The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 12, 2022.

 

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

 

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > 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®]), please visit fepblue.org > Policies & Guidelines.

 

New policies

Below are the new medical policies and/or clinical guidelines that have been approved.

 

* Denotes prior authorization required.

 

Policy/guideline

Information

Effective date

*DME.00046

Intermittent Abdominal Pressure Ventilation Devices

Intermittent abdominal pressure ventilation devices are considered investigational and not medically necessary (INV & NMN) for all indications

 

Listed existing HCPCS code K1021 (code effective 10/1/2021) for exsufflation belt; considered INV & NMN

12/1/2022

DME.00047

Rehabilitative Devices with Remote Monitoring

The use of rehabilitative devices with remote monitoring or adjustment capabilities (for example, ROMTech PortableConnect® and ROMTech AccuAngle®) is considered INV & NMN for all indications

 

No specific code for this type of device, considered INV & NMN; listed E1399 NOC

12/1/2022

DME.00048

Virtual Reality Assisted Therapy Systems

Use of virtual reality systems (for example, EaseVRx, SootheVR, and RelieVR) for screening, diagnosis, or treatment of a health condition is considered INV & NMN for all indications

 

No specific code for this type of device, considered INV & NMN; listed E1399 NOC

12/1/2022

*GENE.00059

Hybrid Personalized Molecular Residual Disease Testing for Cancer

Oncologic hybrid personalized molecular residual disease (MRD) tests are considered INV & NMN for all indications

 

No specific code currently for this test, considered INV & NMN; listed 81479 NOC

12/1/2022

* LAB.00048

Pain Management Biomarker Analysis

The functional pain biomarker urine test panel is considered INV & NMN for chronic pain management and for all other indications

 

Listed existing CPT® PLA code 0117U specific to this test; considered INV & NMN

12/1/2022

MED.00139
Electrical Impedance Scanning for Cancer Detection

Electrical impedance scanning for cancer detection is considered INV & NMN for all indications

 

No specific code for this type of scanning, considered INV & NMN; listed 99199 NOC

12/1/2022

TRANS.00039

Portable Normothermic Organ Perfusion Systems

Outlines the MN and INV & NMN criteria for Portable Normothermic Organ Perfusion Systems

 

No specific transplant-related CPT codes for this technology; listed 32999 NOC lung and 47399 NOC liver having MN criteria, listed 33999 heart and 53899 kidney considered INV & NMN

12/1/2022

 

Updated policies

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-MED-90

Chelation Therapy

Moved content of MED.00127 Chelation Therapy to new clinical UM guideline document with the same title

 

HCPCS codes J0470, J0600, J0895, J3520, M0300, S9355 for chelation therapy now addressed in this document; considered NMN if criteria not met

7/6/2022

*GENE.00023

Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma

 

Previously titled: Gene Expression Profiling of Melanomas

·        Revised title

·        Expanded Scope and Position Statement to include cutaneous squamous cell carcinoma

·        Added existing CPT PLA code 0315U for GEP for squamous cell carcinoma; considered INV & NMN

12/1/2022

*SURG.00011

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

Revised INV & NMN statement to NMN for products with MN indications

 

Updated to consider NMN where indicated; added HCPCS codes Q4259, Q4260, Q4261 effective 7/1/2022 for products considered INV & NMN

7/1/2022

*SURG.00097

Scoliosis Surgery

Added MN criteria for vertebral body tethering

CPT Category III codes 0656T, 0657T, and associated ICD-10-PCS codes for tethering considered MN when criteria are met (were considered INV & NMN)

7/6/2022

*MED.00132
Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

Added CPT Category III codes 0717T, 0718T, effective 7/1/2022 for autologous ADRC therapy for rotator cuff tear; considered INV & NMN

7/1/2022

DME.00011

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

Added CPT Category III code 0720T effective 7/1/2022 for PENFS device (e.g., IB-Stim); considered INV & NMN

7/1/2022

*GENE.00053

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Added CPT PLA code 0323U effective 7/1/2022, for metagenomic NGS assay; considered INV & NMN

7/1/2022

LAB.00027

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Added existing CPT code 83520, considered INV & NMN for food allergy diagnoses

7/6/2022

*CG-GENE-14

Gene Mutation Testing for Cancer Susceptibility and Management

For CPT PLA code 0229U (Colvera test) descriptor revision only effective 7/1/2022

7/1/2022

*CG-GENE-21

Cell-Free Fetal DNA-Based Prenatal Testing

Added CPT PLA code 0327U effective 7/1/2022, for Vasistera test; considered MN based on diagnosis

7/1/2022

*GENE.00049

Circulating Tumor DNA Panel Testing (Liquid Biopsy)

Added CPT PLA code 0326U effective 7/1/2022, for Guardant360 panel; considered INV & NMN

7/1/2022

*GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

Added CPT PLA code 0329U for Oncomap test having MN criteria, and CPT PLA code 0331U for genome mapping test considered INV & NMN; both codes effective 7/1/2022

7/1/2022

*GENE.00056

Gene Expression Profiling for Bladder Cancer

For CPT code 0016M (Decipher Bladder TURBT) descriptor revision only effective 7/1/2022

7/1/2022

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

Added CPT PLA codes 0324U, 0325U effective 7/1/2022, for ovarian tumor drug response panels, considered NMN

7/1/2022

LAB.00019

Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

For CPT PLA code 0166U (Liverfast test) descriptor revision only effective 7/1/2022

7/1/2022

 

MULTI-BCBS-CM-004632-22



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September 2022 Anthem Provider News - Kentucky