Effective with dates of service on or after May 1, 2019, Anthem Blue Cross and Blue Shield will require review of the below 2 Clinical Guidelines for medical necessity. Medical necessity review will require preauthorization. Ordering and servicing providers may submit prior authorization requests by contacting the phone number on the back of the members ID card.


Clinical Guideline Name


CG-SURG-49: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

This document addresses the use of peripheral vascular angioplasty, with and without stenting, and with or without atherectomy, for the treatment of occlusive peripheral arterial disease (PAD) of the lower extremities. 

CG-SURG-55: Intracardiac Electrophysiological Studies and Catheter Ablation

This document addresses two intracardiac electrophysiological procedures and studies, including electrophysiological studies (EPS) and catheter ablation. EPS with programmed ventricular stimulation (PVS) is used, as a complement to a full workup, to document the inducibility and type of induced arrhythmia, (for example, atrial fibrillation, ventricular tachycardia, etc.); also to assess the risks for recurrent ventricular tachycardia or sudden cardiac death; to evaluate symptoms, such as syncope; and to guide catheter ablation procedures in selected individuals when arrhythmias are suspected to be the etiology. EPS is also used, in appropriate individuals, for the purpose of assessment for eligibility for treatments, such as implantable cardioverter defibrillator therapy.

Transcatheter or intracardiac catheter ablation is a treatment option for individuals with certain types of arrhythmias and is performed following imaging and electro-anatomic mapping, which is done during EPS to identify the specific location of the ectopic excitable foci. Catheter ablation utilizes radiofrequency or cryoablation energy to eradicate or ablate the arrhythmogenic foci in the heart which is the source of the arrhythmia. In this way, catheter ablation reduces or prevents recurrent episodes of certain supraventricular and ventricular arrhythmias that have demonstrated therapeutic response to this treatment modality in clinical practice.


Anthem’s Medical Polices and Clinical UM Guidelines are available online on Anthem’s website at Anthem.com. Select Providers > Select your State > Select Review Policies > Select View Policies and Guidelines > Select Medical Policies and Clinical UM Guidelines (for Local Plan members).


Featured In:
February 2019 Anthem Missouri Provider Newsletter