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 February 20, 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.   

 

Medical policy updates

Revised medical policies effective February 27, 2020

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

• GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
• SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

 

Coding updates effective April 1, 2020

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

• LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Patients with Chronic Liver Disease
• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

 

Revised medical policies effective April 1, 2020

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

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

 

Revised medical policies effective April 15, 2020

The following policies were reviewed and may have word changes or clarifications, but 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
• GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
• GENE.00007 - Cardiac Ion Channel Genetic Testing
• GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
• GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
• GENE.00038 - Genetic Testing for Statin-Induced Myopathy
• GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
• 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, 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.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
• MED.00102 - Ultrafiltration in Decompsensated  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 - Gene Therapy for Ocular Conditions
• MED.00125 - Biofeedback and Neurofeedback
• OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
• RAD.00001 - Computed Tomography of Detect Coronary Artery Calcification
• RAD.00044 - Magnetic Resonance Neurography
• RAD.00052 - Positional MRI
• RAD.00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
• SURG.00022 - Lung Volume Reduction Surgery
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
• 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.00107 - Prostate Saturation Biopsy
• SURG.00113 - Artificial Retinal Devices
• SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
• SURG.00127 - Sacroiliac Joint Fusion
• 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.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
• 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
• SURG.00152- Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
• TRANS.00011 - Pancreas Transplant and Pancreas-Kidney Transplant
• TRANS.00013 - Small Bowel and Multivisceral Transplant including Small Bowel/Liver
• TRANS.00016 - Umbilical Cord Blood Progenitor Cell Traansplant
• TRANS.00025  - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
• TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodkin's Disease & Non-Hodgkins Lymphoma
• TRANS.00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease & Misc. Solid Tumors

Archived medical policies effective April 15, 2020

These polices are now an Anthem Clinical Guidelines.  

• SURG.00016 - Stereotactic Radiofrequency Pallidotomy (recategorized to CG-SURG-108)

 

Archived medical policies effective April 15, 2020

• MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
• MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data    
• RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
• THER-RAD.00009 - Intraocular Epiretinal Brachytherapy

 

Archived medical policy effective May 17, 2020

This policy has been archived and transitioned to an AIM Guideline.

• SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

 

Archived medical policies effective July 1, 2020

This policy has been archived and transitioned to an Anthem Clinical Guideline.  

• SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) (recategorized to CG-SURG-107)

 

Archived medical policy effective July 1, 2020

This policy has been archived and transitioned to a MCG Behavioral Health Guideline.  

• BEH.00002 - Transcranial Magnetic Stimulation

 

New medical policy effective August 1, 2020

The policy below is new and may result in services previously covered, but now being considered either not medically necessary and/or investigational.

• DME.00041 - Low Intensity Therapeutic Ultrasound for the Treatment of Pain
• GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
• GENE.00054 - Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
• SURG.00154 - Microsurgical Procedures for the Treatment of Lymphedema
• SURG.00155 - Cryoneurolysis for Treatment of Peripheral Nerve Pain

 

Revised medical policies effective August 1, 2020

The following policies listed below might result in services that were previously covered 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
• RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
• SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
• SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches

Clinical guideline updates

 

Revised clinical guidelines effective February 27, 2020

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

• CG-REHAB-04 - Rehabilitative and Habilitative Services: Physical Medicine/Physical Therapy
• CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
• CG-REHAB-06 - Rehabilitative and Habilitative Services: Speech-Language Pathology

 

Coding updates effective April 1, 2020

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

• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
• CG-MED-23 – Home Health
• CG-REHAB-04 - Rehabilitative and Habilitative Services: Physical Medicine/Physical Therapy
• CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
• CG-SURG-27 - Gender Reassignment Surgery

 

Revised clinical guidelines effective April 15, 2020

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

• CG-DME-06 - Pneumatic Compression Devices for Lymphedema
• CG-GENE-01 - JAK2, CALR and MPL Gene Mutation Testing for Myeloproliferative Disorders
• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-GENE-07 - BCR-ABL Mutation Analysis
• CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
• CG-GENE-09 - Genetic Testing for CHARGE Syndrome
• CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
• CG-MED-55 - Level of Care: Advanced Radiologic Imaging
• CG-MED-69 - Inhaled Nitric Oxide
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-74 - Total Ankle Replacement
• CG-SURG-97 - Cardioverter-Defibrillators
• CG-SURG-99 - Panniculectomy, Abdominoplasty
• CG-TRANS-02 - Kidney Transplantation

 

Archived clinical guideline effective April 15, 2020

This clinical guideline has been archived and renumbered as another clinical guideline.

• CG-GENE-06 - Preimplantation Genetic Diagnosis Testing [renumbered as CG-MED-88]

 

Archived clinical guideline effective April 15, 2020

• CG-MED-82 - Intravenous versus Oral Drug Administration

 

Revised clinical guideline effective May 1, 2020

The following adopted clinical guideline was updated with a new procedure code.

• CG-GENE-13 - Genetic Testing for Inherited Diseases

 

Adopted clinical guideline effective July 1, 2020 

The following guideline was previously a medical policy and has been adopted with no significant changes.

• CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) [previously SURG.00028]

 

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