The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

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

 

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

 

Notes/updates

 

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

  • DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
  • LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
  • LAB.00033 — clarified investigational and not medically necessary statement to include 4K score and AR-V7
  • OR-PR.00003:
    • Clarified medically necessary position statement criteria 2 through 4
    • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
  • SURG.00011:
    • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
    • Added new products to investigational and not medically necessary statement
  • SURG.00045:
    • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
    • Revised title
  • SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

 

The following AIM Specialty Health® updates were approved on June 6, 2019:

  • Advanced imaging:
    • Imaging of the heart
    • Oncologic imaging
    • Vascular imaging
    • Proton beam therapy
    • Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)

 

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

Publish date

Medical Policy 

Medical Policy title

New or revised

June 13, 2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

New

June 13, 2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

June 13, 2019

* SURG.00011

Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting

Revised

June 13, 2019

SURG.00023

Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

June 13, 2019

SURG.00028

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

Revised

June 27, 2019

GENE.00025

Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

Revised

June 27, 2019

DRUG.00046

Ipilimumab (Yervoy®)

Revised

June 27, 2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

June 27, 2019

DRUG.00062

Obinutuzumab (Gazyva®)

Revised

June 27, 2019

DRUG.00067

Ramucirumab (Cyramza®)

Revised

June 27, 2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

June 27, 2019

DRUG.00075

Nivolumab (Opdivo®)

Revised

June 27, 2019

DRUG.00107

Avelumab (Bavencio®)

Revised

June 27, 2019

GENE.00044

Analysis of PIK3CA Status in Tumor Cells

Revised

June 27, 2019

* SURG.00121

Transcatheter Heart Valve Procedures

Revised

June 27, 2019

GENE.00001

Genetic Testing for Cancer Susceptibility

Revised

June 27, 2019

GENE.00043

Genetic Testing of an Individual’s Genome for Inherited Diseases

Revised

June 27, 2019

LAB.00011

Analysis of Proteomic Patterns

Revised

June 27, 2019

LAB.00015

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

Revised

July 10, 2019

GENE.00051

Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

New

July 10, 2019

SURG.00153

Cardiac Contractility Modulation Therapy

New

July 10, 2019

* DME.00037

Cooling Devices and Combined Cooling/Heating Devices

Revised

July 10, 2019

DME.00038

Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

Revised

July 10, 2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

July 10, 2019

* LAB.00027

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Revised

July 10, 2019

* LAB.00033

Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer

Revised

July 10, 2019

MED.00109

Corneal Collagen Cross-Linking

Revised

July 10, 2019

* OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

July 10, 2019

SURG.00005

Partial Left Ventriculectomy

Revised

July 10, 2019

* SURG.00045

Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions

Revised

July 10, 2019

SURG.00120

Internal Rib Fixation Systems

Revised

September 4, 2019

GENE.00010

Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

 

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.

 

Publish date

Clinical UM Guideline #

Clinical UM Guideline title

New or revised

June 27, 2019

CG-SURG-97

Cardioverter Defibrillators

New

June 27, 2019

CG-DRUG-98

Bendamustine Hydrochloride

Revised

June 27, 2019

CG-LAB-09

Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain

Revised

June 27, 2019

CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

Revised

July 10, 2019

CG-SURG-100

Laser Trabeculoplasty and Laser Peripheral Iridotomy

New

July 10, 2019

CG-ADMIN-01

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Revised

July 10, 2019

CG-ANC-06

Ambulance Services: Ground; Non-Emergent

Revised

July 10, 2019

CG-DME-03

Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Revised

July 10, 2019

CG-DME-07

Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

Revised

July 10, 2019

CG-DME-08

Infant Home Apnea Monitors

Revised

July 10, 2019

CG-DME-39

Dynamic Low-Load Prolonged-Duration Stretch Devices

Revised

July 10, 2019

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

July 10, 2019

CG-DME-45

Ultrasound Bone Growth Stimulation

Revised

July 10, 2019

CG-MED-41

Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Revised

July 10, 2019

CG-MED-49

Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

Revised

July 10, 2019

CG-MED-57

Cardiac Stress Testing with Electrocardiogram

Revised

July 10, 2019

CG-MED-59

Upper Gastrointestinal Endoscopy in Adults

Revised

July 10, 2019

CG-SURG-11

Surgical Treatment for Dupuytren's Contracture

Revised

July 10, 2019

CG-SURG-17

Trigger Point Injections

Revised

July 10, 2019

CG-SURG-35

Intracytoplasmic Sperm Injection (ICSI)

Revised

July 10, 2019

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Revised

July 10, 2019

CG-SURG-81

Cochlear Implants and Auditory Brainstem Implants

Revised

July 10, 2019

CG-SURG-85

Hip Resurfacing

Revised

July 10, 2019

CG-SURG-93

Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

Revised

September 4, 2019

CG-GENE-11

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

New

September 4, 2019

CG-GENE-10

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

New

September 4, 2019

CG-SURG-101

Ablative Techniques as a Treatment for Barrett’s Esophagus

New

September 4, 2019

CG-SURG-102

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

New

 

503273MUPENMUB

 



Featured In:
October 2019 Anthem Provider News - Kentucky