Medical Policies and Clinical Utilization Management Guidelines update

Clinical Utilization Management Guidelines

Attached is a list of the Clinical UM Guidelines Anthem has adopted.

The full list of Medical Policies and Clinical Utilization Management (UM) Guidelines are publicly available on the Medical Policy and Clinical UM Guideline subsidiary website. Their purpose is to help you provide quality care by reducing inappropriate use of medical resources.

MCG Care Guidelines are used for:

• Medical necessity review for medical and behavioral health inpatient review.
• Inpatient site of service appropriateness.
• Inpatient rehabilitation and skilled nursing facility review.
• Outpatient based service or procedure where there is not an established medical policy or clinical UM guideline.

If MCG Care Guidelines do not cover a behavioral health service; the following standardized tools for medical necessity determinations are used:

• Adults: Level of Care Utilization System^® (LOCUS)
• Children and Adolescents: Child and Adolescent Service Intensity Instrument (CASII)
• Young Children: Early Childhood Service Intensity Instrument (ECSII)

In addition, American Society of Addiction Medicine^® (ASAM) criteria are used for substance abuse services according to state requirements.

Medicaid state contracts, regulatory guidance, CMS requirements and our Medical Policy/Clinical UM Guidelines, when approved by the Department for Medicaid Services (DMS), supersede MCG Care Guidelines.

Note: We make determinations of medical necessity on a case-by-case basis in accordance with the definition of medical necessity that is contained within the Medicaid state contract, regulatory guidance, CMS requirements or in our Medical Necessity Criteria Policy ADMIN.0004.

If the request doesn’t meet established criteria guidelines, it will be referred to a licensed physician reviewer with the appropriate clinical expertise to make a decision.

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and 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 providers in your practice and office staff.

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search.

Notes/updates

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

• MED.00146 - Gene Therapy for Sickle Cell Disease:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These Medical Policies take effect July 14, 2024.