Medical Policies and Clinical Utilization Management Guidelines Update for February 2023

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 https://www.anthem.com/provider/policies/clinical-guidelines/. 

Notes/updates:

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

• MED.00145 - Digital Therapy Devices for Treatment of Amblyopia:
  • Digital therapy devices for treatment of amblyopia are considered Investigational & Not Medically Necessary
• CG-LAB-26 - Outpatient Alpha-Fetoprotein Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient alpha-fetoprotein testing
• CG-LAB-27 - Human Chorionic Gonadotropin Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing of human chorionic gonadotropin (hCG)
• CG-LAB-28 - Prostate Specific Antigen Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for prostate specific antigen (PSA) testing
• CG-SURG-18 – Septoplasty:
  • Re-formatted hierarchy in Clinical Indications section 
  • Revised Medically Necessary criteria related to conservative management 
  • Revised “chronic recurrent sinusitis” to “chronic or recurrent acute sinusitis” 
  • Revised Not Medically Necessary statement to remove bulleted list below statement

Carelon Medical Benefits Management, Inc.* updates

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

Medical Policies

On February 16, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to AMH Health, LLC These guidelines take effect July 27, 2023.

 Clinical UM Guidelines

On February 16, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to AMH Health. These guidelines were adopted by the medical operations committee for Medicare Advantage members on March 23, 2023. These guidelines take effect July 27, 2023.