 Provider News MissouriJune 2022 Anthem Provider News - MissouriBeginning in June 2022, Anthem Blue Cross and Blue Shield (Anthem) will implement new processes for providers to validate the information we have in our online provider directories.
Individual providers
Anthem is partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.
Facilities and groups
Anthem is also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information and provide updates as needed.
If you have questions, please contact Provider Services.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Please review your demographic information in our online provider directories to ensure members and fellow providers can reach you.
Submit your updates by using our online Provider Maintenance Form. Update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.
Thank you for doing your part to help keep our online provider directories up to date.
One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.
Measure up
Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Anthem members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:
- Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
- Eye exam (retinal) performed
- Evaluation for kidney disease
- BP control (< 140/90 mm Hg)
|
Code type
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Description
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Code
|
|
ICD-10
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Type 1 diabetes mellitus without complications
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E10.9
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|
ICD-10
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Type 2 diabetes mellitus without complications
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E11.9
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ICD-10
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Other specified diabetes mellitus without complications
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E13.9
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HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Register today for the Exploring the Intersection of Race and Disability forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on
June 22, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias, is critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Forum: Exploring the Intersection of Race and Disability
Wednesday, June 22, 2022
4:00 p.m. to 5:30 p.m. ET
Please register for this event by June 22, 2022
Register today!
In its efforts to improve the health of humanity, Anthem Blue Cross and Blue Shield (Anthem) has made a long-term commitment to reducing morbidity and mortality associated with substance use disorder. In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, Anthem has been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).
Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise in deaths from overdose that the nation has experienced with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”). Anthem’s internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.
What can we do to address this?
First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, which is an organization that Anthem has historically supported.
Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.
Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health musculoskeletal clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by guideline
Spine surgery:
- Lumbar disc arthroplasty – add indication for 2-level lumbar disc arthroplasty when using a 2-level FDA-approved implant
- Lumbar discectomy – remove exclusion for annular closure devices (note: medical necessity of the implant is determined by health plan medical policy)
- Lumbar fusion – remove exclusion for anterior lumbar interbody fusion for indirect lumbar decompression in the absence of instability
- Cervical decompression with or without Fusion – add criteria for when revision or replacement may be medically necessary
- Cervical disc arthroplasty – add criteria for when revision or replacement may be medically necessary
- Two-level cervical disc arthroplasty – add indication for second level arthroplasty when prior arthroplasty already performed
- Lumbar disc arthroplasty – add requirement to manage underlying psychiatric disorder; add contraindications including prior fusion, poorly managed psychiatric disorder, chronic radiculopathy; add exclusion for prior lumbar fusion
- Scheurmann’s kyphosis – removed “associated neurological deficits” as a clinical consideration
- Scoliosis – expand indication to include thoracic for progressive adolescent idiopathic scoliosis; increased Cobb angle for skeletally mature patients to greater than 50 degrees
- Spinal stenosis – require surgeon’s interpretation of flexion-extension lateral spine x-ray documented in the medical record; added indications for recurrent stenosis, adjacent-level stenosis after a prior fusion, and planned indirect decompression via anterior approach decompression via anterior approach
Joint surgery:
- Total shoulder arthroplasty – add fracture indication for total shoulder arthroplasty (although reverse total shoulder arthroplasty is preferred) to align with AAOS feedback
- Total shoulder arthroplasty – add exception for Kellgren-Lawrence grade 4 to be consistent with total knee and total hip arthroplasty
- Hemiarthroplasty – added indications for hemiarthroplasty for glenohumeral arthritis with irreparable rotator cuff and for malignancy involving the glenohumeral joint or surrounding soft tissue
- Reverse shoulder arthroplasty – add indication when glenoid bone stock inadequate to support anatomic glenoid prosthesis
- Labrum repair – remove requirement that MRI-demonstrated SLAP lesion is traumatic in nature
- Adhesive capsulitis – match requirements in knee arthroscopy; reduce timeframe of conservative management to 6 weeks post-surgery for lysis of adhesions/capsular release and MUA
- Total knee arthroplasty – add patellofemoral osteoarthritis as an indication for total knee arthroplasty
- Knee arthroscopy – new indication for abrasion arthroplasty/microfracture
- Knee/arthroscopically assisted lysis of adhesions – remove 12-week post-surgery requirement
- Knee/manipulation under anesthesia – remove 12-week post-surgery requirement
- Treatment of osteochondral defects – remove BMI 35 or less from patient selection criteria
- Autologous chondrocyte implantation – Added contraindications from MACI package insert, including severe osteoarthritis, inflammatory joint disease, knee surgery other than biopsy or MACI preparation, and inability to cooperate with postoperative rehab program
Small joint surgery:
- Hallux rigidus – add criteria for select implant arthroplasties in great toe; remove exclusion for percutaneous osteotomy
- Hallux valgus/bunionette – remove exclusion for implant arthroplasties
- Lesser toe deformities – remove exclusions for implant arthroplasties and intramedullary fixation devices
- First metatarsophalangeal joint arthrodesis – remove requirement for 6 months of symptoms
- First metatarsophalangeal joint arthroplasty – new indication
- Hallux rigidus/exclusions – clarified specific types of excluded implants; excluded metatarsophalangeal joint arthroplasties for any other indications; excluded peripheral neuropathy/Charcot joint
Sacroiliac joint (SU) fusion:
- Expand indication to include any FDA-approved minimally invasive/percutaneous SI joint fusion device with fixation
- Require a trial of at least one therapeutic intra-articular SI joint injection
- New criteria for revision minimally invasive SI joint fusion
- Add exclusion for posterior (dorsal) minimally invasive SI joint fusion procedures using only bone grafts and no internal fixation device
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 833-305-1807, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health sleep disorder management clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
- Established sleep disorder (OSA or other) – follow-up laboratory studies – added indication for one follow-up in-lab sleep study as appropriate following insertion of a hypoglossal nerve stimulator
- Multiple Sleep Latency Testing (MSLT) and/or Maintenance of Wakefulness Testing (MWT) – new indication for MWT in occupational safety evaluation
- Management of OSA using Oral Appliances (OA) – limit guideline for oral appliance use to patients 16 years and older
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 833-305-1807, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health advanced imaging clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by Guideline
Imaging of the Spine:
- Perioperative and periprocedural imaging – added requirement for initial evaluation with radiographs
Imaging of the Extremities:
- Trauma – added CT as an alternative to MRI for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular Imaging:
- Stenosis or occlusion, extracranial carotid arteries: - New indications for post neck irradiation, incidental carotid calcification scenarios.
- Stroke/TIA, extracranial evaluation - Subacute stroke/TIA: CTA/MRA Neck allowed without prerequisite ultrasound (US), in alignment with 2021 AHA/ASA guidelines.
- Chronic stroke/TIA - New indication; modality approach by circulation presentation.
- Pulmonary Embolism - Removal of nondiagnostic CXR requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID infection, etc).
- Imaging study modality and/or site expansion - Pulsatile Tinnitus, Acute Aortic Syndrome, Abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries - Post-revascularization scenario aligned with SVS guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries - Management/surveillance scenarios aligned with SVS guidelines.
- Upper or Lower Extremity Peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 833-305-1807, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
This information applies to Anthem Blue Cross and Blue Shield Local Commercial health plans in Indiana, Kentucky, Missouri, Ohio and Wisconsin.
Anthem has updated guidance on prior authorization requirements for admissions to an in-network long-term acute care hospital (LTACH).
Effective April 18, 2022, we allow a 7-day initial length of stay upon notification of an admission to an in-network LTACH for members in Indiana, Kentucky, Missouri, Ohio and Wisconsin.
This process applies to transfers from hospital inpatient to LTACH ONLY.
It does not apply to transfers from acute in-patient rehab, LTACH to LTACH, skilled nursing facility (SNF) to LTACH, or out-of-network LTAC facilities.
This process to will remain in place until further notice.
Process Description:
- Facility and physician must be in-network for the member.
- Anthem requires notification of the LTACH admission, which includes sending demographics and verification of benefits, via the usual channels to aid in our members’ care coordination and management.
- Anthem will approve the initial 7-day length of stay without the need to provide clinical information.
- LTACH providers need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required, but we allow the transfer to LTACH, and then allow providers to send clinical within 2-days after the admission and prior to the last covered day for concurrent review.
- Concurrent review will be required starting on day 8 of the LTACH stay.
- Anthem may apply monetary penalties, such as a reduction in payment, for failure to provide timely notice of admission.
The following Anthem Blue Cross and Blue Shield medical policies and clinical guidelines were reviewed on February 17, 2022.
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
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Policy/ Guideline
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Information
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Effective date
|
|
*LAB.00043
Immune Biomarker Tests for Cancer
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• Oncologic immune biomarker tests are considered investigational (INV)and not medically necessary (NMN) for all indications
Listed CPT PLA code 0261U effective 10/01/2021, considered INV and NMN
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9/1/2022
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|
*LAB.00044
Saliva-based Testing to Determine Drug-Metabolizer Status
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• Saliva-based testing to determine drug-metabolizer status is considered INV and NMN for all indications
No specific code for tests of CYP450 enzymes for drug-metabolizer status using a saliva specimen, considered INV and NMN; listed 84999 NOC
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9/1/2022
|
|
*LAB.00045
Selected Tests for the Evaluation and Management of Infertility
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• The following tests or procedures are considered INV and NMN for diagnosing or managing infertility:
- Endometrial receptivity analysis;
- Sperm-capacitation test;
- Sperm deoxyribonucleic acid (DNA) fragmentation test;
- Sperm penetration assay; and
- Uterine natural killer (uNK) cells test
Listed existing CPT codes 89329, 89330, 0253U, 0255U 86357 considered INV and NMN for infertility; no specific code for sperm DNA fragmentation, 89398 NOC
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9/1/2022
|
|
*LAB.00046
Testing for Biochemical Markers for Alzheimer’s Disease
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• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered INV and NMN as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered INV and NMN
• Moved content related to biomarker testing for Alzheimer’s disease (AD) from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document
Listed codes 83520, 84999 NOC, 0206U, 0207U for biochemical marker testing for Alzheimer’s disease, previously addressed in GENE.00003 considered INV and NMN
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9/1/2022
|
|
*RAD.00067
Quantitative Ultrasound for Tissue Characterization
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• Quantitative ultrasound for tissue characterization is considered INV and NMN for all indications
Listed CPT Category III codes 0689T, 0690T effective 1/1/2022 for quantitative US for tissue characterization, considered INV and NMN
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9/1/2022
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*SURG.00160
Implanted Port Delivery Systems to Treat Ocular Disease
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• The use of a port delivery system to treat ocular disease is considered INV and NMN for all indications
Listed existing codes 67027, 67028 considered INV and NMN when described as implantation and refill of a port delivery system; no specific code for SUSVIMO product, C9399, J3490, J3590 NOC codes
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9/1/2022
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*TRANS.00038
Thymus Tissue Transplantation
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• Outlines the medical necessity (MN) and INV
No specific code for thymus tissue transplantation, listed 27599, L8699 NOC codes considered medically necessary when criteria met
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9/1/2022
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Below are the current clinical guidelines and/or medical policies we reviewed and updates were approved.
* Denotes prior authorization required
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Policy/Guideline
|
Information
|
Effective date
|
|
*SURG.00154
Microsurgical Procedures for the Prevention or Treatment of Lymphedema
Previously titled: Microsurgical Procedures for the Treatment of Lymphedema
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• Revised title
• Revised Position Statement to include the prevention of lymphedema
Added existing CPT codes 15756, 49906 considered INV and NMN when specified as tissue transfer for lymphedema; no specific codes for lymph node procedures
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9/1/2022
|
Below is the clinical guideline we reviewed and will be adopted for prior authorization.
* Denotes prior authorization required
|
Policy/Guideline
|
Information
|
Effective date
|
|
*CG-DME-46
Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
|
• All Claims containing a request for pneumatic compression devices
• All extremities are included already in our Pneumatic Compression Devices initiative
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9/1/2022
|
In the February 2021 issue of Provider News, we announced a new reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services which states that Anthem Blue Cross and Blue Shield (Anthem) does not allow reimbursement for office evaluation and management services when reported with revenue code 761.
Beginning with dates of service on or after September 1, 2022, Anthem will expand the current policy to include two additional revenue codes (760 and 769).
For specific policy details, visit the Reimbursement Policy page at anthem.com.
Effective September 1, 2022, AIM Specialty Health® (AIM), a separate company, will expand the AIM Musculoskeletal program to perform medical necessity review of the requested site of service for certain spine, joint and interventional pain procedures for Anthem Blue Cross and Blue Shield (Anthem) fully insured members, as outlined below.
AIM will continue to manage the AIM Musculoskeletal program and Level of Care review. The AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the Level of Care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on the Anthem Provider portal Clinical UM Guidelines page. Please note, this does not apply to procedures performed on an emergent basis.
A subset of the AIM Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization for the AIM Musculoskeletal Program applies for an Anthem member on or after September 1, 2022, contact the Anthem Provider Services phone number on the back of the member’s ID card. AIM will also have a file from Anthem of the membership for whom the program applies and will not provide prior authorization for members for whom the program does not apply. Note: If providers attempt to use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient musculoskeletal case, ICR will produce a message referring the provider to AIM. (ICR cannot accept prior authorization requests for services administered by AIM.)
Members included in the new program
All fully-insured members currently participating in the AIM Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal Program to add to their members’ benefit package as of September 1, 2022. The following members are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®).
Prior authorization review requirements
For services scheduled to begin on or after September 1, 2022, providers must contact AIM to obtain prior authorization. Ordering and servicing providers may begin contacting AIM on August 15, 2022.
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 833-305-1807, Monday through Friday, from 7:30 a.m. to 6:00 p.m. Central time
Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, number of visits and valid time frame. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Musculoskeletal training webinars
Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Effective October 1, 2022, AIM Specialty Health® (AIM), a separate company, will enhance the AIM Musculoskeletal program by adding a Monitored Anesthesia Care for Interventional Pain component to perform medical necessity review of monitored anesthesia, or conscious sedation, when performing certain interventional pain procedures for Anthem Blue Cross and Blue Shield (Anthem) fully insured members, as outlined below.
Prior authorization will now be required for the clinical appropriateness of monitored anesthesia services when the pain management clinician requests monitored anesthesia services in conjunction with interventional pain codes. It is the obligation of the requesting provider to have available the health plan’s determination for the anesthesiologist on the day of the procedure. AIM will use the following Anthem Clinical UM Guideline: CG-Med-78: Anesthesia Services for Interventional Pain Management Procedures. The clinical criteria to be used for these reviews can be found on the Anthem provider portal Clinical UM Guidelines page.
Clinical site of care may also be applicable if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center. AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services.
If you have a member in a current course of treatment for pain management where we approved without reviewing the monitored anesthesia care (MAC), please identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.
If the prior authorization was not obtained or did not result in authorization, the anesthesiologist may still determine that member requires monitored anesthesia on the day of service. A retrospective review may be requested or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC and a detailed description of the procedure performed in order for AIM to determine coverage for the service as medically necessary.
At this time, the codes to be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT codes requiring prior authorization for the AIM Monitored Anesthesia Care for Interventional Pain program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after October 1, 2022, Providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information. AIM will recognize out of scope membership and will not require prior authorization for such members. If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)
Members included in the new program
All fully insured members currently participating in the AIM Musculoskeletal program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal program to add to their members’ benefit package as of October 1, 2022.
Prior authorization requirements
For interventional pain procedures that are scheduled to begin on or after October 1, 2022, all providers must contact AIM to obtain prior authorization. The following groups are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®).
For services provided on or after October 1, 2022, ordering and servicing providers may begin contacting AIM on September 17, 2022 for review.
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 833-305-1807, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time
Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Musculoskeletal training webinars
Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.
We value your participation in our network and look forward to working with you to help improve the health of our members.
Effective June 1, 2022, the Blue Cross Blue Shield Service Benefit Plan, aka Federal Employee Program (FEP)®, will be changing the process for responses to third-party requests for correspondence for claim processing. Currently, Anthem Blue Cross and Blue Shield (Anthem) sends correspondence to the third-party biller who requested the information. Effective June 1, 2022, responses to correspondence requests received from third-party billers will be mailed to the servicing provider office to align with internal Anthem policy directives.
Questions can be directed to the FEP Customer Service team at 800-392-8043.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after September 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0214
|
Carvykti (ciltacabtagene autoleucel)
|
C9399
J3490
J3590
|
|
ING-CC-0200
|
Aduhelm (aducanumab-avwa)
|
J0172
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Updates by Guideline
- Imaging of the spine
- Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs
- Imaging of the extremities
- Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
- Vascular imaging
- Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
- Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
- Chronic stroke/TIA – New indication; modality approach by circulation presentation
- Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
- Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
- Upper or lower extremity peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortal℠ directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization
- Access AIM via the Availity Portal* at availity.com
- Call the AIM Contact Center toll-free number Monday through Friday from 8 a.m. to 8 p.m. Eastern time:
- Indiana: 833-342-1252
- Missouri: 833-775-1956
- Ohio: 833-419-2143
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:
- *CG-LAB-20 — Thyroid Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
- *CG-LAB-21 — Serum Iron Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
- *LAB.00043 — Immune Biomarker Tests for Cancer:
- Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
- *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
- Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
- *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
- The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
- Endometrial receptivity analysis
- Sperm-capacitation test
- Sperm deoxyribonucleic acid (DNA) fragmentation test
- Sperm penetration assay
- Uterine natural killer (uNK) cells test
- *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
- Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
- Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
- Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
- *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
- Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
- *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
- Revised Position Statement to include the prevention of lymphedema.
- *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
- The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
- *TRANS.00038 — Thymus Tissue Transplantation:
- Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.
Medical Policies
On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2022.
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
04/13/2022
|
*LAB.00043
|
Immune Biomarker Tests for Cancer
|
New
|
|
04/13/2022
|
*LAB.00044
|
Saliva-based Testing to Determine Drug-Metabolizer Status
|
New
|
|
04/13/2022
|
*LAB.00045
|
Selected Tests for the Evaluation and Management of Infertility
|
New
|
|
04/13/2022
|
*LAB.00046
|
Testing for Biochemical Markers for Alzheimer’s Disease
|
New
|
|
04/13/2022
|
*RAD.00067
|
Quantitative Ultrasound for Tissue Characterization
|
New
|
|
04/13/2022
|
*SURG.00160
|
Implanted Port Delivery Systems to Treat Ocular Disease
|
New
|
|
03/25/2022
|
*TRANS.00038
|
Thymus Tissue Transplantation
|
New
|
|
04/13/2022
|
GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
|
04/1/2022
|
SURG.00011
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Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
|
02/24/2022
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
Revised
|
|
04/13/2022
|
SURG.00096
|
Surgical and Ablative Treatments for Chronic Headaches
|
Revised
|
|
04/13/2022
|
*SURG.00154
|
Microsurgical Procedures for the Prevention or Treatment of Lymphedema
|
Revised
|
Clinical UM Guidelines
On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect June 4, 2022.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or Revised
|
|
04/13/2022
|
*CG-LAB-20
|
Thyroid Testing
|
New
|
|
04/13/2022
|
*CG-LAB-21
|
Serum Iron Testing
|
New
|
|
04/13/2022
|
CG-ANC-03
|
Acupuncture
|
Revised
|
|
04/13/2022
|
CG-GENE-14
|
Gene Mutation Testing for Cancer Susceptibility and Management
|
Revised
|
|
04/13/2022
|
CG-MED-73
|
Hyperbaric Oxygen Therapy (Systemic/Topical)
|
Revised
|
|
04/13/2022
|
CG-SURG-36
|
Adenoidectomy
|
Revised
|
|
02/24/2022
|
CG-SURG-86
|
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
|
Revised
|
On November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
|
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
06/09/2022
|
*ING-CC-0211
|
Kimmtrak (tebentafusp-tebn)
|
New
|
|
06/09/2022
|
*ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
New
|
|
06/09/2022
|
*ING-CC-0213
|
Voxzogo (vosoritide)
|
New
|
|
06/09/2022
|
*ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
New
|
|
06/09/2022
|
*ING-CC-0086
|
Spravato (esketamine) Nasal Spray
|
Revised
|
|
06/09/2022
|
ING-CC-0157
|
Padcev (enfortumab vedotin)
|
Revised
|
|
06/09/2022
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
|
06/09/2022
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0099
|
Abraxane (paclitaxel, protein bound)
|
Revised
|
|
06/09/2022
|
ING-CC-0120
|
Kyprolis (carfilzomib)
|
Revised
|
|
06/09/2022
|
ING-CC-0126
|
Blincyto (blinatumomab)
|
Revised
|
|
06/09/2022
|
ING-CC-0129
|
Bavencio (avelumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0090
|
Ixempra (ixabepilone)
|
Revised
|
|
06/09/2022
|
ING-CC-0110
|
Perjeta (pertuzumab)
|
Revised
|
|
06/09/2022
|
ING-CC-0115
|
Kadcyla (ado-trastuzumab)
|
Revised
|
|
06/09/2022
|
ING-CC-0108
|
Halaven (eribulin)
|
Revised
|
|
06/09/2022
|
*ING-CC-0033
|
Xolair (omalizumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Revised
|
|
06/09/2022
|
ING-CC-0038
|
Human Parathyroid Hormone Agents
|
Revised
|
|
06/09/2022
|
*ING-CC-0186
|
Margenza (margetuximab-cmkb)
|
Revised
|
|
06/09/2022
|
*ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0078
|
Orencia (abatacept)
|
Revised
|
|
06/09/2022
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
|
06/09/2022
|
ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
|
06/09/2022
|
*ING-CC-0029
|
Dupixent (dupilumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0208
|
Adbry (tralokinumab)
|
Revised
|
|
06/09/2022
|
*ING-CC-0209
|
Leqvio (inclisiran)
|
Revised
|
|
06/09/2022
|
*ING-CC-0166
|
Trastuzumab Agents
|
Revised
|
|
06/09/2022
|
*ING-CC-0107
|
Bevacizumab for Non-ophthalmologic Indications
|
Revised
|
Applicable to the following states:
California, Colorado, Connecticut, Georgia, Kentucky, Maine, Missouri, Nevada, New Hampshire, New Mexico, Ohio, Virginia, Washington, and Wisconsin.
For services beginning on September 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS.* Through this program, myNEXUS clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.
How to submit or check a prior authorization request
For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.
Providers are encouraged to request authorization using NexLync. Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.
If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 833-311-2986.
Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.
To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com or email Provider_Network@myNEXUScare.com.
If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622.
*Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.
This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).
Effective with dates of service on or after September 1, 2022, Anthem will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, Anthem will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Anthem will reimburse using CPT code 99211.
Professional providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.
If you have questions on this program, contact your Provider Experience manager.
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