Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
The continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — Additional outpatient UM (utilization management) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.
The Clinical UM Guidelines and Medical Policies adopted by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.
Members included in the new program
Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program® (FEP®). For more information, please contact the phone number on the back of the member ID card.
Pre-service review requirements
For procedures that are scheduled to begin on or after October 1, 2024, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including, but not limited to, the following non-emergency modalities. Please refer to the Clinical Guidelines at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.
Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.
Program | Services | Medical Policies or Clinical Guidelines |
Additional Outpatient Utilization Management | - Fertility
- Therapeutic Apharesis
- Hyperbaric Oxygen Therapy
- Physiologic Record of Tremor
- Home Parenteral Nutrition
- Imaging Evaluation. of Skin Lesions
- Ambulance Services (not applicable to Connecticut)
- Virtual Reality-Assisted Therapy Systems
- Quantitative Sensory Testing
- Automated Nerve Conduction Testing
- Bioimpedance Spectroscopy
- Autonomic Testing
- Continuous Monitoring of Intraocular Pressure
- Seizure Monitoring
- Electronic Home Visual Field Monitoring
- Eye Movement Analysis for Diagnosis of Concussion
- High-volume Colonic Irrigation
- Electrical Stimulation as a Treatment for Pain and Other Conditions
- Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- Automated Evacuation of Meibomian Gland
- Selected Sleep Testing
| - CG-ANC-04
- CG-ANC-06
- CG-MED-66
- CG-MED-68
- CG-MED-73
- CG-MED-88
- CG-MED-89
- CG-SURG-35
- DME.00048
- LAB.00045
- MED.00004
- MED.00082
- MED.00092
- MED.00101
- MED.00103
- MED.00105
- MED.00112
- MED.00118
- MED.00130
- MED.00131
- MED.00137
- MED.00141
- DME.00011
- MED.00011
- MED.00002
|
Cardiovascular | - Intracardiac Ischemia Monitoring
- Outpatient Cardiac Hemodynamic Monitoring w/Wireless Sensor for Heart Failure Management
- Non-invasive Heart Failure and Arrhythmia Monitoring System
- Carotid Sinus Baroreceptor Stimulation Devices
- Venous Angioplasty w/wo stent placement
- VeinEembolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- Treatment of Varicose Veins (Lower Extremity)
- Artery Stent Placement w/wo Angioplasty
- Select Embolization procedures
- Evaluation and Intervention for Dialysis Circuit Dysfunction
| - MED.00111
- MED.00115
- MED.00134
- SURG.00124
- SURG.00062
- CG-SURG-106
- CG-SURG-28
- CG-SURG-76
- CG-SURG-83
- CG-SURG-93
- CG-SURG-119
- RAD.00059
|
Musculoskeletal | - Ultrasound Bone Growth Stimulation.
- Manipulation Under Anesthesia
- Anesthesia for Interventional Pain Procedures.
- Facet Joint Allograft Implants for Facet Disease
- Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
- Extracorporeal Shock Wave Therapy
- Implant of Nerve Stimulation Devices
- Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
| - CG-MED-78
- SURG.00114
- SURG.00158
- CG-DME-45
- SURG.00112
- CG-MED-65
- CG-SURG-08
- CG-SURG-89
- SURG.00043
- SURG.00045
- SURG.00140
- SURG.00144
|
Radiology | - Magnetic Source Imaging & Magnetoencephalography
- Low-Frequency Ultrasound Therapy for Wound Mgmt
- Dynamic Spinal Visualization (Including Digital Motion X-ray & Cineradiography/ Videofluoroscopy)
- Cervical and Thoracic Discography
| - CG-MED-76
- MED.00096
- RAD.00034
- RAD.00053
|
Radiation Oncology | - Neutron Beam Radiotherapy
| |
Sleep | - Electronic Positional Devices for Tx of OSA
- Neuromuscular Electrical Training for Tx of OSA
- Surgical Tx for OSA
| - DME.00042
- DME.00043
- SURG.00129
|
Surgical | Surgical GI: - High Resolution Anoscopy Screening
- Doppler-Guided Transanal Hemorrhoidal Dearterialization
Base Surgical: - Anesthesia for Dental Services.
- Skin Related Cosmetic and Reconstructive Services
- Balloon Dilation of Eustachian Tubes
- Functional Endoscopic Sinus Surgery
- Bronchial Thermoplasty
- Balloon Sinus Ostial Dilation
- Cochlear and Auditory Brainstem Implants
- Implantable Hearing Aids
- Surgical Treatment for Obstructive Sleep Apnea and Snoring
- Drug-Eluting Devices to Maintain Sinus Ostial Patency
- Minimally Invasive Treatment of Posterior Nasal Nerve for Rhinitis
- MRI Guided High-intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- Uterine Fibroid Ablation
- Sacral Nerve Stimulation as a reatment of Neurogenic Bladder secondary to Spinal Cord Injury
- Vagus Nerve Stimulation
- Ablation for Solid Tumors Outside the Liver
- Irreversible Electroporation
- Corneal Collagen Cross Linking
- Intraocular Telescope
- Automated Evacuation of Meibomian Gland
- Presbyopia and Astigmatism-correcting Intraocular Lenses
- Viscocanalostomy and Canaloplasty
- Intraocular Anterior Segment Aqueous Drainage Devices
- Implanted Artificial Iris Devices
- Implanted Port Delivery Systems for Ocular Disease
- Implantable Infusion Pumps
- Treatments for Urinary and Fecal Incontinence, Urinary Retantion
- Reduction Mammaplasty
- Mastectomy for Gynecomastia
- Panniculectomy and Abdominoplasty
- Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation
- Products for Wound Healing and Soft Tissue Grafting
- Surgical and Ablative Treatments for Chronic Headaches
- Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- Mandibular/Maxillary Surgery
- Blepharoplasty, Repair and Brow Lift
- Internal Rib Fixation Systems
- Prostate Saturation Biopsy
- Focal Laser Ablation for the Treatment of Prostate Cancer
- Penile Prosthesis Implantation
- Diaphragmatic/Phrenic Nerve Stimulation and Pacing Systems
- High Intensity Focused Ultrasound Ablation for Oncologic Indications
- Renal Sympathetic Nerve Ablation
- Hysterectomy
- Laparoscopic Gynecologic Surgery
- Myomectomy
- Transurethral Destruction, Prostate Tissue
- Temporomandibular Disorders (SURG-09)
- Septoplasty (SURG-18)
- Bariatric Surgery and Other Treatment for Clinically Severe Obesity (SURG-81)
- Nasal Valve Repair (SURG.00079)
- Bone-Anchored and Bone Conduction Hearing Aids (SURG-82)
| - ANC.00007
- CG-MED-41
- CG-MED-79
- CG-MED-81
- CG-SURG-03
- CG-SURG-08
- CG-SURG-09
- CG-SURG-105
- CG-SURG-12
- CG-SURG-117
- CG-SURG-118
- CG-SURG-120
- CG-SURG-18
- CG-SURG-24
- CG-SURG-61
- CG-SURG-71
- CG-SURG-73
- CG-SURG-79
- CG-SURG-81
- CG-SURG-82
- CG-SURG-83
- CG-SURG-84
- CG-SURG-88
- CG-SURG-95
- CG-SURG-96
- CG-SURG-99
- MED.00057
- MED.00103
- MED.00132
- SURG.00010
- SURG.00011
- SURG.00118
- SURG.00061
- SURG.00077
- SURG.00079
- SURG.00084
- SURG.00095
- SURG.00096
- SURG.00107
- SURG.00116
- SURG.00120
- SURG.00126
- SURG.00129
- SURG.00132
- SURG.00135
- SURG.00139
- SURG.00141
- SURG.00156
- SURG.00157
- SURG.00159
- SURG.00160
- MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
- MCG: ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy
- MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
- MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic
- MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy
|
To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)
Care providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.
For more information
For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:
Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQs. You can also contact your local network relations representative if you have any questions.
Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.
* For New York, notice subject to regulatory approval.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Carelon Insights, Inc. provides payment integrity services on behalf of the health plan.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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PUBLICATIONS: June 2024 Provider Newsletter
