Medical policy and clinical guideline updates are available on anthem.com

The following new and revised medical policies and clinical guidelines were endorsed at the November 5, 2020 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, 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.   

 

Reviewed medical policy effective November 12, 2020

The following policy was reviewed, but had no significant changes to the policy position or criteria.

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin

 

Revised medical policies effective November 12, 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
• MED.00129 - Gene Therapy for Spinal Muscular Atrophy

 

Revised medical policy effective December 16, 2020

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

• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

 

Reviewed medical policies effective December 16, 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
• GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
• GENE.00016 - Gene Expression Profiling for Colorectal Cancer
• GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies
• GENE.00036 - Genetic Testing for Hereditary Pancreatitis
• GENE.00037 - Genetic Testing for Macular Degeneration
• GENE.00039 - Genetic Testing for Frontotemporal Dementia
• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
• LAB.00024 - Immune Cell Function Assay
• LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
• LAB.00034 - Serological Testing for Helicobacter Pylori
• MED.00002 - Selected Sleep Testing Services
• MED.00065 - Hepatic Activation Therapy
• MED.00091 - Rhinophototherapy
• MED.00092 - Automated Nerve Conduction Testing
• MED.00097 - Neural Therapy
• MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
• MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
• MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
• MED.00121 - Implantable Interstitial Glucose Sensors
• MED.00122 - Wilderness Programs including Adventure Therapy
• MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
• MED.00128 - Insulin Potentiation Therapy
• MED.00130 - Surface Electromyography Devices for Seizure Monitoring
• RAD.00036 - MRI of the Breast
• RAD.00053 - Cervical and Thoracic Discography
• RAD.00065 - Radiostereometric Analysis
• REHAB.00003 - Hippotherapy
• SURG.00019 - Transmyocardial Revasculareization (TMR)
• SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
• SURG.00073 - Epiduroscopy
• SURG.00079 - Nasal Valve Suspension
• SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
• SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
• SURG.00100 - Cryoblation for Plantar Fasciitis and Plantar Fibroma
• SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
• SURG.00112 - Implanted Peripheral (Occipital, Supraorbital and Trigeminal) Nerve Stimulation
• SURG.00123 - Transmyocardial/perventricular Device Closure of a Ventricular Septal Defect
• SURG.00130 - Annulus Closure After Discectomy
• SURG.00138 - Laser Treatment of Onychomycosis
• SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• SURG.00146 - Extracorporeal Carbon Dioxide Removal
• THER-RAD.00008 - Neutron Beam Radiotherapy
• TRANS.00008 - Liver Transplant
• TRANS.00009 - Lung and  Lobar Transplant
• TRANS.00010 - Autologous and Allogenic Pancreatic Islet Cell Transplant
• TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
• TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
• TRANS.00026 - Heart-Lung Transplantation
• TRANS.00027 - Hemotopoetic Stem Transplant for Pediatric Solid Tumors
• TRANS.00029 - Hematopoietic Stem Cell Transplant for Genetic Diseases & Acquired Anemias
• TRANS.00030 - Hematopoetic Stem Cell Transplant for Germ Cell Tumors
• TRANS.00033 - Heart Transplant
• TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Archived medical policy effective December 16, 2020

The following policy has been archived and has been transitioned to a Clinical UM Guideline.

• GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing

 

Coding updates effective January 1, 2021

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

• GENE.00023 - Gene Expression Profiling of Melanomas
• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• SURG.00151 - Balloon Dilation of Eustachian Tubes
• TRANS.00025  - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

New medical policies effective April 1, 2021

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

• GENE.00055 - Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD)
• LAB.00037 - Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
• SURG.00158 - Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

 

Revised medical policies effective April 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.

• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• SURG.00062 - Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Revised clinical guidelines effective November 12, 2020

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

• CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
• CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome
• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Reviewed clinical guideline effective November 12, 2020

The following adopted guideline was reviewed, but had no significant changes to the position or criteria.

• CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Revised clinical guidelines effective November 16, 2020

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

• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-GENE-18 - Genetic Testing for TP53 Mutations
• CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing

 

Reviewed clinical guidelines effective December 16, 2020

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

• CG-ANC-04 - Ambulance Services; Air and Water
• CG-ANC-07 - Inpatient Interfacility Transfers
• CG-BEH-14 - Intensive In-Home Behavioral Health Services
• CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)
• CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
• CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
• CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
• CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
• CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
• CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
• CG-LAB-13 - Skin Nerve Fiber Density Testing
• CG-MED-19 - Custodial Care
• CG-MED-23 - Home Health
• CG-MED-26 - Neonatal Levels of Care
• CG-MED-38 - Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
• CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
• CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
• CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• CG-SURG-71 - Reduction Mammoplasty
• CG-SURG-72 - Endothelial Keratoplasty
• CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
• CG-SURG-77 - Refractive Surgery
• CG-SURG-92 - Paraesophageal Hernia Repair
• CG-SURG-94 - Keratoprosthesis
• CG-SURG-96 - Intraocular Telescope
• CG-SURG-105 - Corneal Collagen Cross-Linking
• CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
• CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-coronary)

 

Coding updates effective January 1, 2021

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

• CG-GENE-01 - JAK2, CALR and MPL Gene Mutation Testing for Myeloproliferative Disorders
• CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
• CG-GENE-13 - Genetic Testing for Inherited Diseases
• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-SURG-27 - Gender Reassignment Surgery
• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

 

Reviewed clinical guideline effective January 20, 2021

The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.

• CG-BEH-02 - Adaptive Behavioral Treatment

 

Revised clinical guideline effective April 1, 2021

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-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

 

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