CommercialMay 31, 2023
Medical Policies and Clinical Guidelines Updates — June 2023
The following Anthem Blue Cross and Blue Shield (Anthem) medical policies and clinical guidelines were reviewed on February 16, 2023, 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 (PA) 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 PA required
Policy/guideline | Information | Effective date |
*MED.00145 Digital Therapy Devices for Treatment of Amblyopia | Digital therapy devices for treatment of amblyopia are considered INV&NMN | September 1, 2023 |
Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.
* Denotes PA required
Policy/guideline | Information | Effective date |
CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing | Added new CPT PLA code 0364U for clonoSEQ (was NOC code); MN when criteria are met | September 1, 2023 |
*CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) | Removed diagnosis code L88 (not applicable) | September 1, 2023 |
CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone | Added new MN criterion for idiopathic intracranial hypertension (IIH) | September 1, 2023 |
*CG-SURG-97 Cardioverter Defibrillators | Removed code 00534 for associated anesthesia, not addressed | April 12, 2023 |
*GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) | Added new MN statement for panels that assess tumor mutation burden (TMB) and revised INV&NMN statement. | September 1, 2023 |
*GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer | Added CPT PLA codes 0130U, 0131U, 0132U, 0134U, 0135U previously addressed in GENE.00052; considered INV&NMN | September 1, 2023 |
*LAB.00039 Pooled Antibiotic Sensitivity Testing | Added new CPT PLA codes 0372U, 0374U for genitourinary antibiotic resistance tests, considered INV&NMN | September 1, 2023 |
*MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s) | Added existing CPT Category III code 0778Tconsidered INV&NMN | April 12, 2023 |
*MED.00135 PGene Therapy for Hemophilia | Added new HCPCS code J1411 effective 4/1/2023 for Hemgenix, MN when criteria are met (NOC codes no longer applicable for Hemgenix) | September 1, 2023 |
*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | • Revised MN statement to include SimpliDerm for breast reconstruction • Revised MN statement to include Kerecis and TheraSkin for diabetic foot ulcers • Revised MN statement to include AmnioBand for venous stasis ulcers • Revised MN statement to include OviTex for complex abdominal wall wounds • Revised formatting in several MN statements • Revised NMN statement to align with revisions to MN statements • Added new products to the INV&NMN statement HCPCS code Q4158 for Kerecis considered MN when criteria are met (was Inv&NMN), code Q4151 for AmnioBand considered MN for additional diagnoses when criteria are met, OviTex & SimpliDerm (NOC codes) considered MN when criteria are met; added new HCPCS codes A2019, A2020, A2021, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271 for products considered INV&NMN | September 1, 2023 |
*CG-GENE-13 Genetic Testing for Inherited Diseases | Added new CPT PLA code 0378U effective April 1, 2023, for UCGSL RFC1 Repeat Expansion Test, and gene RFC1 to table; considered NMN | September 1, 2023 |
*DME.00048 Virtual Reality-Assisted Therapy Systems | Added new HCPCS code E1905 effective 4/1/2023 for VR cognitive behavioral therapy device such as RelieVRx; considered INV&NMN | September 1, 2023 |
*SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) | Revised MN and INV&NMN Position Statements to address iStent infinite Trabecular Micro-Bypass Stent System, model iS3 | April 12, 2023 |
*DME.00049 External Upper Limb Stimulation for the Treatment of Tremors | Revised descriptor for HCPCS code K1019 | September 1, 2023 |
*GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | Added new CPT PLA code 0380U for Personalized RX; considered INV&NMN | September 1, 2023 |
*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Added new CPT PLA code 0379U for a molecular profiling panel, MN when criteria are met; removed codes 0130U, 0131U, 0132U, 0134U, 0135U that will be addressed in GENE.00054 | September 1, 2023 |
LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | Removed CPT PLA codes 0324U, 0325U | March 29, 2023 |
*LAB.00026 Systems Pathology Testing for Prostate Cancer | Added new CPT PLA code 0376U for Artera AI Prostate Test; considered INV&NMN | September 1, 2023 |
*LAB.00031 Advanced Lipoprotein Testing | Added new CPT PLA code 0377U for Liposcale®; considered INV&NMN | September 1, 2023 |
*SURG.00010 Treatments for Urinary Incontinence | Added new HCPCS codes A4341, A4342 for inFlow device and supplies, considered INV&NMN (NOC code A4335 no longer applicable) | September 1, 2023 |
*SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | Added new HCPCS code L8678 for stimulator supplies (patch), considered INV&NMN when used with PNS pain device; also added existing code L8681 for programming device used with PNS | September 1, 2023 |
*DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Adding to Anthem PA | September 1, 2023 |
*DME.00012 Intrapulmonary Percussive Ventilation Devices | Adding to Anthem PA | September 1, 2023 |
*DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) | Adding to Anthem PA | September 1, 2023 |
*DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices | Adding to Anthem PA | September 1, 2023 |
*DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea | Adding to Anthem PA | September 1, 2023 |
*MED.00122 Wilderness Programs | Adding to Anthem PA | September 1, 2023 |
*OR-PR.00005 Upper Extremity Myoelectric Orthoses | Adding to Anthem PA | September 1, 2023 |
*OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices | Adding to Anthem PA | September 1, 2023 |
*SURG.00084 Implantable Middle Ear Hearing Aids | Adding to Anthem PA | September 1, 2023 |
*SURG.00118 Bronchial Thermoplasty | Adding to Anthem PA | September 1, 2023 |
*SURG.00121 Transcatheter Heart Valve Procedures | Adding to Anthem PA | September 1, 2023 |
*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring | Adding to Anthem PA | September 1, 2023 |
*TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) | Adding to Anthem PA | September 1, 2023 |
*TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation | Adding to Anthem PA | September 1, 2023 |
*TRANS.00035 Therapeutic use of Stem Cells, Blood, and Bone Marrow Products | Adding to Anthem PA | September 1, 2023 |
MULTI-BCBS-CM-024768-23
PUBLICATIONS: June 2023 Provider Newsletter
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