 Provider News KentuckyAugust 2023 Provider Newsletter Contents
KYBCBS-CDCRCM-030301-23 Availity, LLC is an independent company providing administrative support services on behalf of the health plan. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. As the physician of our members who have Affordable Care Act (ACA) health plans, you play a vital role in the success of this initiative and our compliance with ACA requirements. When members visit your practice or office, we encourage you to document all of the members’ health conditions, especially chronic diseases. As a result, there is ongoing documentation to indicate that these conditions are being assessed and managed. Ensuring proper coding on the claim is to the greatest level of specificity can help reduce the number of medical chart requests in the future. Ensure all codes captured in your electronic medical record (EMR) system are included on the claim and not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes. However, a claim system may only have the ability of capturing four. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being captured. Best practices and documenting guidelines: Use clear terminology.Include a brief statement that updates the status of each diagnosis. For example, use words such as continue, increase, add, name of medication treating the condition, refer to, return to center, follow up, and so on. This informs the coder the condition is current. Include orders for each condition if applicable. For every medication refilled, document a diagnosis and address it in the progress note. Chronic conditions should be evaluated at least once per year. Use the words history of to mean the condition no longer exists. For example: Document the patient has diabetes and hypertension rather than the patient has a history of diabetes and hypertension. Please see forms and guides for a more comprehensive Commercial Risk Adjustment coding brochure.Contact our Commercial Risk Adjustment Network Education representative if you have any questions: For providers in | Commercial Risk Adjustment Network Education representative | California, Colorado, and Nevada | Martha.Bendot@anthem.com | Indiana, Missouri, Wisconsin, Ohio, and Kentucky | Mary.Swanson@anthem.com | New York, Maine, New Hampshire, Connecticut, Georgia, and Virginia | Alicia.Estrada-Hoare@anthem.com |
Thank you for your continued efforts with our Commercial Risk Adjustment Program. MULTI-BCBS-CM-029140-23-CPN28564 BackgroundICD-10-CM laterality codes are developed to precisely define laterality (for example, left, right, or bilateral). ICD-10-CM guidelines for laterality coding provide that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. Impact to providersProviders should code their claims to the highest level of specificity in accordance with ICD‑10-CM coding guidelines for site and laterality when specified laterality codes exist and to submit the appropriate laterality code in accordance with the condition. Professional claims submitted on a CMS-1500 form or facility claims submitted on CMS-1450 date of service on or after October 1, 2023, that do not reflect the highest level of specificity when the code exists will be denied. Example:- Reported diagnosis: H60.339 (swimmer’s ear, unspecified ear)
- Billed CPT® code or modifier: CPT 69000-RT (drainage external ear, abscess, or hematoma: simple [right side])
- Determination: It is not appropriate to report unspecified diagnosis codes when a more specific (for example, H60.331 swimmer’s ear, right ear) code is available; therefore, the claim line will be denied.
Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and modifiers billed. Anthem Blue Cross and Blue Shield Medicaid will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. If you have questions about this communication or need assistance, contact your Provider Relationship Management representative or call Provider Services. KYBCBS-CD-027809-23-CPN26898 Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc., an independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-029658-23-CPN29126, MULTI-BCBS-CRCM-066936-24 To support the health of our members, Anthem Blue Cross and Blue Shield (Anthem) is sending urinary tract infection (UTI) tool kits to select members who were seen in the ER for a UTI. This kit contains: - A water bottle to help your patient stay hydrated.
- UTI test strips with instructions on use if having symptoms. These test strips are available over the counter (OTC).
- Basic instructions on how to use the tool kit and on reasons to seek care.
You might be hearing from your patients who are Anthem members. If you have any questions, please contact Provider Services via the number on the back of the patient’s member ID card. As you are aware, the federal Consolidated Appropriations Act (CAA) of 2021 contains several provisions applicable to health plans and their providers. One of the provisions is commonly referred to as a Gag Clause provision; specifically, Section 201: Increasing Transparency by Removing Gag Clauses on Price and Quality Information. Commercial health plans are required to attest annually that their provider agreements are in compliance with the Gag Clause provision. Should your provider agreement with Anthem Blue Cross and Blue Shield (Anthem) have language inconsistent with the Gag Clause provision, it is deemed by Anthem as null and void. To memorialize this provision in your provider agreement, we are providing a CAA Gag Clause Regulatory Addendum. Please attach this addendum to your provider agreement with Anthem. Thank you for the care you provide our members — your patients. Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then under Provider Overview, choose Find Care. Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance page on our website. Online update options include: - Add/change an address location.
- Name change.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. The November 9, 2022, guidance regarding Vitamin D testing has been revised. Effective May 1, 2023, Anthem Blue Cross and Blue Shield Medicaid now reimburses participating providers for medically necessary Vitamin D assay testing according to the CMS Local Coverage Determinations (LCD) L33996 and L34658. As defined in the LCD, CPT®/HCPCS codes 82306 and 82652 are considered medically necessary if billed with ICD-10-CM diagnostic coding specified. This policy applies only to enrollees over 21 years old. As we communicated in July, we will use the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers.** Going forward, Availity PDM is now the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. Take action nowDon’t wait until October to start using the PDM application. Start using it today to take advantage of the benefits of this application and familiarize yourself with the process before the legacy intake channels retire. What features does the Availity PDM application provide?It allows you to: - Update provider demographic information for all assigned payers in one location.
- Attest and manage current provider demographic information.
- Review the history of previously verified data.
Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
- Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload
Want to submit a roster using Availity PDM?Don’t wait — Start submitting today. Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
- Upload your completed roster via the Availity PDM application.
- Join our live webinar:
- Title of webinar: Roster Automation Template and Rules of Engagement Training
- Date: Monday, August 21, 2023
- Time: 4 to 5 p.m. ET
- Registration link: here
What about the previous methods by which I have been submitting information?While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all PDM requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. How to access the Availity PDM applicationLog onto availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Training is available: - Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of the digital applications. Start by logging into availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY. Note: For national providers who provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are not available for Availity PDM until our Strategic Provider System migration. ** Exclusions: - Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. KYBCBS-CRCM-031753-23-CPN30214 As we continue on our path to be your most valued partner in the industry, we will use the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers. Going forward, Availity Essentials PDM is now the intake tool for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. What features does the Availity PDM application provide?It allows you to: - Update provider demographic information for all assigned payers in one location.
- Attest and manage current provider demographic information.
- Review the history of previously verified data.
Benefits to our care providers using Availity PDM:The Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
- Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload
Want to submit a roster using Availity PDM?Now you can! Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
- Upload your completed roster via the Availity PDM application.
What about the previous methods by which I have been submitting information?While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all provider data management requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. How to access the Availity PDM application:Log onto availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. Availity Administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Training is available: - Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of the digital applications. Start by logging into availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY. Note: For national providers that provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are excluded from Availity PDM until our Strategic Provider System migration. Start using Availity PDM today to improve your provider data management experience. ** If any roster data updates require credentialing, your submission will be routed appropriately for further action. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. KYBCBS-CD-027553-23-CPN27427 OverviewWe’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives:- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for them.
Browse the listing of free CME webinars.* * Sessions in this series are approved for one American Academy of Family Physicians credit each. MULTI-BCBS-CRCM-030986-23-CPN29678 Provider Pathways — new VAB module Anthem Blue Cross and Blue Shield Medicaid (Anthem) is pleased to announce the addition of a new, self-paced e-learning training module to our Provider Pathways web page. Provider Pathways is a 24/7 digital repository, providing the key tools and resources needed for successfully doing business with Anthem. The newest training module is: - Value-added benefits — Find out more about the extra no-cost benefits and programs available to Anthem Blue Cross and Blue Shield Medicaid members.
How to find Provider PathwaysProvider Pathways — Doing business with Anthem eLearning can be accessed on our provider website: - Go to https://providers.anthem.com/ky.
- Under Resources in the top navigational bar, select Provider Training Academy.
- Once in the Provider Training Academy page, scroll down to Provider Pathways eLearning, and go to Provider Pathways.
You will find the new module in the table of contents shortly after starting the training. 
If you have questions about this new provider resource, please reach out to your Provider Relationship Management team. Clinical Criteria updates On May 20, 2022, August 19, 2022, September 12, 2022, November 18, 2022, December 12, 2022, and January 12, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Medicaid (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Document number | Clinical Criteria title | New or revised | August 12, 2023 | *CC-0226 | Elahere (mirvetuximab) | New | August 12, 2023 | *CC-0227 | Briumvi (ublituximab) | New | August 12, 2023 | *CC-0228 | Leqembi (lecanemab) | New | August 12, 2023 | *CC-0229 | Sunlenca (lenacapavir) | New | August 12, 2023 | CC-0029 | Dupixent (dupilumab) | Revised | August 12, 2023 | CC-0185 | Oxlumo (lumasiran) | Revised | August 12, 2023 | *CC-0072 | Selective Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | August 12, 2023 | CC-0130 | Imfinzi (durvalumab) | Revised | August 12, 2023 | CC-0223 | Imjudo (tremelimumab-actl) | Revised | August 12, 2023 | CC-0145 | Libtayo (cemiplimab-rwlc) | Revised | August 12, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised | August 12, 2023 | CC-0128 | Tecentriq (atezolizumab) | Revised | August 12, 2023 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised | August 12, 2023 | *CC-0166 | Trastuzumab Agents | Revised | August 12, 2023 | *CC-0182 | Iron Agents | Revised | August 12, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised | August 12, 2023 | *CC-0075 | Rituximab agents for Non-Oncologic Indications | Revised | August 12, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised | August 12, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | August 12, 2023 | *CC-0167 | Rituximab Agents for Oncologic Indications | Revised |
KYBCBS-CD-020010-23-CPN19724 Clinical Criteria updates On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: Newly published criteria
- Revised: Addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in your practice and office staff. Please note:- The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | August 6, 2023 | *CC-0235 | Revcovi (elapegademase-lvlr) | New | August 6, 2023 | *CC-0236 | Signifor LAR (pasireotide) | New | August 6, 2023 | CC-0125 | Opdivo (nivolumab) | Revised | August 6, 2023 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | August 6, 2023 | CC-0038 | Human Parathyroid Hormone Agents | Revised | August 6, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | August 6, 2023 | *CC-0197 | Jemperli (dostarlimab-gxly) | Revised | August 6, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised | August 6, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised | August 6, 2023 | *CC-0065 | Hemophilia A and von Willebrand Disease | Revised | August 6, 2023 | *CC-0034 | Agents for Hereditary Angioedema | Revised | August 6, 2023 | CC-0061 | GnRH Analogs for the Treatment of Non-Oncologic Indications | Revised | August 6, 2023 | CC-0008 | Subcutaneous Hormonal Implants | Revised | August 6, 2023 | CC-0026 | Testosterone, Injectable | Revised |
MULTI-BCBS-CR-027354-23-CPN26411 The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. 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/. Medical PoliciesOn February 16, 2023, the Medical , and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Medicaid (Anthem). These guidelines take effect August 27, 2023. Publish Date | Medical Policy Number | Medical Policy Title | New or Revised | 3/29/2023 | MED.00135 | Gene Therapy for Hemophilia | Reviewed |
Carelon Medical Benefits Management, Inc.* updates:Effective for dates of service on and after September 10, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity review for Anthem: - Musculoskeletal guidelines:
- Spine surgery
- Sacroiliac joint fusion
- Sleep disorder management guideline:
Effective for dates of service on and after August 1, 2023, MRI of the Breast – RAD.00036 is transitioning to Carelon Medical Benefits Management criteria in the following two guidelines: - Imaging of the chest
- Oncologic imaging
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. KYBCBS-CD-025322-23-CPN24966 Clinical Appropriateness Guidelines Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint Surgery updates by sectionMultiple joints:- Loose body — Added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — Added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
Shoulder:- Rotator cuff repair — Modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — Added exclusion for patients with rotator cuff arthropathy
- Labrum repair — Broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — Extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — Added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — Added indications for symptomatic is acromial and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — Extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — Broadened criteria to allow when criteria are met for any shoulder procedure, or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
Hip:- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — Added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — Added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — Added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — Added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
Knee:- Total knee arthroplasty — Added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — Modified requirements related to conservative management and varus/valgus deformities; allow concurrent ACL reconstruction in some scenarios
- Revision knee arthroplasty — Added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — Aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — Reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — Added indications
- ACL reconstruction and PCL repair/reconstruction — Excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — Added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — Waived requirement for conservative management when function is limited due to pain
Osteochondral grafts:- Patient selection requirements — Specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — Added indications for surgical treatment
- Osteochondral allograft transplantation — Decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
- HCPCS code added: S2118
Small Joint Surgery:- Hallux rigidus procedures; hallux valgus and bunionette procedures; lesser toe deformities — Removed poor wound healing as a contraindication
- Hallux valgus surgery — Add allowance for pre-ulcer (Wagner grade 0 to 1 lesion); added criterion for simple exostectomy/resection medial eminence; separated bunionette surgery indications from hallux valgus surgery
- First MTP joint arthrodesis for hallux valgus — Added indication
- Metatarsal osteotomy — Separated criteria into standalone indication; added exclusion for improved cosmesis
- Ankle arthritis — Added indication for revision total ankle arthroplasty
- Ankle arthroplasty — Removed severe ankle deformity and peripheral neuropathy as contraindications
Level of Care for Musculoskeletal Surgery:- Added total or partial primary shoulder arthroplasty to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by: - Accessing Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-027322-23-CPN26945 As communicated in the July Provider Newsletter, effective October 1, 2023, Carelon Medical Benefits Management, Inc.* a specialty health benefits company, will perform medical necessity reviews for procedures for Anthem Blue Cross and Blue Shield (Anthem) members, as outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for pacemakers as part of the Carelon Medical Benefits Management Cardiology program. Due to CPT® code overlap, management of ICD and CRT devices without inclusion of pacemakers creates provider abrasion and operational challenges. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 18, 2023, for dates of service October 1, 2023, and after. Members included in the new programAll fully insured, self-funded (ASO), and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of August 1, 2023. Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and Federal Employee Program® (FEP®). Pre-service review requirementsFor procedures that are scheduled to begin on or after October 1, 2023, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following non-emergency modalities. Please refer to the clinical guidelines at the links below for more details including code lists. Leadless pacemakers: Medical policy related to the insertion, removal, or replacement of permanent leadless pacemakers. Carelon Medical Benefits Management permanent implantable pacemakers: Clinical appropriateness guideline related to insertion, repair, removal, repositioning, or replacement of permanent implantable pacemakers, pacemaker pulse generators, or electrodes. To determine if prior authorization is needed for a member on or after October 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.) Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register. For more informationGo to providers.carelonmedicalbenefitsmanagement.com/cardiology for resources to help your practice get started with the Cardiology program. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs. We value your participation in our network and look forward to working with you to help improve the health of our members. * Carelon Medical Benefits Management, Inc. is an independent company providing administrative support services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-028688-23- CPN28575 Effective September 10, 2023, Anthem Blue Cross and Blue Shield Medicaid will transition the Clinical Criteria for medical necessity review of MRI Breast to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines: - Oncologic imaging
- Chest imaging
As part of this transition of Clinical Criteria, the following procedures will be subject to prior authorization at Carelon Medical Benefits Management*: CPT® code | Description | 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | 77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | 77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral | 77049 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; bilateral |
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Note: This update does not apply to the Federal Employee Program® (FEP®) As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management via the ProviderPortalSM : - Access the Carelon Medical Benefits Management ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
If you have questions related to clinical guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com/. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf ofthe health plan. KYBCBS-CD-021981-23-CPN21926 Effective for dates of service on and after September 10, 2023, the following updates will apply to the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management* guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Updates by guideline — advanced imaging:- Imaging of the extremities:
- Shoulder arthroplasty — clarified that MRI should not be used for preoperative assessment of bone stock and bone version (CT only)
- Imaging of the spine:
- Spinal infection — added criterion for imaging in patients at risk for infection based on American College of Radiology (ACR) appropriateness criteria
- Radiculopathy — added indication for CT when being done as a myelogram, based on ACR appropriateness criteria and feedback from subject matter experts
- Vascular imaging:
- Vascular anatomic delineation prior to procedures — removed exclusions for coronary artery bypass graft (CABG) and open valve replacement/repair
- Vascular anatomic delineation prior to transcatheter aortic valve implantation (TAVI/TAVE) — allowed CT chest as an alternative to CTA
- Stenosis or occlusion of extracranial carotid arteries — limited screening for patients with incidentally detected carotid calcification to those undergoing preoperative evaluation for cardiac surgery; modified criteria for management of known stenosis to allow follow-up per American College of Cardiology guidelines
- Pulmonary hypertension — clarified that criteria are applicable to all causes, not just pulmonary arterial hypertension
- Unexplained hypotension — removed indication as it is more appropriate for inpatient management
- Peripheral arterial disease — removed cilostazol as prerequisite therapy; added baseline evaluation and surveillance indications following endovascular revascularization
- Popliteal artery aneurysm — added diagnosis and management indications; added surveillance for unrepaired aneurysms to align with Society for Vascular Surgery guidelines
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management as follows: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at www.providerportal.com:
- Online access is available 24/7 to process orders in real time and is the fastest and most convenient way to request authorization.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. *Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. KYBCBS-CD-021623-23-CPN21253 Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management Guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint surgery updates by section:- Multiple joints:
- Loose body — added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
- Shoulder:
- Rotator cuff repair — modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — added exclusion for patients with rotator cuff arthropathy
- Labrum repair — broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — added indications for symptomatic os acromiale and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — broadened criteria to allow when criteria are met for any shoulder procedure or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
- Hip:
- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
- Knee:
- Total knee arthroplasty — added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — modified requirements related to conservative management and varus/valgus deformities; allow concurrent anterior cruciate ligament (ACL) reconstruction in some scenarios
- Revision knee arthroplasty — added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — added indications
- ACL reconstruction and posterior cruciate ligament (PCL) repair/reconstruction — excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — waived requirement for conservative management when function is limited due to pain
- Osteochondral grafts:
- Patient selection requirements — specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — added indications for surgical treatment
- Osteochondral allograft transplantation — decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
Level of care for musculoskeletal (MSK) surgery:- Added “total or partial primary shoulder arthroplasty” to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Via Availity Essentials* at availity.com.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-027336-23-CPN26944 Prior authorization updates for medications billed under the medical benefit Effective for dates of service on and after September 1, 2023, the following medication codes billed on medical claims will require prior authorization in accordance with the requirements of the current or new Clinical Criteria documents. Please note, inclusion of a national drug code on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. Clinical Criteria | HCPCS or CPT® code(s) | Drug name | CC-0221 | J1747 | Spevigo (spesolimab-sbzo) | CC-0220 | J0218 | Xenpozyme (olipudase alfa) |
What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 855-661-2028. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. KYBCBS-CD-023917-23-CPN23622 Effective November 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Code description | 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and | 0687T | Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session | 0688T | Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report | 0704T | Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment | 0705T | Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hour | 0706T | Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month | 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle | A2019 | Kerecis omega3 marigen shield, per square centimeter | A2020 | Ac5 advanced wound system (ac5) | A2021 | Neomatrix, per square centimeter | A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | E1905 | Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software | Q4265 | Neostim tl, per square centimeter | Q4266 | Neostim membrane, per square centimeter | Q4267 | Neostim dl, per square centimeter | Q4268 | Surgraft ft, per square centimeter | Q4269 | Surgraft xt, per square centimeter | Q4270 | Complete sl, per square centimeter | Q4271 | Complete ft, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://www.anthem.com/provider/news/archives/ > Providers > Claims > Prior Authorization or for contracted providers by accessing Availity.com.* UM AROW 4505
*Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-028190-23-CPN27641 Effective September 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield Medicaid for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): 81170 | ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (for example, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | 81324 | PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | 81325 | PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | 81326 | PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | 81414 | Cardiac ion channelopathies (for example, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 (when specified as testing for 4 or less genes, including KCNH2 and KCNQ1 [and SCN5A if performed] for LTQS only) |
To request PA, you may use one of the following methods: - Web: Once logged in to Availity Essentials* at https://availity.com.
- Fax: 800-964-3627
- Phone: 855-661-2028
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://providers.anthem.com/kentucky-provider/communications/news-and-announcements on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 855-661-2028 for assistance with PA requirements.
UM AROW #4073
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. KYBCBS-CD-021098-23-CPN20084 InformationalRobotic Assisted Surgery(Policy G-10004, effective 09/01/2023) Effective September 1, 2023, the Robotic Assisted Surgery reimbursement policy with Anthem Blue Cross and Blue Shield will expand to include the computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure and are not separately reimbursed. The policy has been renamed to Technology Assisted Surgical Procedures defines both robotic assisted and computer assisted techniques. For additional information, please review the Technology Assisted Surgical Procedures reimbursement policy at https://www.anthem.com/medicareprovider. MULTI-BCBS-CR-023736-23-CPN22827 Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.* Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesEffective for dates of service on and after November 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Access our Clinical Criteria to view the complete information for these prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240* | Zynyz (retifanlimab-dlwr) | J9999 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates We are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage. Access our Clinical Criteria to view the Medical Step Therapy Drug List. Quantity limit updatesEffective for dates of service on and after November 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process. Access our Clinical Criteria to view the complete information for these quantity limit updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240 | Zynyz (retifanlimab-dlwr) | J9999 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-030324-23-CPN29780 This article originally published with October 1, 2023 effective date in error. This requirement will not go into effect until December 1, 2023. Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* a separate company. Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesEffective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Note: On April 6, 2023, the FDA announced its decision to withdraw approval of Makena and generic versions of Makena for reducing the risk of pre-term birth because these drugs are no longer shown to be effective. Access our Clinical Criteria to view the complete information for these site of prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0238* | hydroxyprogesterone caproate | J1729 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-027440-23-CPN27209 Visit the Drug Lists page on our provider website at https://www.anthem.com/ms/pharmacyinformation/home.html for more information about: - Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October. To locate the exchange, select Formulary and Pharmacy Information, and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed. Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. Did you know?For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes such as blood pressure, blood glucose, or cholesterol control. Knowing this, it’s not surprising there is a strong emphasis on medication adherence and proportion of days covered (PDC) for the medication adherence quality measures. Medications are the primary intervention in treating and preventing disease and require patients to take medications long term. Unrecognized non-adherence can lead to dose escalation or additional medication therapy, potentially leading to an increase in adverse events. In addition, not adherence leads to increased medical utilization and morbidity and mortality. Back to the basics: How can we close the adherence gap?- Know which patients are at risk for non-adherence:
- Cognitive Impairment
- Fear of side effects
- Too many medications
- History of non-adherence
- Lack of perceived benefit
- Confusion
- Transportation
- Cost
Consider medication non-adherence as a reason when a patient’s condition is not under control.
- Implement a standardized process to identify patients with non-adherence:
- Ask about adherence at every appointment.
- Incorporate patient questionnaires or targeted questions using open ended questions into existing workflows.
- Analyze non-adherence reporting or claims to identify patients.
- Together with the patient, tailor the solution to the patient’s needs or concerns:
- Simplify the medication regimen.
- Always educate patients on benefits and risks of taking or not taking their medications.
- Leverage real-time prescription benefit to select lower cost and formulary medications during the electronic prescribing process.
- Encourage CarelonRx, Inc.* Mail and prescribe extended day supply to prevent refill gaps, avoid long waits at the pharmacy, and minimize transportation barriers.
* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.
References:
- Brown M, Sinsky CA. Medication Adherence. Improve Patient Outcomes and Reduce Costs. American Medical Association Steps Forward. 5 June 2015.https://edhub.ama-assn.org/steps-forward/module/2702595. Accessed 16 May 2023
- Eight reasons patients don’t take their medications. American Medication Association. Feb 22, 2023. Accessed May 17, 2023.https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications
- El Halabi J, Minteer W, Boehmer KR. Identifying and Managing Treatment Nonadherence. Medical Clinics of North America. 2022;106(4):615-626. doi:https://doi.org/10.1016/j.mcna.2022.02.003
- Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel). 2021 Jul 31;9(8):976. doi: 10.3390/healthcare9080976..
- Kini V, Ho PM. Interventions to Improve Medication Adherence. JAMA. 2018;320(23):2461. doi: https://doi.org/10.1001/jama.2018.19271
MULTI-BCBS-CR-027442-23-CPN27258 Why it matters:- Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in individuals with diabetes.
- The 2019 ACC/AHA* guidelines recommend statin therapy for primary prevention of ASCVD in patients with diabetes mellitus, aged 40 to 75 years, regardless of estimated 10-year ASCVD risk.
- Statins are generally well-tolerated and safe drugs.
- Benefits of lowering LDL-C with statins far outweigh the likelihood of an adverse effect for most adults at elevated risk for ASCVD and secondary events.
* ACC/AHA- American College of Cardiology and American Heart Association Did you know? - Just over 50% of US adults who would benefit from cholesterol-lowering medications are taking them.
- Reducing LDL-C levels with statins by ~39 mg/dL can reduce heart disease and stroke risk by ~21%
Best practices:- Educate patients on increased risk of cardiovascular disease to understand the benefits of statins.
- Once stable on therapy, prescribe 90-day supply to prevent refill gaps in therapy.
- Consider home delivery through *CarelonRx Mail to avoid long waits at the pharmacy and minimize transportation barriers.
- If statin side effects occur, consider strategies to mitigate them while continuing a statin:
- Lower the dose.
- Intermittent dosing with rosuvastatin may benefit patients with previous statin intolerances.
- Try a brief period of discontinuation, then re-challenge with the same or different statin.
Statin formulary medications Statin therapy intensity | Drug name | Dosage | Low-intensity statin therapy | lovastatin | 20 mg | pravastatin | 10 mg to 20 mg | simvastatin | 10 mg | Moderate-intensity statin therapy | atorvastatin | 10 mg to 20 mg | rosuvastatin | 5 mg to 10 mg | simvastatin | 20 mg to 40 mg | pravastatin | 40 mg to 80 mg | lovastatin | 40 mg | High-intensity statin therapy | atorvastatin | 40 mg to 80 mg | rosuvastatin | 20 mg to 40 mg |
Note: Both pitavastatin (Livalo) 1 to 4 mg and fluvastatin 40 mg BID qualify as moderate-intensity; however, Livalo is non-formulary and fluvastatin is a more expensive agent with member copay (Tier 3 or 4). * CarelonRx, Inc. is an independent company providing pharmacy services on behalf of the health plan.
References:
- American Heart Association: 2021 heart disease and stroke statistics update fact sheet. Accessed 5/8/2023. https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2021-Heart-and-Stroke-Stat-Update/2021_heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi:https://doi.org/10.1161/cir.0000000000000678
- Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. The Lancet. 2016;388(10059):2532-2561. doi:https://doi.org/10.1016/s0140-6736(16)31357-5
- ElSayed NA, Aleppo G, Aroda VR, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. Diabetes Care. 2022;46(Supplement_1):S158-S190. doi:https://doi.org/10.2337/dc23-s010
- Hla D, Jones R, Blumenthal RS, et al. Assessing severity of statin side effects: Fact vs fiction. American College of Cardiology. April 09, 2018. Accessed May 17, 2023. https://www.acc.org/latest-in-cardiology/articles/2018/04/09/13/25/assessing-severity-of-statin-side-effects
- Reston JT, Buelt A, Donahue MP, Neubauer B, Vagichev E, McShea K. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. Annals of Internal Medicine. 2020;173(10):806-812. doi:https://doi.org/10.7326/m20-4680
MULTI-BCBS-CR-026506-23-CPN26142 New specialty pharmacy medical step therapy requirements Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of all drugs noted below. The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria. Clinical Criteria | Status | Drug | HCPCS or CPT® code(s) | CC-0182 | Non-preferred | Infed (iron dextran) | J1750 | CC-0182 | Non-preferred | Injectafer (ferric carboxymaltose) | J1439 | CC-0182 | Non-preferred | Monoferric (ferric derisomaltose) | J1437 | CC-0182 | Preferred | * Feraheme (ferumoxytol) | Q0138 | CC-0182 | Preferred | Ferrlecit (sodium ferric gluconate/sucrose complex) | J2916 | CC-0182 | Preferred | Venofer (iron sucrose) | J1756 |
* Feraheme (ferumoxytol) will change to preferred for both brand and generic. Availity Essentials* Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat. For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. KYBCBS-CD-018622-23-CPN18331 Anthem Blue Cross and Blue Shield is committed to ensuring all of our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment and again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet! MULTI-BCBS-CR-023986-23-CPN23630 Anthem Blue Cross and Blue Shield is committed to ensuring all of our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment and again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet! MULTI-BCBS-CR-023986-23-CPN23630 |