The following new and revised medical policies were endorsed at the March 21, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > 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 > Benefit Plans > Brochures and Forms > Medical Policies.   


Revised medical policies effective March 28, 2019

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

  • DRUG.00053 - Carfilzomib (Kyprolis®)
  • DRUG.00082 - Daratumumab (DARZALEX®)
  • DRUG.00088 - Atezolizumab (Tecentriq®)


Revised medical policies effective April 24, 2019

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

  • GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
  • SURG.00121 - Transcatheter Heart Valve Procedures


 Revised medical policies effective April 24, 2019

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

  • ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
  • DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
  • DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
  • DME.00032 - Automatic External Defibrillators for Home Use
  • DRUG.00076 - Blinatumomab (Blincyto®)
  • DRUG.00107 - Avelumab (Bavencio®)
  • DRUG.00109 - Durvalumab (Imfinzi®)
  • GENE.00001 - Genetic Testing for Cancer Susceptibility
  • GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
  • GENE.00009 - Gene-Based Tests for Screening, Detection or Management of Prostate Cancer
  • GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
  • GENE.00023 - Gene Expression Profiling for Uveal Melanoma
  • GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
  • GENE.00038 - Genetic Testing for Statin-Induced Myopathy
  • LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00011 - Analysis of Proteomic Patterns
  • LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
  • LAB.00025 - Topographic Genotyping
  • MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
  • MED.00011 - Sensory Stimulation for Brain Injured Individuals in Coma or Vegetative State
  • MED.00024 - Adoptive Immunotherapy and Cellular Therapy
  • MED.00053 - Noninvasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
  • MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
  • MED.00059 - Idiopathic Environmental Illness (IEI)
  • MED.00077 - In Vivo Analysis of Gastrointestinal Lesions
  • MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer
  • MED.00102 - Ultrafiltration in Decompensated Heart Failure
  • MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
  • MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
  • MED.00111 - Intracardiac Ischemia Monitoring
  • MED.00112 - Autonomic Testing
  • MED.00118 - Continuous Monitoring of Intraocular Pressure
  • MED.00120 - Voretigene neparvovec-rzyl (Luxturna®)
  • MED.00125 - Biofeedback and Neurofeedback
  • OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
  • RAD.00001 - Computed Tomography of Detect Coronary Artery Calcification
  • RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
  • RAD.00040 - PET Scanning using Gamma Cameras
  • RAD.00044 - Magnetic Resonance Neurography
  • RAD.00052 - Positional MRI
  • RAD.00054 - MRI of the Bone Marrow
  • RAD.00059 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
  • SURG.00016 - Stereotactic Radiofrequency Pallidotomy
  • SURG.00022 - Lung Volume Reduction Surgery
  • SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
  • SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions
  • SURG.00053 - Unicondylar Interpositional Spacer
  • SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
  • SURG.00061 - Presbyoia and Astigmastism-Correcting Intraocular Lenses
  • SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
  • SURG.00070 - Photocoagulation of Macular Drusen
  • SURG.00072 - Lysis of Epidural Adhesions
  • SURG.00075 - Intervertebral Stabilization Devices
  • SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
  • SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
  • SURG.00107 - Prostate Saturation Biopsy
  • SURG.00113 - Artificial Retinal Devices
  • SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
  • SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
  • SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
  • SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
  • SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
  • SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
  • SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
  • SURG.00150 - Leadless Pacemaker
  • SURG.00151- Balloon Dilation of Eustachian Tubes
  • TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
  • TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
  • TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
  • TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
  • TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
  • TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
  • TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases


Archived medical policy numbers effective April 24, 2019

(The following policy numbers have been archived.)

  • DRUG.00003 - Chelation Therapy (renumbered as MED.00127)
  • DRUG.00034 - Insulin Potentiation Therapy (renumbered as MED.00128)


Re-categorized medical policies effective April 24, 2019

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

  • MED.00127 - Chelation Therapy (previously DRUG.00003)
  • MED.00128 - Insulin Potentiation Therapy (previously DRUG.00034)


New medical policy effective April 24, 2019

(The following policy is new and determined to not have significant changes.)

  • SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing


Archived medical policies effective May 9, 2019

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

  • DRUG.00110 - Inotuzumab ozogamicin (Besponsa®) (recategorized as CG-DRUG-113)
  • GENE.00002 - Preimplantation Genetic Diagnosis (recategorized as CG-GENE-06)
  • GENE.00005 - BCR-ABL Mutatin Analysis (Qualitative) (recategorized as CG-GENE-07)
  • GENE.00031 - Genetic Testing for PTEN Hamartoma Tumor Syndrome (recategorized as CG-GENE-08)
  • GENE.00040 - Genetic Testing for CHARGE Syndrome (recategorized as CG-GENE-09)
  • MED.00119 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications (recategorized as CG-MED-81)
  • RAD.00066 - Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy (recategorized as CG-SURG-98)
  • SURG.00048 - Panniculectomy, Abdominoplasty (recategorized as CG-SURG-99)

Archived medical policies effective June 24, 2019

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

  • SURG.00033 - Cardioverter-Defibrillators (recategorized as CG-SURG-97)


Revised medical policies effective September 1, 2019

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

  • GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • 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
  • MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)


New medical policy effective September 1, 2019

(The following policy is new and determined to not have significant changes.)

  • GENE.00050 - Gene Expression Profiling for Coronary Artery Disease

Featured In:
June 2019 Anthem Maine Provider Newsletter