CommercialDecember 1, 2023
Medical Policies and Clinical Guidelines updates — December 2023
The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.
To view Medical Policies and Utilization Management Guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.
To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.
To view Medical Policies and Clinical 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 fepblue.org > Policies & Guidelines.
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Below are the new medical policies and/or clinical guidelines that have been approved.
* Denotes prior authorization required
Policy/guideline | Information | Effective date |
TRANS.00041 Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection | • Histological analysis using microarray gene expression profiling is considered INV&NMN for detection of allograft injury or rejection in kidney transplant recipients | 3/1/2024 |
MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation | • Outlines the MN and INV&NMN criteria for the use of ex-vivo expansion of cord blood stem cell products Existing ICD-10-PCS codes XW133C8, XW143C8 considered MN when criteria are met; no specific CPT/HCPCS codes for omidubicel, listed NOC codes 38999, C9399, J3490, J3590 | 3/1/2024 |
MED.00144 Gene Therapy for Duchenne Muscular Dystrophy | • Outlines the MN and INV&NMN criteria for the infusion of Delandistrogene moxeparvovec-rokl (ELEVIDYS) No specific code for ELEVIDYS; listed NOC codes C9399, J3490, J3590 considered MN when criteria are met | 3/1/2024 |
Below are the current Clinical Guidelines and/or Medical Policies we reviewed, and updates were approved.
* Denotes prior authorization required
Policy/guideline | Information | Effective date |
CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) | Will now use MCG Guideline for review: MCG- Urologic Surgery or Procedure GRG /GRG: W0141 (ISC GRG) (Codes 0421T; 0714T; 52441 52442, 52450, 52647, 52648, 52649; 53850, 53852, 53854; 55873, C2596, C9739; C9740, C9769 and associated ICD-10-PCS codes) | 12/1/2023 |
CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) | Code 53855 Moving to pre-cert. Note: Will now use MCG Guideline for review: MCG- Urologic Surgery or Procedure GRG /GRG: W0141 (ISC GRG) | 3/1/2024 |
SURG.00119 Endobronchial Valve Devices | Will now use MCG Guideline for review: Thoracic Surgery or Procedure GRG/ GRG: SG-TS (ISC GRG) (CPT® codes 31647, 31648, 31649, 31651 and associated ICD-10-PCS codes) | 12/1/2023 |
*CG-SURG-27 Gender Affirming Surgery | Will now use MCG Guideline for review: Gender-Affirming Surgery or Procedure GRG:GG-FMMF (ISC GRG) (Codes: 11920, 11921, 11922, 19325, 19350, 56800, 56805, 57291, 57292, 19303, 19304, 54125, 54520, 54660, 54690, 55180, 55970, 56625, 57110, 57295, 57296, 57426, 58150, 58552, 58554, 58570, 58571, 58572, 58573 and associated ICD-10-PCS codes) | 12/1/2023 |
MED.00122 Wilderness Programs | • MED.00122 will be archived • MCG BHG B-822-T will be used for review | 12/1/2023 |
CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring | Added new ICD-10-CM diagnosis codes G40.C01-G40.C19 for seizures - Adding codes 95700, 95705-95706, 95709, 95711-95726 to pre-cert. | 3/1/2024 |
CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis | Added new ICD-10-CM diagnosis codes D13.91, D48.110-D48.119, Z83.710-Z83.719 effective 10/01/2023 replacing D48.1, Z83.71 | 9/27/2023 |
TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) | Added new ICD-10-CM diagnosis codes G20.A1-G20.C for Parkinson's replacing G20 | 10/1/2023 |
SURG.00150 Leadless Pacemaker | Added ICD-10-PCS X2H63V9, X2HK3V9 for dual chamber leadless pacemaker, considered INV&NMN | 9/27/2023 |
SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) | Added new ICD-10-CM diagnosis codes G43.E01-G43.E19 for migraine (end of range) | 10/1/2023 |
SURG.00096 Surgical and Ablative Treatments for Chronic Headaches | Added new ICD-10-CM diagnosis codes G43.E01-G43.E19 for migraine (end of range) | 10/1/2023 |
SURG.00071 Percutaneous and Endoscopic Spinal Surgery | Added existing HCPCS outpatient code C2614 for probe considered INV&NMN | 3/1/2024 |
SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation | Added existing HCPCS outpatient code C1787 for programming device considered MN when criteria are met; added new ICD-10-CM diagnosis codes G20.A1-G20.C for Parkinson's replacing G20 | 3/1/2024 |
SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Added new HCPCS codes A2022, A2023, A2024, A2025, Q4285, Q4286 for products considered INV&NMN; added existing code C1832 for Recell, considered INV&NMN | 3/1/2024 |
MED.00145 Digital Therapy Devices for Treatment of Amblyopia | Added new HCPCS code A9292 for amblyopia software considered INV&NMN | 3/1/2024 |
MED.00143 Ingestible Devices for the Treatment of Constipation | Added new HCPCS codes A9268, A9269 for Vibrant Gastro System capsule and programmer considered INV&NMN replacing NOC code | 3/1/2024 |
MED.00125 Biofeedback and Neurofeedback | Added new ICD-10-CM diagnosis codes G43.E01-G43.E19 for migraine (end of range) | 10/1/2023 |
LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | Added new CPT PLA code 0412U for PrecivityAD® blood test considered INV&NMN | 3/1/2024 |
LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline | Added new CPT PLA code 0407U for IntelxDKD test, considered INV&NMN6 | 3/1/2024 |
LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders | Added new ICD-10-CM codes K63.8211-K63.829 effective 10/01/2023 for intestinal microbial overgrowth | 10/1/2023 |
GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Added existing CPT PLA code 0262U considered NMN; added new CPT PLA codes 0409U, 0414U (considered MN when criteria are met); 0405U (considered NMN); 0410U, 0413U, 0415U, 0417U (considered INV&NMN); Removed 0397U | 3/1/2024 |
GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | Added new CPT PLA codes 0411U, 0419U considered INV&NMN | 3/1/2024 |
GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer | Added new CPT PLA code 0403U effective 10/01/2023 for MyProstateScore 2.0 considered INV&NMN | 3/1/2024 |
ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck | Changed CPT code 15829 to Reconstructive when criteria are met (was COS&NMN) | 9/27/2023 |
TRANS.00039 Portable Normothermic Organ Perfusion Systems | • Added MN criteria for portable normothermic heart perfusion • Reformatted MN criteria for lung and liver perfusion Added CPT Category III codes 0494T, 0495T, 0496T for lung perfusion (from TRANS.00009); added ICD-10-PCS codes 6ABB0BZ, 6AB50BZ, 6ABF0BZ, 6ABT0BZ | 3/1/2024 |
TRANS.00009 Lung and Lobar Transplantation | Removed CPT Category III codes 0494T, 0495T, 0496T for lung perfusion (now addressed in TRANS.00039) | 9/27/2023 |
TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products | Added new ICD-10-CM diagnosis codes G20.A1-G20.C for Parkinson's replacing G20 | 10/1/2023 |
SURG.00144 "Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
Previously titled: Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia " | • Revised title • Added INV&NMN statement for sphenopalatine ganglion nerve blocks Added existing CPT code 64505, considered INV&NMN for headache or occipital neuralgia; added new ICD-10-CM diagnosis codes G43.E01-G43.E19 for migraine (end of range) | 3/1/2024 |
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring | • Removed the criteria examples for failed CPAP treatment • Added definition for failed CPAP treatment
| 9/27/2023 |
SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures | • Added MN and NMN criteria for intraosseous basivertebral nerve ablation (BVNA) CPT and ICD-10-PCS codes 64628, 64629, 015B3ZZ, 015B4ZZ for BVNA considered MN when criteria are met (were INV&NMN) | 3/1/2024 |
SURG.00007 Vagus Nerve Stimulation | • Removed INV&NMN example under implanted VNS for epilepsy and added stroke rehabilitation as an example • Removed all INV&NMN examples under non implanted VNS Added new ICD-10-CM diagnosis codes G43.E01-G43.E19 for migraine (end of range) | 10/1/2023 |
MED.00140 Lentiviral Gene Therapy for Beta Thalassemia and Sickle Cell Disease
Previously Titled: Gene Therapy for Beta Thalassemia" | • Revised title • Added INV&NMN statement on lovotibeglogene autotemcel Added ICD-10-PCS codes XW133H9, XW143H9 effective 10/1/2023 for transfusion of Lentiglobin, considered INV&NMN; no specific HCPCS codes for Lentiglobin, NOC codes already listed; removed ICD-10-PCS codes 30233C0, 30243C0 no longer applicable | 3/1/2024 |
LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia | Added existing CPT PLA code 0390Ufor PEPredictDx test, considered INV&NMN | 3/1/2024 |
LAB.00028 Blood-based Biomarker Tests for Multiple Sclerosis
Previously titled: Serum Biomarker Tests for Multiple Sclerosis" | • Revised title • Expanded scope of document from serum to blood-based biomarker testing for multiple sclerosis (MS) • Revised Position Statement to indicate blood-based biomarker tests for multiple sclerosis are considered INV&NMN for all uses Added existing CPT PLA code 0361U for Neurofilament Light Chain test, considered INV&NMN | 3/1/2024 |
LAB.00011 Selected Protein Biomarker Algorithmic Assays | • Reformatted bullet points to letters • Added IMMray® PanCan-d test to the INV&NMN statement Added existing CPT PLA code 0342U for IMMray test, considered INV&NMN | 3/1/2024 |
DME.00049 External Upper Limb Stimulation for the Treatment of Tremors | • Revised Position Statement to include INV&NMN for Parkinson’s | 9/27/2023 |
DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | Added HCPCS codes E0490, E0491 effective 10/01/2023 for device with hardware remote, considered INV&NMN | 3/1/2024 |
DME.00041 Ultrasonic Diathermy Devices | Added HCPCS code K1036 effective 10/01/2023 for device supplies and accessories, considered INV&NMN | 3/1/2024 |
DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | • Reformatted bullet points to letters • Added lines to INV&NMN statement on electrical stimulation wound treatment device, electromagnetic wound treatment devices and pulsed electromagnetic field stimulation Added existing HCPCS code E0769 for electromagnetic wound devices, considered INV&NMN | 3/1/2024 |
CG-SURG-97 Cardioverter Defibrillators | Added new ICD-10-CM code I21.B effective 10/01/2023 to end of range | 10/1/2023 |
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity | • Added criteria regarding BMI parameters, pre-operative evaluations and education and treatment plans and removed criteria regarding % weight loss amounts and compliance evaluation for revision/conversion indications • Removed NMN statement regarding stomach stretching and overeating" | 9/27/2023 |
CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure | Added new ICD-10-CM code I21.B to end of range | 10/1/2023 |
CG-MED-83 Site of Care: Specialty Pharmaceuticals | • Revised formatting in Clinical Indications section • Added new MN statement addressing geographic accessibility" | 9/27/2023 |
ANC.00009 "Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
Previously titled: Cosmetic and Reconstructive Services of the Trunk and Groin" | • Revised title to include “Extremities"" • Revised Position Statement regarding lipectomy or liposuction for lymphedema and lipedema" | 3/1/2024 |
CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management | • Revised section “B Gene Mutation Testing to Guide Targeted Cancer Therapy” and section "C Circulating Tumor DNA (liquid biopsy)" to include cancer management in the Clinical Indications section | 9/27/2023 |
LAB.00029 Rupture of Membranes Testing in Pregnancy | Removed CPT PLA code 0066U for PartoSure test.
| 9/27/2023 |
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MULTI-BCBS-CM-044676-23
PUBLICATIONS: December 2023 Provider Newsletter
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