Policy Updates Medical Policy & Clinical GuidelinesCommercialMay 1, 2019

Clinical Guideline Update - May 2019*

The following new Anthem Blue Cross and Blue Shield Clinical Guideline will require Precertification review effective August 1, 2019 in Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

CG-SURG-92

Paraesophageal Hernia Repair

• PEH repair is considered Medically necessary (MN) for symptomatic individuals when criteria are met

• PEH repair during operation for Roux-en-Y gastric bypass, sleeve gastrectomy, or the placement of an adjustable gastric band is considered MN when criteria are met

• Recurrent PEH repair is considered MN when criteria are met

• PEH repair is considered not Medically necessary (NMN) when criteria are not met and for all other indications

Existing codes 43280, 43281, 43282, 43283, 43325, 43327, 43328, 43330, 43331, 43332, 43333, 43334, 43335, 43336, 43337, 43338, 0BQT0ZZ, 0BQT3ZZ, 0BQT4ZZ, 0BUT0JZ will be reviewed for MN criteria


* Notice of Prior Authorization or Material Adverse Change

 

PUBLICATIONS: May 2019 Anthem Provider Newsletter - Missouri