The following new and revised medical policies were endorsed at the March 21, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.

 

If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.

 

Revised clinical guideline effective March 19, 2019

(The following adopted guideline was updated with new HCPCS procedure code.)

  • CG-MED-79 – Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

 

Revised medical policies effective March 28, 2019

(The following guidelines were revised to expand medical necessity indications or criteria.)

  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
  • CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®)
  • CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules

 

 Revised medical policies effective March 28, 2019

(The following policies were updated with new procedure and/or diagnosis codes.)

  • CG-DRUG-63 - Levoleucovorin calcium (Fusilev®)
  • CG-DRUG-78 – Antihemophilic Factor and Clotting Factors
  • CG-DRUG-98 - Bendamustine Hydrochloride

 

Revised clinical guidelines effective April 24, 2019

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
  • CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
  • CG-SURG-09 - Temporomandibular Disorders

 

Revised clinical guidelines effective April 24, 2019

(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)

  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-DME-06 - Pneumatic Compression Devices for Lymphedema
  • CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection
  • CG-DRUG-51 - Romidepsin (Istodax®)
  • CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration
  • CG-DRUG-62 - Fulvestrant (FASLODEX®)
  • CG-DRUG-67 - Cetuximab (Erbitux®)
  • CG-DRUG-100 - Interferon gamma-1b (Actimmune®)
  • CG-DRUG-101 - Ixabepilone (Ixempra®)
  • CG-DRUG-102 - Olaratumab (Lartruvo™)
  • CG-GENE-02 - Analysis of KRAS Status
  • CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
  • CG-MED-55 - Level of Care: Advanced Radiologic Imaging
  • CG-MED-69 - Inhaled Nitric Oxide
  • CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
  • CG-REHAB-08 - Private Duty Nursing in the Home Setting
  • CG-SURG-74 - Total Ankle Replacement
  • CG-SURG-76 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
  • CG-SURG-78 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
  • CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
  • CG-TRANS-02 - Kidney Transplantation

 

Archived clinical guideline numbers effective April 24, 2019

(The following clinical guideline numbers have been archived.)

  • CG-DRUG-25 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered as CG-MED-82.)
  • CG-DRUG-47 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered as CG-MED-83.)

 

Re-categorized clinical guidelines effective April 24, 2019

(The following adopted guidelines were renumbered and had no changes to the policy position or criteria.)

  • CG-MED-82 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered, previously CG-DRUG-25.)
  • CG-MED-83 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered, previously CG-DRUG-47.)

 

Archived medical policy effective May 1, 2019

(The following policy has been archived and has been replaced by AIM guidelines.)

  • CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

 

Adopted clinical guidelines effective May 9, 2019

(The following guidelines were previously medical policies and have been adopted with no significant changes.)

  • CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) (was DRUG.00110)
  • CG-GENE-06 - Preimplantation Genetic Diagnosis Testing (was GENE.00002)
  • CG-GENE-07 - BCR-ABL Mutation Analysis (was GENE.00005)
  • CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome (was GENE.00031)
  • CG-GENE-09 - Genetic Testing for CHARGE Syndrome (was GENE.00040)
  • CG-SURG-99 - Panniculectomy and Abdominoplasty (was SURG.00048)

 

Adopted clinical guideline effective June 24, 2019

(The following guideline was previously a medical policy and has been adopted with no significant changes.)

  • CG-SURG-97 - Cardioverter Defibrillators (was SURG.00033)

 

Revised clinical guidelines effective September 1, 2019

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DME-44 - Electric Tumor Treatment Field (TTF)
  • CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
  • CG-MED-72 - Hyperthermia for Cancer Therapy
  • CG-SURG-09 - Temporomandibular Disorders



Featured In:
June 2019 Anthem Maine Provider Newsletter