolute neutrophil count (ANC) checks.
New studies show a low neutropenia risk for Clozapine.
REMS removal aims to enhance Clozapine access and address treatment disparities, emphasizing patient‑centered care.

We encourage you to integrate updated Clozapine guidelines into your practice, enhancing access for your patients while responsibly managing associated risks. Prioritize ongoing education about monitoring practices and ensure efficient collaboration with laboratory services to deliver optimal patient care.

Background

As of February 24, 2025, the FDA no longer requires adherence to the REMS program for Clozapine. Although warnings about agranulocytosis remain on the drug’s label and prescribers are still encouraged to monitor WBC and ANC, participation in the REMS program is no longer mandatory. The FDA is currently working with manufacturers to update the prescribing information.¹

The decision to discontinue the REMS program for Clozapine was a result of a November 2024 committee meeting, where 14 of 15 experts recommended its removal. This recommendation was based on recent studies from Finland, Australia, and New Zealand showing that the risk of neutropenia is rare and decreases significantly after six months, suggesting less monitoring is needed.^1,2,3,4

Role of Clozapine in schizophrenia treatment

Clozapine remains the only FDA‑approved medication for patients with treatment‑resistant schizophrenia who do not respond to standard treatments. Due to risks such as agranulocytosis and seizures, it should be prescribed only after other treatments have failed.⁵

Impact on prescribers, pharmacies, and patient accessibility

The removal of REMS is expected to make it easier for prescribers and pharmacies to offer Clozapine. However, continued education on managing side effects and improving access to lab testing is crucial for increasing patient access.

This change could also reduce treatment disparities, particularly for patients of African descent who may have genetic variations leading to lower ANC counts. Removing the REMS program for Clozapine does not lessen the need for careful, patient‑centered care. Care providers should focus on expanding access and offering patient support to ensure the best outcomes.

Thank you for your commitment to advancing patient care and staying informed on the latest developments. Together, we can continue to make a meaningful impact in the lives of our members — your patients.

Sources:

https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-clozapine. Accessed 26 February 2025.
Richmond, Linda M. “Clozapine Risks Drop Sharply Within Months, May Warrant Less Monitoring.” Psychiatry Online, June 14, 2024, psychiatryonline.org/doi/10.1176/appi.pn.
Rubio JM, Kane JM, Tanskanen A, Tiihonen J, Taipale H. “Long‑term persistence of the risk of agranulocytosis with clozapine compared with other antipsychotics: a nationwide cohort and case‑control study in Finland.” Lancet Psychiatry. 2024 Jun;11(6):443‑450. doi: 10.1016/S2215‑0366(24)00097‑X. Epub 2024 Apr 30. PMID: 38697177. https://pubmed.ncbi.nlm.nih.gov/38697177/
Evaluating the epidemiology of clozapine‑associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study. Northwood, Korinne et al. The Lancet Psychiatry, Volume 11, Issue 1, 27 – 35
Corell, C U et al. “A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment‑Resistant Schizophrenia.” CNS drugs vol. 36,7 (2022): 659‑679. doi:10.1007/s40263‑022‑00932‑2 https://pmc.ncbi.nlm.nih.gov/articles/PMC9243911/#d32e403

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, Hoosier Care Connect, and IN PathWays for Aging 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-077606-25-CPN77295

Education & TrainingHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 29, 2025

Contractual obligations for care coordination and case management engagement

As valued providers in our Anthem network, your role is essential in ensuring seamless communication and delivering comprehensive case management for all members.

As part of your contract with Anthem, we ask that you:

Coordinate care: Facilitate communication between the member's primary care provider (PCP) and other specialists involved in the member’s care to ensure efficient coordination of healthcare services.
Bidirectionally communicate: Engage in ongoing, two-way communication with Anthem, the member’s PCP, and other specialists involved in the member’s care. Sharing relevant health information, updates, and treatment plans to ensure all parties are informed and aligned in managing the member’s healthcare needs.
Engage in case management: Actively collaborate with our case managers to develop individualized care plans, assist with appointment scheduling, and coordinate a wide range of healthcare services, ensuring holistic and integrated care for each member.

Importance of care coordination with managed care

Effective care coordination within a managed care framework is essential to improving patient outcomes and operational efficiency. By sharing treatment plans, confirming appointments, and ensuring seamless transitions between different care settings, you can help minimize duplication of services, reduce healthcare costs, and ensure that members receive timely, appropriate care.

Anthem and Carelon Behavioral Health, Inc.

Carelon Behavioral Health, a separate company offering services on behalf of Anthem, specializes in behavioral health services. Carelon Behavioral Health is integrated with Anthem to expand and enhance its behavioral health offerings. As such, you may receive communications from a case manager using a Carelon Behavioral Health email address as a part of the coordinated care efforts to ensure members receive necessary services. Please engage with these associates to improve health outcomes.

We encourage you to revisit and enhance your care coordination processes to ensure compliance with these contractual obligations. Active collaboration with our case managers, along with securing the necessary releases of information, will improve care outcomes and member satisfaction.

Thank you for your dedication and partnership in delivering coordinated, effective care to our members.

Important note: You are not permitted to use or disclose Protected Health Information about individuals who you are not treating or are not enrolled in your practice. This applies to Protected Health Information accessible in any online tool, sent in any medium including mail, email, fax or other electronic transmission.

INBCBS-CD-078803-25

Education & TrainingHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 7, 2025

FAQ for Care Central

Care Central overview

Indiana PathWays for Aging offers home‑ and community‑based services (HCBS) care providers an application within Availity Essentials called Care Central. This platform was specifically designed for HCBS care providers to reduce administrative burden, simplify claims, and provide easy access to vital information, serving as a one‑stop shop for all business needs.

Within Care Central, HCBS care providers can:

Submit claims that are billed using the CMS‑1500 form.
View the status of claims submitted.
View HCBS authorizations and details.
Access authorized member lists and view members' demographic information.
Respond to referrals for services.
Access health plan contacts and resources.

Care Central FAQ

Do I need to be registered with Availity Essentials to access Care Central?

Yes. You must be registered with Availity Essentials to access Care Central, which you can do at no charge at https://Availity.com. Once registered, select Payer Spaces > Anthem > Care Central to access the application. You will need to ensure your care provider profile is set up correctly with your Legacy Provider Identifier (LPI) and TIN credentials to access the application.

An error populates when trying to enter the Care Central application stating my identifiers are incorrect. How do I fix this?

If you don’t have an NPI, be sure to have your Payer Assigned Provider ID (PAPI)/LPI and TIN added as identifiers under the Provider tab in Availity Essentials.

Do I have to use the Care Central application to submit claims?

No. Our preferred platform is Care Central, which offers a condensed and easy-to-use claim submission form. However, you can still submit claims directly through the Availity Essentials platform using the claims and encounters tool or through your own electronic data interchange (EDI) software.

I do not see any members listed on my member dashboard in Care Central. How do I add members?

You can add members to the Member Dashboard by selecting the Create Member button from the bottom of the Member Dashboard page.

Please note that only administrators will be able to add members. Once members are added, however, all users within the organization will be able to see those members.

Note: Members for whom you have authorizations should be automatically added to your Member Dashboard.

Why am I unable to add a member to the Member Dashboard?

There are two main reasons why you may not be able to add a member to your Member Dashboard:

The member may no longer be enrolled with Anthem or their coverage may have expired. To confirm a member’s eligibility, check the Eligibility and Benefits page in Availity Essentials.
The Care Central application was designed for our Indiana HCBS waiver providers for the Indiana PathWays for Aging program. If the member is not enrolled in Indiana PathWays for Aging, you will not be able to add them to your Member Dashboard.

Why don’t I see any referrals listed on my Referral Dashboard?

If you do not see any referrals, there may be currently no referrals for the services in the counties where you are contracted. If you believe this to be incorrect, email your provider relations representative and let them know which counties and services you expect to see.

You should check the Referral Dashboard often for new referrals requiring a response. Once a referral becomes available for response, select the Incoming tab to begin the process of responding to the referral.

Is there a way to sign up to be notified when referrals become available for my organization in Care Central?

Yes, providers have the option to opt into receiving referral notification emails up to once a day if they have a referral that needs their response in Care Central. To start receiving referral notification emails:

From the Care Central Dashboard page, select your profile icon, then My Profile.
Scroll to the bottom of the page and switch the toggle button labeled Receive Referral Email Notifications to on.
You are now set up to receive email notifications for referrals. You can turn this setting off anytime by toggling the switch back to the off position.

Why is the Referral Dashboard telling me I am out of network?

This can happen when your contract with us has ended. An out‑of‑network message can also be caused by inaccurate information provided during the digital provider enrollment (DPE) process. If you are experiencing this issue, contact your Provider Relations representative or email the Provider Relations team at INMLTSSProviderRelations@anthem.com.

Who do I contact if I have additional referral questions or questions about a member’s Care Plan?

Email the Care Coordination team or your Provider Relations representative to help you contact the correct individuals.

If you have not already, you can view most members’ Person-Centered Support Plan through Care Central’s Member Dashboard. Select the member on the Member Dashboard. Then, select the Person-Centered Care Plan. For members who do not have their Person-Centered Support plan available to view through the Care Central application, please reach out to the Care Coordinator working with the member or email Ltsscoordination@anthem.com.

Where can I view additional information on the status of my claims?

You can view your claims from the Claims tab in Care Central. For additional claim details, you can also use the Claim Status tool in Availity Essentials. Navigate to the Availity Claim Status tool by selecting the Claims Status tool button from the Care Central Claims tab or navigate to Claims and Payments > Claim Status.

I accepted an available referral in Care Central. How long do I have to wait for the referral to become authorized?

The Referrals Dashboard tracks the workflow and status of a referral, so you should check back often for available updates. Once a referral moves to a status of Await Auth, we will work with the member to select the servicing care provider. If you are chosen to provide the service, an authorization will be created, and you will see the member on your member dashboard.

My organization is now certified to provide additional services. How do I ensure those updates are reflected in Care Central for my organization?

Contact your Provider Relations representative with the updated certification information or email the Provider Relations mailbox at INMLTSSProviderRelations@anthem.com for assistance with making the updates. Once contracted for additional services, your internal record will be updated, and you will receive referrals for those services in the applicable counties.

How do I update my information in Care Central to reflect additional service locations in which my organization is authorized to provide services?

Use the Provider Data Management (PDM) tool in Availity Essentials to update service area locations for your organization. Once your contract has been updated to reflect additional services, you will automatically be set up to receive referrals for the new services.

Why are some authorizations not available to view in Care Central?

Authorizations in Care Central are pulled using a care provider’s LPI/NPI and TIN combination. If the authorization is under a different LPI/NPI and TIN combination than the one used to log into Care Central, it will not display.

Where can I find additional contact information if I have questions?

Select the Contact Us tab in Care Central for helpful contact information. Additional contacts are listed below.

For authorizations, please email Indianaauths@anthem.com or contact Provider Services at 866‑408‑6132 (Hoosier Healthwise), 844‑533‑1995 (Healthy Indiana Plan), 844‑284‑1798 (Hoosier Care Connect), or 833‑569‑4739 (Indiana PathWays for Aging).

For referral questions or to contact a member’s care coordinator, please email Ltsscoordination@anthem.com.

INBCBS-CD-074037-24

Education & TrainingCommercialMay 1, 2025

Streamline your prior authorizations with our digital tools

Manage your prior authorization requests with our digital tools — Availity Essentials and https://anthem.com/provider. These resources simplify requirement determination and request submissions, giving you more time to deliver effective and efficient care to our members. We encourage you to review the instructions below.

Determining prior authorization requirements

Availity Essentials:

If you do not already have access, select Get Started to create an account.

Go to the Payer Spaces tab.
Select the applicable plan.
Select Authorization Rules Lookup.
Enter the required provider information.
Select Next and enter the required member information.

Note: Final determination of prior authorization requirements is completed upon submission and may differ from search results.

Provider website:

Go to https://anthem.com/provider.
Scroll down and select the applicable state.
Scroll down to Commercial‑partnered programs and select Access the Commercial Provider site to access the Provider website homepage.
Under the Resources heading, select Prior Authorization.
Select the applicable state.
Select the appropriate link based on the member’s plan.

If the member’s home plan is not with Anthem, scroll to Helpful Links > Select Medical Policy and Prior Authorization for Blue Plans, then follow the prompts to determine the applicable home plan and prior authorization requirements.

Submitting prior authorization requests

Availity Essentials:

Log in to https://Availity.com.
Select the Patient Registration tab to access Authorizations and Referrals.
Select Authorization Request.

Note: Transplant prior authorization requests must be submitted by phone, fax, or secure email.

MULTI-BCBS-CM-081857-25-CPN81558

Education & TrainingCommercialMay 1, 2025

Free CE training: Lifestyle Medicine & Food as Medicine Essentials Course

Anthem is happy to support the announcement of an exciting partnership between Premera Blue Cross, Amazon, and the American College of Lifestyle Medicine (ACLM) offering a free online Lifestyle Medicine & Food as Medicine Essentials Course for the entire provider community.

In this comprehensive online course, you will explore the six pillars of lifestyle medicine, emphasizing how food and nutrition can play a critical role in preventing and treating chronic diseases. The course is tailor‑made for healthcare providers looking to enrich their care approach with practical evidence‑based strategies. This course is available until September 14, 2025.

Benefits for providers:

Free access: Participate in this valuable training at no cost.
Earn credits: Completing the course awards, you earn 5.5 CME/CE credits.
Enhance your practice: Acquire tools to transform care and effectively address chronic disease.

How to enroll:

Visit https://lifestylemedicine.org/essentials.
Log in or create an ACLM account.
Enter promo code ESS‑AMZNEDU at checkout to access the course for free.

Contact us

Please reach out to Dr. Jon Liu at jonliu@amazon.com with questions regarding the free course.

MULTI-BCBS-CM-081296-25-CPN80998

Medical Policy & Clinical GuidelinesCommercialApril 10, 2025

Change to Prior Authorization Requirements

Medical Policies and Clinical Guidelines updates, May 2025

The following Medical Polices and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Utilization Management Guidelines, go to https://anthem.com > Providers > select your state > Provider Resources > Policies, Guidelines & Manuals.

To help determine if preapproval is needed, go to https://anthem.com > Providers > select your state > Claims > Prior Authorization. You can also call the preapproval phone number on the back of the member’s ID card.

To view Medical Policies and Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® FEP^®), please visit fepblue.org> Policies & Guidelines.

Below are the new Medical Policies and/or Clinical Guidelines that have been approved.

* Denotes prior authorization required.

*Policy/Guideline*	Information	Effective date
*CG‑MED‑98 Parenteral Antibiotics for the Treatment of Lyme Disease	Moved content from MED.00013 to new clinical UM guideline with the same title NV&NMN changed to NMN as a result of MP to CUMG transition Moved CPT^® codes 96365, 96366, 96367, 96368, 96372 and HCPCS codes for antibiotics from MED.00013	August 1, 2025
*CG‑SURG‑123 Autologous Fat Grafting and Injectable Soft Tissue Fillers	Moved content related to autologous fat grafting and injectable soft tissue filters from MED.00132 to new clinical UM guideline Moved codes 15771, 15772, 15773, 15774, 11950, 11951, 11952, 11954, 31574, C1878, G0429, L8607, Q2026, Q2028, and NOC 17999, L8699 from MED.00132	August 1, 2025
*CG‑SURG‑125 Canaloplasty	Moved content for canaloplasty from SURG.00095 to new clinical UM guideline NV&NMN changed to NMN as a result of MP to CUMG transition Revised MN statement to remove mild to moderate stage	August 1, 2025
*DME.00053 Home Video‑Assisted Robotic Rehabilitation Systems	Home video‑assisted robotic rehabilitation systems are considered INV&NMN for all indications Existing HCPCS code E0739 (code effective 4/1/2024) for Motus hand/Motus foot considered INV&NMN	August 1, 2025
*MED.00151 Gene Therapy for Aromatic L‑Amino Acid Decarboxylase Deficiency	Gene therapy for aromatic l‑amino acid decarboxylase deficiency using eladocagene exuparvovec‑tneq is considered INV&NMN for all indications Existing ICD‑10‑PCS code XW0Q316 for KEBILIDI considered INV&NMN; NOC CPT and HCPCS codes 64999, C9399, J3490, J3590 when specified as KEBILIDI considered INV&MN	August 1, 2025
*MED.00152 Outpatient Intravenous Insulin Therapy	Outpatient intravenous insulin therapy is considered INV&NMN as a treatment for all indications, including diabetes Existing HCPCS code G9147 is considered INV&NMN	August 1, 2025
*SURG.00165 Histotripsy	Histotripsy is considered INV&NMN for all indications Existing CPT category III codes 0686T (moved from CG‑SURG‑78), 0888T, NOC code 55899 specified as histotripsy, and associated ICD‑10‑PCS codes are considered INV&NMN	August 1, 2025

Below are the current Clinical Guidelines and/or Medical Policies we reviewed and updates were approved.

* Denotes prior authorization required

*Policy/Guideline*	Information	Effective date
CG‑ANC‑03 Acupuncture	Revised descriptors for 97811, 97814 effective 1/1/2025	January 1, 2025
CG‑MED‑64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins	Revised descriptor for 93656 effective 1/1/2025	January 1, 2025
CG‑MED‑91 Remote Therapeutic and Physiologic Monitoring Services	Revised descriptors for 98975, 98976, 98977, 98978 effective 1/1/2025	January 1, 2025
*CG‑SURG‑61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver	Added new CPT codes 60660, 60661 effective 1/1/2025 for radiofrequency ablation thyroid considered NMN (was included in NOC 60699)	January 1, 2025
CG‑SURG‑120 Vagus Nerve Stimulation	Added new CPT Category III codes 0908T, 0909T, 0910T, 0911T, 0912T effective 1/1/2025 for a stimulator (not yet FDA approved) for rheumatoid arthritis considered NMN	January 1, 2025
LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays	Added new CPT PLA code 0525U effective 1/1/2025 for 3D Predict Ovarian test considered NMN; removed 0564T deleted as of 1/1/2025	January 1, 2025
LAB.00015 Detection of Circulating Tumor Cells	Clarified CPT codes 86152, 86153 considered INV&NMN only for blood specimen; other specimens (eg, CSF) not addressed	February 1, 2025
LAB.00026 Pathology Systems and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions	Added MN criteria for ArteraAI Prostate cancer risk stratification test Revised INV&NMN statement to remove prostate cancer CPT PLA code 0376U will be considered MN when criteria are met (was INV&NMN)	February 1, 2025
*LAB.00028 Blood‑based Biomarker Tests for Multiple Sclerosis	Added new CPT code 83884 effective 1/1/2025 for neurofilament light chain considered INV&NMN	January 1, 2025
*LAB.00035 Multi‑biomarker Disease Activity Blood Tests for Rheumatoid Arthritis	Added new CPT PLA code 0521U effective 1/1/2025 for rheumatoid arthritis panel considered INV&NMN	January 1, 2025
*LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia	Added new CPT PLA code 0524U effective 1/1/2025 for sFlt‑1/PlGF test considered INV&NMN	January 1, 2025
LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy	Added CPT NOC code 81599 replacing PLA code 0456U for PrismRA deleted as of 1/1/2025	January 1, 2025
*LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease	Revised formatting and content of MN statement Added new CPT codes 82233, 82234, 84393, 84394 for Abeta and pTau considered MN when criteria are met and new CPT code 83884 for neurofilament light chain considered INV&NMN all effective 1/1/2025, removed PLA code 0346U deleted as of 1/1/2025	January 1, 2025
*MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications	Revised INV&NMN to include examples bilateral staged focused ultrasound thalamotomy or pallidotomy, BPH and uterine fibroids Added new CPT code 61715 effective 1/1/2025 for intracranial MRgFUS considered MN when criteria are met replacing 0398T deleted as of 1/1/2025	January 1, 2025
MED.00132 Autologous Adipose‑derived Regenerative Cell Therapy. Previously titled: Adipose‑derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures	Revised title, Revised Position Statement Revised scope of document to address autologous adipose‑derived regenerative cell therapy Moved content related to autologous fat grafting and injectable soft tissue fillers to new document CG‑SURG‑123 Removed codes 15771‑15774, 11950‑11952, 11954; 31574; C1878; G0429; L8607; Q2026; Q2028 17999; L8699 now addressed in CG‑SURG‑123	February 1, 2025
*MED.00135 Gene Therapy for Hemophilia	Added new HCPCS code J1414 effective 1/1/2025 for Beqvez considered MN when criteria are met replacing C9172 deleted as of 1/1/2025	January 1, 2025
MED.00137 Eye Movement Analysis Using Non‑spatial Calibration for the Diagnosis of Concussion	Revised descriptor for 0615T effective 1/1/2025	January 1, 2025
MED.00140 Gene Therapy for Beta Thalassemia	Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590	January 1, 2025
MED.00146 Gene Therapy for Sickle Cell Disease	Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590	January 1, 2025
*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Added new 1/1/2025 CPT and HCPCS codes 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, C8002 for skin cell suspension considered MN when criteria are met, and new HCPCS codes Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353 for products considered INV&NMN	January 1, 2025
*SURG.00135 Renal Sympathetic Nerve Ablation	Added new HCPCS codes C1735, C1736 effective 1/1/2025 for renal denervation catheters considered INV&NMN	January 1, 2025
*SURG.00155 Cryoneurolysis	Added new HCPCS codes C9808, C9809 effective 1/1/2025 for cryoICE and Iovera devices considered INV&NMN	January 1, 2025
SURG.00156 Implanted Artificial Iris Devices	Added new CPT code 66683 effective 1/1/2025 for iris prosthesis implantation considered INV&NMN, replacing category III codes 0616T‑0618T deleted as of 1/1/2025	January 1, 2025
SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain	Added new HCPCS code C9807 effective 1/1/2025 for the Sprint device considered INV&NMN	January 1, 2025
*SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis	Added new HCPCS code C8003 effective 1/1/2025 for implantation MISHA knee system considered INV&NMN	January 1, 2025
TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors	Added ICD‑10‑CM diagnosis code C49.3 as MN when criteria are met	January 1, 2025

MULTI-BCBS-CM-080572-25

Medical Policy & Clinical GuidelinesMedicare AdvantageApril 24, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective May 25, 2025

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

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

To view a guideline, visit the Medical Policies & Clinical UM Guidelines website.

Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 25, 2025.

Publish date	*Medical Policy* number	*Medical Policy* title	Status
1/30/2025	DME.00011	Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices	Revised
1/30/2025	DME.00053	Home Video-Assisted Robotic Rehabilitation Systems	New
1/30/2025	LAB.00026	Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions	Revised
1/30/2025	LAB.00037	Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)	Revised
1/30/2025	MED.00151	Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency	New
1/30/2025	MED.00152	Outpatient Intravenous Insulin Therapy	New
1/30/2025	SURG.00165	Histotripsy	New
1/30/2025	TRANS.00029	Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias	Revised
1/30/2025	TRANS.00033	Heart Transplantation	Revised

Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect May 25, 2025.

Publish date	*Clinical UM Guideline* number	*Clinical UM Guideline* title	Status
1/30/2025	CG-DME-06	Compression Devices for Lymphedema	Revised
1/30/2025	CG-MED-98	Parenteral Antibiotics for the Treatment of Lyme Disease	Conversion New
1/30/2025	CG-OR-PR-04	Cranial Remodeling Bands and Helmets (Cranial Orthoses) Previously Titled: Cranial Remodeling Bands and Helmets (Cranial Orthotics)	Revised
1/30/2025	CG-RAD-26	Maternity Ultrasound in the Outpatient Setting Previous category and number: CG-MED-42	Conversion New
1/30/2025	CG-SURG-123	Autologous Fat Grafting and Injectable Soft Tissue Fillers	Conversion New
1/30/2025	CG-SURG-124	Viscocanalostomy	Conversion New
1/30/2025	CG-SURG-125	Canaloplasty	Conversion New
1/30/2025	CG-THER-RAD-07	Intravascular Coronary and Non-Coronary Brachytherapy Previously Titled: Intravascular Brachytherapy (Coronary and Non-Coronary)	Revised

MULTI-BCBS-CR-082359-25-CPN81285

Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageApril 30, 2025

Change to Prior Authorization Requirements

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Chromosomal microarray analysis:

Added neonatal death to the list of indications considered medically necessary.
Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.

Whole Exome Sequencing (WES) and Whole Genome Sequencing:

Clarified and restructured the criteria for improved readability.
Added Medically Necessary criteria for Prenatal and PostNatal testing
Added Not Medically Necessary statement for early neonatal death
Added note that WES may include comparator testing.

Pharmacogenomic testing:

Deleted typo (“one” before “genotyping”) in first sentence
Added “considered medically necessary for genotyping” to title of Table 1
Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics

Predictive and prognostic polygenic testing:

Updated Description/Scope and Rationale and added References

Musculoskeletal

Interventional pain management:

Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
Exclusions:

Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.

Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:

Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.

Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:

Specified nonsurgical low back pain as an exclusion.

As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management using the following:

Access the Carelon Medical Benefits Management provider portal directly at www.providerportal.com:

Online access is available 24/7 to process orders in real‑time and is the fastest and most convenient way to request authorization.

For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com.

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

MULTI-BCBS-CRCM-078958-25-CPN78066

Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 2, 2025

Precertification/prior authorization requirement changes

Effective June 1, 2025, the below CPT^®codes will require precertification/prior authorization. All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The precertification/prior authorization lookup tool allows providers to search codes by the specific Medicaid line of business to determine whether precertification/prior authorization is required and which guideline is used for the case review. To access the precertification/prior authorization lookup tool, go to https://providers.anthem.com/in and select the precertification/prior authorization lookup tool under the Claims drop-down.

Contracted providers can also access the precertification/prior authorization look up tool via Availity Essentials at https://Availity.com by logging in, selecting Payer Spaces, then selecting the precertification/prior authorization look up tool tile.

For assistance with questions regarding the precertification/prior authorization requirement change, please call Provider Services at one of the phone numbers listed below:

Hoosier Healthwise — 866‑408‑6132
Healthy Indiana Plan — 844‑533‑1995
Hoosier Care Connect — 844‑284‑1798
Indiana PathWays for Aging – 833‑412‑4405

*CUMG* number	*CUMG* title	CPT code
MCG GRG: SG-NS (ISC GRG)	Neurosurgery pt Procedure GRG	61624
MCG NCD: N2016	NCD Cardic Output Monitoring by Thoracic Electrical Bioimpedance	93701
MCG ACG: A-0487	Lower Limb Prosthesis	L5783, L5841

UM AROW A2025M2968

INBCBS-CD-078453-25

Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 29, 2025

Prior authorization requirement changes

Effective July 1, 2025, the below CPT^® codes will require prior authorization. All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The precertification lookup tool allows care providers to search codes by the specific line of business to determine whether a PA is required, and which guideline is utilized for the case review. To access the precertification lookup tool, go to https://providers.anthem.com/in and select the precertification lookup tool in the Claims drop-down.

Contracted providers can also access the precertification lookup tool via Availity Essentials at https://Availity.com. Select Payer Spaces; then, select the precertification lookup tool tile.

For assistance with questions regarding the PA requirement change, call Provider Services at one of these phone numbers:

Hoosier Healthwise — 866-408-6132
Healthy Indiana Plan — 844-533-1995
Hoosier Care Connect — 844-284-1798
Indiana PathWays for Aging — 833-569-4739

*CUMG* number	*CUMG* title	CPT code
MCG A-0893	Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components, and supplies for all functions	E0468
MCG A-0884	Cough stimulating device, alternating positive and negative airway pressure	E0482
MCG LCD L33690	Automatic external defibrillator	E0617

INBCBS-CD-072384-24

Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingApril 21, 2025

New preapproval requirements for coronary artery catheter placement procedures

Effective August 1, 2025, the CPT^® codes listed below require preapproval.

*Clinical Utilization Management Guideline (CUMG)* number	*CUMG* title	CPT code
MCG A‑0001	Cardiac Catheterization and Angiography	C7552 and C7553

To view a complete list of preapproval requirements:

You can access detailed preapproval requirements via the provider self‑service tool at https://Availity.com.
If you do not have access to Availity, we offer a Precertification Lookup Tool, which allows you to search codes by line of business and program. To access the Precertification Lookup Tool, visit https://providers.anthem.com/in and select Precertification Lookup Tool under the Claims drop‑down.

To request preapproval:

From the Availity homepage, select Patient Registration from the top navigation.
Then, select Auth/Referral Inquiry or Authorizations.

Please note that all covered services are contingent upon medical necessity and benefit coverage at the time of service. To determine coverage of a particular service or procedure for a specific member, you can access eligibility and benefits information within Availity Essentials. If you do not have access to Availity Essentials, please contact Provider Services at 866‑408‑6132 (Hoosier Healthwise), 844‑533‑1995 (Healthy Indiana Plan), 844‑284‑1798 (Hoosier Care Connect), or 833‑569‑4739 (Indiana PathWays for Aging).

INBCBS-CD-076333-25

PharmacyMedicare AdvantageApril 18, 2025

New specialty pharmacy medical step therapy requirement

Effective June 1, 2025, the following Medicare Part B medication from the current Clinical Criteria Guidelines will be included in our medical step therapy preapproval review process. Step therapy review will apply upon preapproval initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving the medication listed below.

Visit our Clinical Criteria page to search for specific criteria.

Clinical Criteria	Drug	Status
CC‑0166	Hercessi (trastuzumab‑strf)	Non‑preferred

MULTI-BCBS-CR-077570-25-CPN77133

PharmacyMedicare AdvantageApril 18, 2025

Specialty pharmacy preapproval list update

Effective for dates of service on and after August 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our preapproval review process.

Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over preapproval rules and must be considered first when determining coverage. Claims that do not comply with these new requirements may not be approved.

HCPCS code	Medicare Part B drug
Q5136	Jubbonti; Wyost (denosumab‑bbdz)

MULTI-BCBS-CR-077559-25-CPN77132

May 2025 Provider Newsletter

Featured Articles