As of November 1, 2020, AIM Specialty Health_® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem Blue Cross fully insured members and some ASO groups.   

 

Effective March 14, 2021, the AIM Small Joint Surgery Guideline has been updated with the following:

• Clarified requirements for imaging reports.
• Removed radiographic requirement for confirmation of lesser toe deformities.
• Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
• Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
• Clarified contraindications only apply to total ankle arthroplasty.

 

Providers should continue to submit prior authorization review requests to AIM using one of the following ways:

• Access AIM ProviderPortal_SM 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 toll-free number at 800-554-0580, Monday through Friday, 8:30 a.m. to 7 p.m. ET.

 

For questions, please contact the provider number on the back of the member ID card.

 

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Beginning with dates of service on or after February 1, 2021 Anthem has implemented revised claims editing logic tied to Excludes 1 notes from ICD-10-CM 2020 coding guidelines.  To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes 1 notes that may prohibit billing a specific code combination.

 

For assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm

 

One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 note. These notes appear below the affected codes – if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category.  If the Excludes 1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code 

 

In ICD-10-CM, when a category includes an Excludes 1 note, it outlines what codes should NOT be billed together.  Examples of this code scenario would include but are not limited to the following:

• Reporting Z01.419 with Z12.4
  • 41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix)
• Reporting Z79.891with F11.2X
  • 891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
• Reporting M54.2 with M50.XX
  • 2 (Cervicalgia) has an Excludes 1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
• Reporting M54.5 with S39.012X and/or M54.4x
  • 5 (low back pain) has an Excludes 1 note below it which includes; S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9
  • - (Acute tonsillitis) has an Excludes 1 note below it which includes; J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (Peritonsillar abscess)
• Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, 00
  • N89 (Other inflammatory disorders of the vagina) has an Excludes 1 note below the category for R87.62X(abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623(HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis), A59.00 (trichomonal leukorrhea)

 

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM code book to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.

 

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Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Anthem Commercial plan members:  

• Neulasta® & Neulasta Onpro® (pegfilgrastim)
• Fulphila® (pegfilgrastim-jmdb)
• Udenyca® (pegfilgrastim-cbqv)
• Ziextenzo® (pegfilgrastim-bmez)
• Nyvepria™ (pegfilgrastim-apgf)

 

The review will be administered by AIM Specialty Health^® (AIM).

 

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Clinical Criteria page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

 

The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

 

Submit a request for review

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

• Access AIM ProviderPortal_SM 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: 800-554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. Eastern time.

 

Please note, this review does not apply to the following plans: BlueCard_®, Federal Employee Program_® (FEP_®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Clinical Criteria page.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the member’s ID card.

 

Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”

 

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Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, 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.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0185	J3490 C9399	Oxlumo
**ING-CC-0184	J3490 J3590 J9999	Danyelza

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Prior authorization update – change in effective date

 

Please note the change in effective date of prior authorization for injectable iron deficiency anemia products listed below.

 

The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.

 

Please note, 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.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0182	J1756	Venofer
*ING-CC-0182	J2916	Ferrlecit
*ING-CC-0182	J1750	Infed
*ING-CC-0182	J1439	Injectafer
*ING-CC-0182	Q0138	Feraheme
*ING-CC-0182	J1437	Monoferric

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Step therapy update – change in effective date

 

Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.

 

To access the Clinical Criteria information with step therapy drug lists, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
*ING-CC-0182	Preferred	Venofer	J1756
*ING-CC-0182	Preferred	Ferrlecit	J2916
*ING-CC-0182	Preferred	Infed	J1750
*ING-CC-0182	Non-preferred	Injectafer	J1439
*ING-CC-0182	Non-preferred	Feraheme	Q0138
*ING-CC-0182	Non-preferred	Monoferric	J1437

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Prior authorization update – change in code list

 

In a recent notification, we shared that effective April 1, 2021 the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
*ING-CC-0095	J9041	Velcade (Bortezomib)
**ING-CC-0095	J9041	Velcade (Bortezomib)
*ING-CC-0095	J9044	Bortezomib
**ING-CC-0095	J9044	Bortezomib
*ING-CC-0093	J9171	Docetaxel
**ING-CC-0093	J9171	Docetaxel

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

**Oncology use is managed by AIM.

 

Prior authorization update – medical specialty pharmacy update

 

In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.

 

Drug	Code	Code description
*Avastin	C9257 J9035	intravitreal bevacizumab
*Mvasi	Q5107	bevacizumab-awwb
*Zirabev	Q5118	bevacizumab-bvzr

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

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Starting May 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new prior authorization for HIV medications to help ensure patients are not receiving therapeutic duplications when taking certain combinations. Providers and members expected to be impacted by this policy will receive advanced notice by mail.

 

In order for members to continue to receive coverage for the drug combination, providers must submit a separate prior authorization form for each drug and provide the medical necessity rationale for why the drug combination is clinically needed.

 

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

 

The duplicate therapy policy may trigger as a result of one of the following drug combinations:

 

Duplicate Name	Duplicate Description	Example
Integrase stand transfer inhibitors (INSTI)	Two drug products each containing a drug with an INSTI mechanism of action.	Isentress (raltegravir) and Dovato (dolutegravir/ lamivudine).
Non-nucleoside reverse transcriptase inhibitors (NNRTI)	Two drug products each containing a drug with an NNRTI mechanism of action.	Edurant (rilpivirine) and Symfi (efavirenz/lamivudine/TDF).
Protease inhibitors (PI)	Two drug products each containing a drug with a PI mechanism of action.	Prezcobix (darunavir/cobicistat) and Reyataz (atazanavir).
Nucleoside reverse transcriptase inhibitors (NRTI)	Two drug products that together result in four NRTI active ingredients.	Truvada (emtricitabine/TDF) and Biktarvy (bictegravir/ emtricitabine/TAF).
Boosters	Two drug products that result in a combination of the protease inhibitor boosters, ritonavir and cobicistat.	Prezcobix (darunavir/cobicistat) and Kaletra (lopinavir/ritonavir).

 

As a reminder, prior authorizations may be submitted via phone, fax, or online (through CoverMyMeds.com).

If you have any questions regarding this policy, please contact Provider Services.

 

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