The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on February 11, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.


To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit > Policies & Guidelines.


The new Medical Policies listed below have been approved.


Note: *Precertification required




Effective date


Gene Expression Profiling for Bladder Cancer

• Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered INV&NMN -- Existing CPT codes 0012M, 0013M (Cxbladder GEP) moved from LAB.00011, still considered INV&NMN; CPT 0016M effective 01/01/2021 for Decipher TURBT® will be considered INV&NMN



Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection

  • Cell-free DNA testing is considered INV&NMN as a non-invasive method of determining the risk of rejection in kidney transplant recipients

- Existing code 0118U for Vitacor TRAC will be considered INV&NMN for kidney transplant diagnoses; no specific codes for other tests, listed 81479, 81599 NOC codes



Pooled Antibiotic Sensitivity Testing

• Pooled antibiotic sensitivity testing is considered INV&NMN in the outpatient setting for all indications

- No specific codes for these tests (eg Guidance® assay for UTI [Pathnostics, Inc.]), considered INV&NMN; listed NOC codes 81479, 87999



Focal Laser Ablation for the Treatment of Prostate Cancer

• Focal laser ablation is considered INV&NMN for the treatment of prostate cancer

- No specific code for focal laser ablation of prostate for cancer, considered INV&NMN; listed 55899 NOC and associated ICD-10-PCS code; also listed 0655T (will be effective 07/01/2021) considered INV&NMN



Uterine Transplantation

• Uterine transplantation is considered INV&NMN for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus

- No specific CPT code for uterine transplant services, considered INV&NMN; listed 58999 NOC and associated ICD-10-PCS codes, also listed 0664T-0670T (will be effective 07/01/2021) considered INV&NMN



The current Medical policies and/or Clinical Guidelines listed below were reviewed and updates were approved.


Note: *Precertification required




Effective date


Gene Expression Profiling for Managing Breast Cancer Treatment

• Content moved from GENE.00011

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Removed Insight DX test (no longer marketed) and added Insight TNBC type test as NMN



Genetic Testing for Heritable Cardiac Conditions

• Content moved from GENE.00007 and GENE.00017

• INV&NMN changed to NMN as a result of MP to CUMG transition

• No other change to clinical indications



Cosmetic and Reconstructive Services of the Head and Neck

• Removed the word “physical” from the term “physical functional impairment” in Facial Plastic Surgery, Otoplasty, Rhinophyma, Rhinoplasty or Rhinoseptoplasty and Cranial Nerve Procedures position statements

• Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as COS&NMN

- No specific code for implanted auricular prosthesis, added L8699 NOC, considered COS&NMN for specific implants



Cranial Remodeling Bands and Helmets (Cranial Orthotics)

• Removed condition requirement from REC criteria

• Replaced current diagnostic REC criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry



Bone-Anchored and Bone Conduction Hearing Aids

• Reorganized Clinical Indications section

• Reorganized and clarified bilateral hearing loss MN criteria

• Clarified MN criteria for transcutaneously-worn bone conduction hearing aids for both bilateral and unilateral hearing loss

• Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss

• Moved device-specific threshold information to the Discussion section

• Clarified MN criteria for transcutaneously worn and fully- or partially-implantable bone conduction hearing aids for unilateral hearing loss

• Added NMN statement for when MN criteria have not been met

• Clarified NMN statement regarding replacement parts or upgrades

• Added bone conduction hearing aids using an adhesive adapter behind the ear as NMN for all indications



Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

• Reorganizing genetic testing topics: Moved the content of the following topics into CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

   - CG-GENE-02 Analysis of RAS Status

   - CG-GENE-03 BRAF Mutation Analysis

   - CG-GENE-12 PIK3CA Mutation Testing for Malignant Condition

   - CG-GENE-20 Epidermal Growth Factor Receptor [EGFR] Testing)

• Added circulating tumor DNA (ctDNA) to guide targeted cancer therapy in individuals with solid tumor(s) as MN when criteria are met

• Added NMN criteria on circulating tumor DNA (ctDNA) when the medically necessary criteria are not met, including to detect the recurrence of a solid tumor, including ectal cancer, and to test for solid tumor cancer susceptibility

   - Content addressing ctDNA involving 4 or fewer genes or gene variants, moved from GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) and added to this document (CG-GENE-14)

   - Content addressing ctDNA involving 5 or more genes or gene variants (gene panel), will continue to be addressed in GENE.00049

- Added PLA code 0229U (Colvera® 2-gene test) considered NMN (moved from GENE.00049, was considered INV&NMN); added specific codes from merged guidelines (PIK3CA 81309, 0155U, 0177U; RAS 81275, 81276, 81311, 0111U; BRAF 81210; EGFR 81235) and genes to Tier 2 codes, with no changes




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April 2021 Anthem Provider News - Missouri