The following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.

 

If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.

 

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 November 15, 2018

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

• DRUG.00046 - Ipilimumab (Yervoy®)
• DRUG.00071 - Pembrolizumab (Keytruda®)
• DRUG.00075 - Nivolumab (Opdivo®)
• MED.00109 - Corneal Collagen Cross-Linking
• SURG.00120 - Internal Rib Fixation Systems
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

  

Revised medical policies effective December 12, 2018

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

• DRUG.00062 - Obinutuzumab (Gazyva®)
• DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
• DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®)
• SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
• SURG.00121 - Transcatheter Heart Valve Procedures
• TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

 

Archived medical policy effective December 12, 2018

(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)

• DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)

 

Revised medical policies effective December 12, 2018

(The following policies were reviewed and had no significant changes to the policy position or criteria.)

• ADMIN.00001 - Medical Policy Formation
• BEH.00002 - Transcranial Magnetic Stimulation
• DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
• DRUG.00034 - Insulin Potentiation Therapy
• DRUG.00063 - Ofatumumab (Arzerra®)
• DRUG.00074 - Alemtuzumab (Lemtrada™)
• DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
• DRUG.00086 - Mecasermin (Increlex®)
• DRUG.00099 - Cerliponase alfa (Brineura)
• DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
• DRUG.00111 - Monoclonal Antibodies to Interleukin-23
• DRUG.00116 - Vestronidase alfa (Mepsevii™)
• DRUG.00118 - Copanlisib (Aliqopa®)
• GENE.00006 - Epithelial Growth Factor Receptor (EGFR) Testing
• GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
• GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility
• GENE.00035 - Genetic Testing for TP53 Mutations
• GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
• LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
• LAB.00029 - Rupture of Membranes Testing in Pregnancy
• MED.00041 - Microvolt T-Wave Alternans
• MED.00055 - Wearable Cardioverter Defibrillators
• MED.00085 - Antineoplaston Therapy
• MED.00121 - Implantable Interstitial Glucose Sensors
• RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
• RAD.00036 - MRI of the Breast
• RAD.00061 - PET/MRI
• RAD.00065 - Radiostereometric Analysis
• SURG.00019 - Transmyocardial Revasculareization (TMR)
• SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
• SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
• SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
• SURG.00130 - Annulus Closure After Discectomy
• SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
• TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
• TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
• TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
• TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised medical policies effective December 27, 2018

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

• DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
• DRUG.00080 - Monoclonal Antibodies for the Treatment of Eoslinophilic Asthma
• DRUG.00108 - Edaravone (Radicava®)
• DRUG.00109 - Durvalumab (Imfinzi™)

• GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

• GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
• GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

• GENE.00023 - Gene Expression Profiling of Melanomas

• GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

• LAB.00011 - Analysis of Proteomic Patterns

• LAB.00019 - Serum Markers for Liver Fibrosis in the Evalution and Monitoring of Patients with Chronic Liver Disease
• MED.00109 - Corneal Collagen Cross-Linking
• MED.00111 - Intracardiac Ischemia Monitoring
• MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
• MED.00120 - Voretigene Neparvovec
• MED.00123 - Axicabtagene ciloleucel (Yescarta®)
• MED.00124 - Tisagenlecleucel (Kymriah®)
• OR.PR.00005 - Upper Extremity Myoelectric Orthoses
• SURG.00007 - Vagus Nerve Stimulation
• SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
• SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• SURG.00111 - Axial Lumbar Interbody
• SURG.00113 - Artifical Retinal Devices
• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
• SURG.00150 - Leadless Pacemaker
• THER-RAD.00009 - Intraocular Epirentinal Brachytherapy

 

Revised medical policies effective January 1, 2019

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

• DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)

 

Archived medical policy effective January 1, 2019

(The following policy has been archived and has been replaced by AIM guidelines.)

• SURG.00066 - Percutaneous Thermal Neurolysis for Chronic Back Pain

 

 Archived medical policies effective January 3, 2019

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

• MED.00100 - Diaphragmatic/ Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion

 

Revised medical policies effective April 1, 2019

(The following policies were updated with procedure and/or diagnosis codes and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

 

Revised medical policy effective April 1, 2019

(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• DRUG.00071 - Pembrolizumab (Keytruda®)
• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

New medical policy effective April 1, 2019

(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

The following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.

If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.

 

Revised clinical guideline effective November 15, 2018

(The following adopted guideline was revised to expand medical necessity indications or criteria

• CG-DRUG-88 - Dupilumab (Dupixent®)

 

Revised clinical guidelines effective December 12, 2018

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

• CG-DRUG-62 - Fulvestrant (FASLODEX®)
• CG-DRUG-63 - Levoleucovorin Products
• CG-DRUG-65 - Tumor Necrosis Factor Antagonists
• CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
• CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
• CG-GENE-03 - BRAF Mutation Analysis
• CG-SURG-60 - Cervical Total Disc Arthroplasty
• CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

 

Revised clinical guidelines effective December 12, 2018

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

• CG-DRUG-38 - Pemetrexed (Alimta®)
• CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
• CG-DRUG-44 - Pegloticase (Krystexxa®)
• CG-DRUG-45 - Octreotide Acetate (Sandostatin, Sandostatin LAR)
• CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
• CG-DRUG-64 - FDA-Approved Biosimilar Products
• CG-DRUG-66 - Panitumumab (Vectibix®)
• CG-DRUG-70 - Eribulin mesylate (Halaven®)
• CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
• CG-DRUG-75 - Romiplostim (Nplate®)
• CG-DRUG-76 - Plerixafor Injection (Mozobil™)
• CG-DRUG-79 - Siltuximab (Sylvant®)
• CG-DRUG-80 - Cabazitaxel (Jevtana)
• CG-DRUG-87 - Vedolizumab (Entyvio®)
• CG-MED-19 - Custodial Care
• CG-MED-26 - Neonatal Levels of Care
• CG-MED-67 - Melanoma Vaccines
• CG-MED-68 - Therapeutic Apheresis
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services
• CG-SURG-60 - Cervical Total Disc Arthroplasty
• CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
• CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

 

Revised clinical guideline effective December 12, 2018

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

• CG-DRUG-16 - White Blood Cell Growth Factors

 

Revised clinical guidelines effective December 27, 2018

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

• CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
• CG-DRUG-29 - Hyaluronan Injections
• CG-DRUG-61 - Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
• CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
• CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions
• CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Archived clinical guideline effective January 1, 2019

(The following adopted guideline has been archived and has been replaced by AIM guidelines.)

• CG-SURG-60 - Cervical Total Disc Arthroplasty

 

Revised clinical guidelines effective January 1, 2019

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

• CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
• CG-MED-65 - Manipulation Under Anesthesia

 

Adopted clinical guidelines effective January 3, 2019

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

• CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion

 

Revised clinical guidelines effective April 1, 2019

(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-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
• CG-GENE-01 - Janus Kinase 2 (JAK2) V617F and JAK2 exon 12 Gene Mutation Assays
• CG-SURG-27 - Sex Reassignment Surgery
• CG-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver

In the October 2018 issue of our provider newsletter in the article titled ‘Clinical guideline updates are available on anthem.com’, we advised that the following guidelines previously unadopted would become effective January 1, 2019. Recently, a decision was made that these guidelines will not become effective in January, and will remain unadopted.  

 

• CG-DME-09 - Continuous Local Delivery of Analgesia to Operative Sites using and Elastromeric Infusion Pump during the Post-operative Period
• CG-DME-13 - Lower Limb Prosthesis
• CG-DME-21 - External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
• CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
• CG- REHAB-02 - Outpatient Cardiac Rehabilitation

We are committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, we will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.

 

• Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change:  99490, 99487and 99489.

 

• Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.  No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498

 

Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information at Reimbursement Policy.

For more information, review our Bundled Services and Supplies policy dated February 23, 2019 by visiting the Reimbursement Policy page at anthem.com/provider.

We continually monitor and update the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, we notify impacted members that the drug is not FDA approved and will no longer be covered.

 

Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA. For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.

 

Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.