Medical policy and clinical guideline updates

The following new and revised medical policies and clinical guidelines were endorsed at the August 13, 2020 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.' 

 

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 policy effective September 1, 2020

The following policy was revised to expand medical necessity indications or criteria.

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling

 

Reviewed medical policy effective September 1, 2020

The following policy was reviewed and may have coding updates, but had no significant changes to the policy position or criteria.

• GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies

 

Coding update effective September 1, 2020

The following policy was updated with new procedure and/or diagnosis codes.

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling

 

Coding updates effective October 1, 2020

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

• GENE.00037 - Genetic Testing for Macular Degeneration
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
• SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
• SURG.00127 - Sacroiliac Joint Fusion
• SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• TRANS.00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease & Misc. Solid Tumors
• TRANS.00035 - Other Stem Cell Therapy

 

Reviewed medical policies effective October 7, 2020

The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.

• ADMIN.00001 - Medical Policy Formation
• ADMIN.000006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
• DME.00025 - Self-Operated Spinal Unloading Devices
• GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site 
• GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
• GENE.00023 - Gene Expression Profiling of Melanomas
• GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• GENE.00034 - SensiGene® Fetal RhD Genotyping Test
• GENE.00046 - Prothrombin (Factor II) Mutation Testing
• GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
• LAB.00011 - Analysis of Proteomic Patterns
• LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Patients with Chronic Liver Disease
• LAB.00028 - Serum Biomarkers for Multiple Sclerosis
• LAB.00029 - Rupture of Membranes Testing in Pregnancy
• LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
• MED.00055 - Wearable Cardioverter Defibrillators
• MED.00082 - Quantitative Sensory Testing
• MED.00085 - Antineoplaston Therapy
• MED.00089 - Quantitative Muscle Testing Devices
• MED.00095 - Anterior Segment Optical Coherence Tomography
• MED.00096 - Low-Frequency Ultrasound Therapy for Wound Management
• MED.00099 - Electromagnetic Navigational Bronchoscopy
• OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
• RAD.00037 - Whole Body Computed Tomography Scanning                    
• RAD.00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging
• RAD.00061 - PET/MRI
• RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• SURG.00008 - Mechanized Spinal Distraction Therapy
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
• SURG.00092 - Implanted Devices for Spinal Stenosis
• SURG.00095 - Viscocnalosomy and  Canaloplasty
• SURG.00101 - Suprachoroidal Injection of a Pharmocoligc Agent
• SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• SURG.00114 - Facet Joint Allograft Implants for Facet Disease
• SURG.00119 - Endobronchial Valve Devices
• SURG.00128 - Implantable Left Atrial Hemodynamic Monitor
• SURG.00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• SURG.00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
• SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
• SURG.00153 - Cardiac Contractility Modulation Therapy
• TRANS.00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)

Archived medical policy effective October 7, 2020

The following policy has been archived.

• RAD.00062 - Intravascular Optical Coherence Tomography (OCT)

 

New medical policies effective January 1, 2021

The following policies are new and may result in services previously covered now being considered either not medically necessary and/or investigational.

• MED.00134 - Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
• SURG.00156 - Implanted Artificial Iris Devices
• SURG.00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

Revised medical policies effective January 1, 2021

The following policies listed below were revised and might result in services previously covered, but now being considered either not medically necessary and/or investigational.

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• MED.00103 - Automated Evacuation of Meibomian Gland
• SURG.00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
• SURG.00112 - Implanted Peripheral (Occipital, Supraorbital and Trigeminal) Nerve Stimulation
• SURG.00129 -  Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

 

Revised clinical guidelines effective August 20, 2020

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

• CG-GENE-03 - BRAF Mutation Analysis
• CG-SURG-27 - Gender Reassignment Surgery
• CG-SURG-59 - Vena Cava Filters
• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised clinical guidelines effective August 20, 2020

The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.

• CG-MED-55 - Site of Care: Advanced Radiologic Imaging
• CG-MED-83 - Site of Care: Specialty Pharmaceuticals
• CG-SURG-52 - Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

 

Coding updates effective October 1, 2020

The following guidelines were updated with new procedure and/or diagnosis codes.

• CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• CG-MED-68 - Therapeutic Apheresis
• CG-MED-76 - Magnetic Source Imaging and Magneto-encephalography
• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-72 - Endothelial Keratoplasty
• CG-SURG-92 - Paraesophageal Hernia Repair
• CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention

 

Revised clinical guideline effective October 1, 2020

The following guideline was reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.

• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use

 

Revised clinical guidelines effective October 7, 2020

The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the guideline position or criteria.

• CG-DME-10 - Durable Medical Equipment
• CG-DME-44 - Electric Tumor Treatment Field (TTF)
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-MED-69 - Inhaled Nitric Oxide
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 - Private Duty Nursing
• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
• CG-SURG-79 - Implantable Infusion Pumps

 

Archived clinical guideline effective November 1, 2020

This guideline has been archived and is now an AIM Clinical Guideline.

• CG-SURG-74 - Total Ankle Replacement

 

Revised clinical guideline effective January 1, 2021

The following guideline was revised and may have resulted in services that were previously covered now being considered either not medically necessary and/or investigational.

• CG-SURG-28 - Transcatheter Uterine Artery Embolization

 

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