Policy Updates Medical Policy & Clinical GuidelinesCommercialAugust 14, 2024

Medical Policies and Clinical UM Guidelines updates — September 2024

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

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.

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

* Denotes prior authorization required

Policy/guideline

Information

Effective date

*MED.00148 Gene Therapy for Metachromatic Leukodystrophy

  • Outlines the MN and NMN criteria for gene therapy for metachromatic leukodystrophy
  • New technology No specific code for Lenmeldy, listed NOC codes C9399, J3490, J3590

12/1/2024

*RAD.00069 Absolute Quantitation of Myocardial Blood Flow Measurement

  • The use of absolute quantitation of myocardial blood flow testing is considered INV&NMN for all indications
  • Existing CPT® codes 0742T and 78434 and new CPT codes 0899T, 0900T effective 07/01/2024 will be considered INV&NMN

12/1/2024

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

  • Revised ocular indications, including the addition of SurSight to MN and NMN section and added new MN criterion addressing non-healing or persistent corneal epithelial defects
  • Removed VersaWrap from INV&NMN statement
  • Removed Phasix Mesh from INV&NMN statement
  • Added Phasix Mesh and Phasix ST Mesh to MN and NMN statements
  • Revised coding section for ocular indications to considered MN when criteria are met; no specific code for Phasix, included in listed NOC codes; added new HCPCS codes Q4311-Q4333 effective 07/01/2024 considered INV&NMN and removed deleted codes Q4210, Q4277

12/1/2024

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

*LAB.00019 Proprietary Algorithms for Liver Fibrosis

Added new CPT PLA code 0468U effective 07/01/2024 for the NASHnext test, considered INV&NMN

7/1/2024

*LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy

Added new CPT PLA code 0456U effective 07/01/2024 for PrismRA test considered INV&NMN, replacing NOC codes

7/1/2024

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

Added new CPT PLA code 0459U effective 07/01/2024 for Elecsys® Total Tau CSF (tTau) and β-Amyloid (1-42) CSF II (Abeta 42) Ratio, considered INV&NMN

7/1/2024

*MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease

  • Revised MN criteria related to heart blocks
  • Revised formatting in Clinical Indications section

Added existing HCPCS codes J0688, J0689, J0744, J2184, J2281 and new codes J0687, J2183 effective 07/01/2024, for brand non-equivalent products considered INV&NMN for Lyme disease

7/1/2024

*MED.00140 Gene Therapy for Beta Thalassemia

Added HCPCS code J3393 effective 07/01/2024 for Zynteglo (replacing NOC codes for Zynteglo)

7/1/2024

*MED.00146 Gene Therapy for Sickle Cell Disease

Added HCPCS code J3394 effective 07/01/2024 for Lyfgenia (replacing NOC codes for Lyfgenia)

7/1/2024

*SURG.00052 Percutaneous Vertebral Disc Procedures

Previously titled: Percutaneous Vertebral Disc and Vertebral Endplate Procedures

  • Revised Title
  • Removed MN and NMN criteria for intraosseous basivertebral nerve ablation (BVNA) from Position Statement (other criteria available)

Criteria for intraosseous basivertebral nerve ablation (BVNA) have been transitioned to Carelon Medical Benefits Management Musculoskeletal guidelines

Removed CPT codes 64628, 64629 and associated ICD-10-PCS codes

9/1/2024

*TRANS.00039 Portable Normothermic Organ Perfusion Systems

Added new CPT Category III codes 0894T, 0895T, 0896T effective 07/01/2024 for liver perfusion systems MN when criteria are met, replacing NOC code

7/1/2024

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MULTI-BCBS-CM-064737-24

PUBLICATIONS: September 2024 Provider Newsletter