Medical policy and clinical guideline updates available on anthem.com

Medical policy updates

The following new and revised medical policies were endorsed at the May 14, 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.  

 

Revised medical policies effective May 21, 2020

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

• DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
• DME.00034 - Standing Frames
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

 

Revised medical policies effective July 1, 2020

The following policies were reviewed and updated with new procedure and/or diagnosis codes. No significant changes to the policy position or criteria.

• GENE.00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
• MED.00129 - Gene Therapy for Spinal Muscular Atrophy
• SURG.00010 - Treatments for Urinary Incontinence
• SURG.00126 - Irreversible Electroporation
•  

Coding updates effective July 1, 2020

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

• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
• LAB.00011 - Analysis of Proteomic Patterns
• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

Revised medical policys effective July 8, 2020

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

• MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

 

Revised medical policies effective July 8, 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.00002 - Preventive Health Guidelines
• ADMIN.00004 - Medical Necessity Criteria
• ADMIN.00005 - Investigational Criteria
• ADMIN.00007 - Immunizations
• ANC.00006 - Biomagnetic Therapy
• DME.00024 - Transtympanic Micropressure for the Treatment of Meniere's Disease
• DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
• DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
• DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
• DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
• GENE.00007 - Cardiac Ion Channel Genetic Testing
• GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
• LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• LAB.00031 - Advanced Lipoprotein Testing 
• LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer Test
• LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
• MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders  
• MED.00098 - Hyperoxemic Reperfusion Therapy
• MED.00127 - Chelation Therapy
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
• RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
• SURG.00005 - Partial Left Ventriculectomy
• SURG.00045 - Extracorporeal Shock Wave Therapy
• SURG.00071 - Percutaneous and Endoscopic Spinal Surgery  
• SURG.00076 - Nerve Graft After Prostatectomy
• SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
• SURG.00084 - Implantable Middle Ear Hearing Aids
• SURG.00105 - Bicmpartmental Knee Arthroplasty
• SURG.00111 - Axial Lumbar Interbody
• SURG.00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
• SURG.00118 - Bronchial Thermoplasty
• SURG.00120 - Internal Rib Fixation Systems
• SURG.00121 - Transcatheter Heart Valves Procedures
• SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
• SURG.00134 - Interspinous Process Fixation Devices
• SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
• SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
• TRANS.00035 - Other Stem Cell Therapy

 

Archived medical policy effective July 8, 2020

The following policy has been archived and its content has been transferred to an existing Medical Policy.

• TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease (content transitioned to TRANS.00035)

 

New medical policies effective October 1, 2020

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

• DME.00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
• MED.00131 - Electronic Home Visual Field Monitoring
• MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
• MED.00133 - Ingestion Event Sensors
• THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

 

Revised medical policies effective October 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.

• ANC.00007 - Cosmetic and Reconstructive Services; Skin Related [content addressing dermal fillers, collagen injections and hyaluronic acid gel products transferred to a new policy, MED.00132]
• MED.00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications [content addressing autologous adipose-derived regenerative cell therapy transferred to a new policy, MED.00132]

 

Coding update effective October 1, 2020

The following policy had some content transferred to an existing Medical Policy.

• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting [some content transitioned to MED.00132]

 

Revised medical policies effective October 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
• GENE.00007 - Cardiac Ion Channel Genetic Testing
• GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
• GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
• SURG.00007 - Vagus Nerve Stimulation

 

Clinical guideline updates

The following new and revised medical policies were endorsed at the May 14. 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.' 

 

Revised clinical guidelines effective May 21, 2020

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

• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
• CG-MED-77 - SPECT/CT Fusion Imaging
• CG-SURG-27 - Gender Reassignment Surgery

 

Revised clinical guidelines effective July 1, 2020

The following adopted guideline was reviewed and updated with new procedure and/or diagnosis codes. No significant changes to the guideline position or criteria.

• CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome

 

Coding updates effective July 1, 2020

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

• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions

 

Revised clinical guidelines effective July 8, 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-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
• CG-DME-45 - Ultrasound Bone Growth Stimulation
• CG-GENE-02 - Analysis of RAS Status
• CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
• CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
• CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
• CG-MED-76 - Magnetic Source Imaging and Magneto-encephalography
• CG-MED-83 - Level of Care: Specialty Pharmaceuticals
• CG-REHAB-11 - Cognitive Rehabilitation
• CG-SURG-05 - Maze Procedure
• CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-12 - Penile Prosthesis Implantation
• CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
• CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
• CG-SURG-85 - Hip Resurfacing
• CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
• CG-SURG-88 - Mastectomy for Gynecomastia
• CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
• CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
• CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised clinical guidelines effective October 1, 2020

The following adopted guidelines listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.

• CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities
• CG-GENE-02 - Analysis of RAS Status
• CG-GENE-13 - Genetic Testing for Inherited Diseases
• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
• CG-MED-68 - Therapeutic Apheresis
• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Adopted clinical guideline effective November 1, 2020

The following guideline has been adopted.

• CG-SURG-104 - Intraoperative Neurophysiological Monitoring

 

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