The following new and revised medical policies were endorsed at the November 8, 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.

 

Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.   

 

Revised medical policies effective November 15, 2018

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

  • DRUG.00046 - Ipilimumab (Yervoy®)
  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • DRUG.00075 - Nivolumab (Opdivo®)
  • MED.00109 - Corneal Collagen Cross-Linking
  • SURG.00120 - Internal Rib Fixation Systems
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

  

Revised medical policies effective December 12, 2018

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

  • DRUG.00062 - Obinutuzumab (Gazyva®)
  • DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
  • DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®)
  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00121 - Transcatheter Heart Valve Procedures
  • TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

 

Archived medical policy effective December 12, 2018

(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)

  • DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)

 

Revised medical policies effective December 12, 2018

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

  • ADMIN.00001 - Medical Policy Formation
  • BEH.00002 - Transcranial Magnetic Stimulation
  • DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
  • DRUG.00034 - Insulin Potentiation Therapy
  • DRUG.00063 - Ofatumumab (Arzerra®)
  • DRUG.00074 - Alemtuzumab (Lemtrada™)
  • DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
  • DRUG.00086 - Mecasermin (Increlex®)
  • DRUG.00099 - Cerliponase alfa (Brineura)
  • DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
  • DRUG.00111 - Monoclonal Antibodies to Interleukin-23
  • DRUG.00116 - Vestronidase alfa (Mepsevii™)
  • DRUG.00118 - Copanlisib (Aliqopa®)
  • GENE.00006 - Epithelial Growth Factor Receptor (EGFR) Testing
  • GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
  • GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
  • GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
  • GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility
  • GENE.00035 - Genetic Testing for TP53 Mutations
  • GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
  • LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
  • LAB.00029 - Rupture of Membranes Testing in Pregnancy
  • MED.00041 - Microvolt T-Wave Alternans
  • MED.00055 - Wearable Cardioverter Defibrillators
  • MED.00085 - Antineoplaston Therapy
  • MED.00121 - Implantable Interstitial Glucose Sensors
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
  • RAD.00036 - MRI of the Breast
  • RAD.00061 - PET/MRI
  • RAD.00065 - Radiostereometric Analysis
  • SURG.00019 - Transmyocardial Revasculareization (TMR)
  • SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
  • SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
  • SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00130 - Annulus Closure After Discectomy
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
  • TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
  • TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised medical policies effective December 27, 2018

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

  • DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
  • DRUG.00080 - Monoclonal Antibodies for the Treatment of Eoslinophilic Asthma
  • DRUG.00108 - Edaravone (Radicava®)
  • DRUG.00109 - Durvalumab (Imfinzi™)
  • GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
  • GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
  • LAB.00011 - Analysis of Proteomic Patterns
  • LAB.00019 - Serum Markers for Liver Fibrosis in the Evalution and Monitoring of Patients with Chronic Liver Disease
  • MED.00109 - Corneal Collagen Cross-Linking
  • MED.00111 - Intracardiac Ischemia Monitoring
  • MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • MED.00120 - Voretigene Neparvovec
  • MED.00123 - Axicabtagene ciloleucel (Yescarta®)
  • MED.00124 - Tisagenlecleucel (Kymriah®)
  • OR.PR.00005 - Upper Extremity Myoelectric Orthoses
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
  • SURG.00111 - Axial Lumbar Interbody
  • SURG.00113 - Artifical Retinal Devices
  • SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
  • SURG.00150 - Leadless Pacemaker
  • THER-RAD.00009 - Intraocular Epirentinal Brachytherapy

 

Revised medical policies effective January 1, 2019

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

  • DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)

 

Archived medical policy effective January 1, 2019

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

  • SURG.00066 - Percutaneous Thermal Neurolysis for Chronic Back Pain

 

 Archived medical policies effective January 3, 2019

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • MED.00100 - Diaphragmatic/ Phrenic Nerve Stimulation and Diaphragm Pacing Systems
  • RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion

 

Revised medical policies effective April 1, 2019

(The following policies were updated with procedure and/or diagnosis codes and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

 

Revised medical policy effective April 1, 2019

(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

New medical policy effective April 1, 2019

(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

  • MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders



Featured In:
January 2019 Anthem Maine Provider Newsletter