The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Guidelines were reviewed on November 10, 2022.


To view medical policies and utilization management guidelines, go to, select Providers, and then select your state. Under Provider Resources, select Policies, Guidelines & Manuals.


To help determine if prior authorization is needed for Anthem members, go to, select Providers, and then select your state. Under Claims, select Prior Authorization. You can also call the prior authorization 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®]), visit > Policies & Guidelines.


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


* Denotes prior authorization required




Effective date

*CG-DME-31 Powered Wheeled Mobility Devices

Added NMN statement for powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT Personal Mobility Device) for all indications



Genetic Testing for Inherited Diseases

Incorporated content from CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions, GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies, GENE.00037 Genetic Testing for Macular Degeneration (partial content), GENE.00038 Genetic Testing for Statin-induced Myopathy, and GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD) into this document- Added CPT and HCPCS codes 81324, 81325, 81326, 81328, 81414, S3861, S3865, S3866, and genes to Tier 2 codes from the documents listed above; also some additional genes added to Tier 2 and NOC codes



Gene Mutation Testing for Cancer Susceptibility and Management

Moved content from CG-GENE-07 BCR-ABL Mutation Analysis and CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility into this document


Added CPT and HCPCS codes 81170 and S3840 and additional genes to Tier 2 codes from documents listed above



Home Health

Added HCPCS codes G0320, G0321, G0322 for home health services MN when criteria are met


*CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Added HCPCS code G0330 for facility billing for dental services requiring anesthesia, replacing NOC code 41899


*CG-SURG-27 Gender Affirming Surgery

Added ‘Placement of penile or testicular prostheses’ to NMN statement


*CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Added HCPCS codes C7531, C7534, C7535 for revascularization of femoral, popliteal arteries, MN when criteria are met


*CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

Added HCPCS codes C7538, C7539, C7540 when related to cardiac resynchronization therapy, MN when criteria are met


*CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

Added CPT codes 69729, 69730 for BAHA with magnetic transcutaneous attachment, MN when criteria are met; also descriptor revisions for codes 69716, 69717, 69719


*CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Added new CPT codes 43290, 43291 for intragastric balloon considered INV&NMN; added NOC code 64999 replacing CPT category III codes 0312T-0317T when specified as VBLOC considered INV&NMN; removed CPT code 00797 for associated anesthesia not addressed


DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Added new CPT Category III codes 0766T, 0767T, 0768T, 0769T, 0783T effective for transcutaneous electromagnetic pulse stimulation and transcutaneous auricular neurostimulation, considered INV&NMN


DME.00048 Virtual Reality-Assisted Therapy Systems

Added new CPT Category III codes 0770T, 0771T, 0772T, 0773T, 0774T for services using virtual reality technology, considered INV&NMN


GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

Added new CPT code 81418 for drug metabolism panel, considered INV&NMN


GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)

Added CPT PLA code 0356U for NavDx test considered INV&NMN


*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document


Added chromosome conformation signatures to scope of document and INV&NMN statement


*GENE.00056 Gene Expression Profiling for Bladder Cancer

Added CPT PLA code 0363U for Cxbladder Triage test considered INV&NMN


LAB.00011 Selected Protein Biomarker Algorithmic Assays

Added CPT PLA code 0360U for Nodify CDT test considered INV&NMN


LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer

Added CPT PLA code 0359U for IsoPSA test, considered INV&NMN


LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease

Added CPT PLA codes 0358U for Lumipulse G βAmyloid Ratio and 0361U for Neurofilament Light Chain (NfL) tests, considered INV&NMN


*MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring


Previously titled: Surface Electromyography Devices for Seizure Monitoring

Revised title

Revised Position Statement by adding electrodermal activity sensor devices


Added HCPCS code E1399 NOC, no specific code for electrodermal activity devices considered INV&NMN


*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Added HCPCS codes Q4262, Q4263, Q4264 for products considered INV&NMN; also added Q4236 reactivated for Care patch, considered INV&NMN


*SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Added chest wall reconstruction with flat chest closure to the list of surgical procedures considered ‘Reconstructive’ following surgery for breast cancer


SURG.00079 Nasal Valve Repair

Added new CPT code 30469 for Vivaer procedure, considered INV&NMN


SURG.00095 Viscocanalostomy and Canaloplasty

Revised descriptors for CPT codes 66174, 66175


*SURG.00097 Scoliosis Surgery

Added magnetically controlled growing rods to scope of document in INV&NMN statement


SURG.00113 Artificial Retinal Devices

Removed HCPCS codes C1841, C1842 HCPCS update


SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain

Revised descriptors for CPT codes 64415, 64417, 64447


TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation

Added the term “Multivisceral” and the phrase, “including but not limited to treatment of pseudotumor peritonei” to the first INV&NMN statement


Removed the third INV&NMN on “all other Multivisceral transplants”


TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias

Expanded scope of document to address autologous hematopoietic stem cell mobilization and pheresis for the treatment of genetic diseases as part of the development of an FDA-approved ex vivo gene therapy (for example, betibeglogene autotemcel or elivaldogene autotemcel)


Added MN and INV&NMN criteria for Autologous hematopoietic stem cell mobilization and pheresis


THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radio-ablation

Added new CPT Category III codes 0745T, 0746T, 0747T for cardiac radio-ablation services considered INV&NMN: replacing non-specific radiation therapy codes


TRANS.00035 Therapeutic use of Stem Cells, Blood, and Bone Marrow Products

Added CPT Category III code 0748T for injection of stem cell product into perianal peri fistular soft tissue considered INV&NMN



Featured In:
February 2023 Anthem Provider News - Kentucky