CommercialJanuary 1, 2025
Medical Policies and Clinical Guidelines updates — December 2024
The following 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 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.
Below are the new Medical Policies and/or Clinical Guidelines that have been approved.
* Denotes prior authorization required
Policy/guideline | Information | Effective date |
*DME.00052 Brain Computer Interface Rehabilitation Devices | Brain computer interface rehabilitation devices, including but not limited to electroencephalography (EEG)‑driven upper extremity powered exercisers, are considered INV&NMN
Existing HCPCS code E0738 effective 4/1/2024 for IpsiHand is considered INV&NMN for all indications | April 1, 2025 |
*LAB.00051 Per‑ and Polyfluoroalkyl Substances PFAS Testing | Testing for PFAS substances is considered INV&NMN for all indications
Existing CPT® PLA codes 0394U, 0457U for PFAS tests, and codes 82542, 83921 when specified as PFAS testing based on diagnosis, considered INV&NMN | April 1, 2025 |
*MED.00150 Hepzato Kit™ (melphalan hepatic delivery system) | Outlines the MN and INV&NMN criteria for Liver‑directed administration of high‑dose melphalan (Hepzato Kit)
Added existing HCPCS and ICD‑10-PCS codes J9248, XW053T9 and CPT 93799 NOC, considered MN when criteria are met | April 1, 2025 |
*DME.00052 Brain Computer Interface Rehabilitation Devices | Brain computer interface rehabilitation devices, including but not limited to electroencephalography (EEG)‑driven upper extremity powered exercisers, are considered INV&NMN
Existing HCPCS code E0738 effective 4/1/2024 for IpsiHand is considered INV&NMN for all indications | April 1, 2025 |
*LAB.00051 Per‑ and Polyfluoroalkyl Substances PFAS Testing | Testing for PFAS substances is considered INV&NMN for all indications
Existing CPT PLA codes 0394U, 0457U for PFAS tests, and codes 82542, 83921 when specified as PFAS testing based on diagnosis, considered INV&NMN | April 1, 2025 |
Below are the current Medical Policies and/or Clinical Guidelines that have been approved.
* Denotes prior authorization required
Policy/guideline | Information | Effective date |
CG‑MED-46 Ambulatory Electroencephalography (Previously titled: Electro‑encephalography and Video Electroencephalographic Monitoring) | Revised title
Removed attended video EEG monitoring in a healthcare facility from scope of document
Removed ICD‑10-PCS code 4A10X4Z for inpatient monitoring, no longer applicable
| October 1, 2024 |
CG‑SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity | Updated ICD‑10-CM diagnosis codes, added E66.811‑E66.813, E88.82, Z68.56 | October 1, 2024 |
*DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised INV&NMN statement, adding external lower extremity nerve stimulator
Added new HCPCS codes A4543, E0721 for Sparrow device, A4544, E0743 for TOMAC device effective 10/1/2024, all considered INV&NMN | April 1, 2025 |
*DME.00012 Intrapulmonary Percussive Ventilation Devices | Added new HCPCS codes A7021, E0469 effective 10/1/2024 for Volara system considered INV&NMN (replacing E1399 NOC) | April 1, 2025 |
*LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | Added new CPT PLA code 0511U effective 10/1/2024 for PARIS test considered NMN | April 1, 2025 |
*LAB.00015 Detection of Circulating Tumor Cells | Added new CPT PLA codes 0490U, 0491U, 0492U effective 10/1/2024 for CELLSEARCH tests, considered INV&NMN | April 1, 2025 |
*LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions (Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer) | Revised title
Added precancerous lesions with Barrett’s esophagus as an example to Position Statement
Added existing CPT PLA code 0108U for TissueCypher Barrett's Esophagus Assay, considered INV&NMN | April 1, 2025 |
*LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | Added new CPT PLA code 0495U effective 10/1/2024 for Stockholm3 test considered INV&NMN | April 1, 2025 |
*LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia | Revised diagnosis with diagnose in the INV&NMN statement
Added new CPT PLA code 0482U effective 10/1/2024 for preeclampsia test considered INV&NMN | April 1, 2025 |
*LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | Codes 0445U, 0459U will be considered MN when criteria met for leqembi therapy; added new CPT PLA codes 0479U, 0503U effective 10/1/2024 for pTau and blood testing considered INV&NMN | April 1, 2025 |
*LAB.00050 Metagenomic Sequencing for Infectious Diseases in the Outpatient Setting | Added new CPT PLA code 0480U effective 10/1/2024 for Mayo Clinic metagenomic test considered INV&NMN | April 1, 2025 |
*MED.00134 Non‑invasive Heart Failure and Arrhythmia Management and Monitoring Systems (Previously titled: Non‑invasive Heart Failure and Arrhythmia Management and Monitoring System) | Revised title
Revised Position Statement to remove device name and change from singular to plural devices
No specific codes for new devices AVIVO, VitalConnect, Zoe systems & BodyPort scale considered INV&NMN, added existing code 93701 (non‑specific) and E1399 NOC | April 1, 2025 |
*MED.00135 Gene Therapy for Hemophilia | Added new HCPCS code C9172 effective 10/1/2024 for Beqvez considered MN when criteria are met | April 1, 2025 |
*MED.00140 Gene Therapy for Beta Thalassemia | Added new MN statement regarding autologous hematopoietic stem cell mobilization and pheresis
Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures, MN when criteria are met for gene therapy | April 1, 2025 |
*MED.00142 Gene Therapy for Cerebral Adrenoleuko‑dystrophy | Added new MN statement regarding autologous hematopoietic stem cell mobilization and pheresis
Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures, MN when criteria are met for gene therapy | April 1, 2025 |
*MED.00144 Gene Therapy for Duchenne Muscular Dystrophy | Revised wording in the INV&NMN statement to include the brand name (ELEVIDYS) and remove the phrase for all other indications, including
Removed NOC codes C9399, J3490, J3590 no longer applicable | October 1, 2024 |
*MED.00146 Gene Therapy for Sickle Cell Disease | Added new MN statement regarding autologous hematopoietic stem cell mobilization and pheresis
Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures, MN when criteria are met for gene therapy | April 1, 2025 |
*MED.00148 Gene Therapy for Metachromatic Leukodystrophy | Added new MN statement regarding autologous hematopoietic stem cell mobilization and pheresis
Added codes 38206, 38232, 38241, 6A550ZV, 6A551ZV for autologous stem cell procedures, MN when criteria are met for gene therapy | April 1, 2025 |
*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Added new HCPCS codes A2027, A2028, A2029, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345 effective 10/1/2024 for products considered INV&NMN | April 1, 2025 |
*SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures | Added new ICD‑10-PCS codes 0HRT07B, 0HRU07B, 0HRV07B effective 10/1/2024 for lumbar artery perforator flap for breast reconstruction when criteria are met | October 1, 2024 |
*SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices (Previously titled: Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention) | Revised title
Revised MN statement
Added NMN statements for PFO and LAAA closure
Added an INV&NMN statement for PFO
Revised coding section to indicate PFO and LAAA codes considered NMN when criteria not met (were Inv&NMN) | October 1, 2024 |
*SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis (Previously titled: Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis) | Revised title
Changed the word and to or in the INV&NMN statement
Added ICD‑10-CM Q39.5 considered MN for POEM procedure when criteria are met | October 1, 2024 |
*SURG.00121 Transcatheter Heart Valve Procedures | Added new ICD‑10-PCS code X2RJ3RA effective 10/1/2024 for tricuspid valve replacement procedure considered INV&NMN | October 1, 2024 |
*SURG.00128 Implantable Left Atrial Hemodynamic Monitor | Added new CPT Category III codes 0933T, 0934T effective 1/1/2025, considered INV&NMN | April 1, 2025 |
*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring | Added existing CPT code 64568 for new single‑lead Inspire upper airway HNS, MN when criteria are met | April 1, 2025 |
*SURG.00135 Renal Sympathetic Nerve Ablation | Added ICD‑10-PCS X05133A effective 10/1/2024 and CPT Category III code 0935T effective 1/1/2025 for renal nerve ablation considered INV&NMN; removed non‑specific code 015M3ZZ | April 1, 2025 |
*SURG.00153 Cardiac Contractility Modulation Therapy | Added new CPT Category III codes 0915T‑0931T effective 1/1/2025 for CCM plus CD considered INV&NMN | April 1, 2025 |
*TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation | Added new ICD‑10-PCS code XW033DA effective 10/1/2024 for Lantidra, considered INV&NMN | October 1, 2024 |
*TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome | Updated ICD‑10-CM diagnosis codes, added C83.0A, C83.5A effective 10/1/2024 | October 1, 2024 |
*TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non‑Hodgkin Lymphoma | Updated ICD‑10-CM diagnosis codes, added C81.9A, C85.9A, C86.61 effective 10/1/2024 | October 1, 2024 |
*TRANS.00038 Thymus Tissue Transplantation | Added existing code J3590 NOC being used for RETHYMIC, replacing L8699 | October 1, 2024 |
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: January 2025 Provider Newsletter
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