 Provider News MissouriMay 1, 2025 May 2025 Provider Newsletter Featured Articles Administrative | Commercial | May 1, 2025
MOBCBS-CRCM-081400-25-CPN81360 BackgroundWe previously shared details about an enhancement to the medical claims editing system for pharmaceutical drug procedure codes. This improvement ensures that claims align with FDA‑approved or off‑label indications, based on the list of pharmaceutical compendia defined by CMS. This change aims to promote accuracy in claims and improve reimbursement efficiency. Provider impactBeginning with claims processing on or after June 1, 2025, we will introduce additional drug procedure codes into our system. Codes requiring preapproval or those tied to specific medical policies will not be affected by this update. Note: A drug procedure code will not be approved if the diagnosis reported is not an approved indication. If you would like your claim decision reviewed, follow the claims dispute process outlined in the provider manual. You must include relevant medical record details regarding the drug provided for faster resolution. If you have questions about this notification, contact your contract manager or provider relationship management representative. Thank you for your cooperation and commitment to improving member care. 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. MULTI-BCBS-CR-078848-25-CPN77148 Take your success as a care provider to the next level by managing claims online with Availity Essentials
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- Comprehensive support for all your healthcare claims — medical, institutional, and dental
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To access the registration page, go to https://Availity.com and select New to Availity? Get Started at the top of the home screen. If you have more than one TIN, ensure you have registered all TINs associated with your account.
Assistance
For assistance, contact Availity Client Services online via Help & Training > Availity Support > Contact Support > Create a case, use Chat with Support, or call Monday through Friday from 8 a.m. to 8 p.m. Eastern time at 800‑AVAILITY (282‑4548).
We're dedicated to lightening your administrative load and securing timely payments because we value you, our care provider partners. 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. MULTI-BCBS-CM-082273-25-CPN82130 Annual wellness and well-woman visits are covered with no member cost-sharing when provided by in-network providers for our members with Affordable Care Act (ACA)compliant plans. Individual and small group plan members are encouraged to schedule these visits within the first 90 days of their plan starting or renewing, so your practice may see an increase in requests, especially at the beginning of the second and fourth quarters. Providers can perform the annual wellness or well‑woman visit, even if it has been less than one calendar year since the last wellness visit. We ask that your practice be flexible in accommodating members wanting to schedule their visits earlier than they may have previously. The wellness or well‑woman visit claim will be processed as a preventive care service covered with no member cost share. Please note that this benefit may not apply to all health plans. You should continue to verify eligibility and benefits for all members in Availity Essentials (https://Availity.com) before providing services or receiving member copayments, deductibles, or coinsurance. 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. MULTI-BCBS-CM-079025-24-CPN73418 Manage your prior authorization requests with our digital tools — Availity Essentials and https://anthem.com/provider. These resources simplify requirement determination and request submissions, giving you more time to deliver effective and efficient care to our members. We encourage you to review the instructions below. Determining prior authorization requirementsAvaility Essentials: - Log in to https://Availity.com.
- If you do not already have access, select Get Started to create an account.
- Go to the Payer Spaces tab.
- Select the applicable plan.
- Select Authorization Rules Lookup.
- Enter the required provider information.
- Select Next and enter the required member information.
Note: Final determination of prior authorization requirements is completed upon submission and may differ from search results. Provider website: - Go to https://anthem.com/provider.
- Scroll down and select the applicable state.
- Scroll down to Commercial‑partnered programs and select Access the Commercial Provider site to access the Provider website homepage.
- Under the Resources heading, select Prior Authorization.
- Select the applicable state.
- Select the appropriate link based on the member’s plan.
If the member’s home plan is not with Anthem, scroll to Helpful Links > Select Medical Policy and Prior Authorization for Blue Plans, then follow the prompts to determine the applicable home plan and prior authorization requirements. Submitting prior authorization requestsAvaility Essentials: - Log in to https://Availity.com.
- Select the Patient Registration tab to access Authorizations and Referrals.
- Select Authorization Request.
Note: Transplant prior authorization requests must be submitted by phone, fax, or secure email. 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. MULTI-BCBS-CM-081857-25-CPN81558 Anthem is happy to support the announcement of an exciting partnership between Premera Blue Cross, Amazon, and the American College of Lifestyle Medicine (ACLM) offering a free online Lifestyle Medicine & Food as Medicine Essentials Course for the entire provider community. In this comprehensive online course, you will explore the six pillars of lifestyle medicine, emphasizing how food and nutrition can play a critical role in preventing and treating chronic diseases. The course is tailor‑made for healthcare providers looking to enrich their care approach with practical evidence‑based strategies. This course is available until September 14, 2025. Benefits for providers:- Free access: Participate in this valuable training at no cost.
- Earn credits: Completing the course awards, you earn 5.5 CME/CE credits.
- Enhance your practice: Acquire tools to transform care and effectively address chronic disease.
How to enroll:- Visit https://lifestylemedicine.org/essentials.
- Log in or create an ACLM account.
- Enter promo code ESS‑AMZNEDU at checkout to access the course for free.
Contact us
Please reach out to Dr. Jon Liu at jonliu@amazon.com with questions regarding the free course. 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. MULTI-BCBS-CM-081296-25-CPN80998 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 https://anthem.com > Providers > select your state > Provider Resources > Policies, Guidelines & Manuals. To help determine if preapproval is needed, go to https://anthem.com > Providers > select your state > Claims > Prior Authorization. You can also call the preapproval 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 | *CG‑MED‑98 Parenteral Antibiotics for the Treatment of Lyme Disease | - Moved content from MED.00013 to new clinical UM guideline with the same title
- NV&NMN changed to NMN as a result of MP to CUMG transition
- Moved CPT® codes 96365, 96366, 96367, 96368, 96372 and HCPCS codes for antibiotics from MED.00013
| August 1, 2025 | *CG‑SURG‑123 Autologous Fat Grafting and Injectable Soft Tissue Fillers | - Moved content related to autologous fat grafting and injectable soft tissue filters from MED.00132 to new clinical UM guideline
- Moved codes 15771, 15772, 15773, 15774, 11950, 11951, 11952, 11954, 31574, C1878, G0429, L8607, Q2026, Q2028, and NOC 17999, L8699 from MED.00132
| August 1, 2025 | *CG‑SURG‑125 Canaloplasty | - Moved content for canaloplasty from SURG.00095 to new clinical UM guideline
- NV&NMN changed to NMN as a result of MP to CUMG transition
- Revised MN statement to remove mild to moderate stage
| August 1, 2025 | *DME.00053 Home Video‑Assisted Robotic Rehabilitation Systems | - Home video‑assisted robotic rehabilitation systems are considered INV&NMN for all indications
- Existing HCPCS code E0739 (code effective 4/1/2024) for Motus hand/Motus foot considered INV&NMN
| August 1, 2025 | *MED.00151 Gene Therapy for Aromatic L‑Amino Acid Decarboxylase Deficiency | - Gene therapy for aromatic l‑amino acid decarboxylase deficiency using eladocagene exuparvovec‑tneq is considered INV&NMN for all indications
- Existing ICD‑10‑PCS code XW0Q316 for KEBILIDI considered INV&NMN; NOC CPT and HCPCS codes 64999, C9399, J3490, J3590 when specified as KEBILIDI considered INV&MN
| August 1, 2025 | *MED.00152 Outpatient Intravenous Insulin Therapy | - Outpatient intravenous insulin therapy is considered INV&NMN as a treatment for all indications, including diabetes
- Existing HCPCS code G9147 is considered INV&NMN
| August 1, 2025 | *SURG.00165 Histotripsy | - Histotripsy is considered INV&NMN for all indications
- Existing CPT category III codes 0686T (moved from CG‑SURG‑78), 0888T, NOC code 55899 specified as histotripsy, and associated ICD‑10‑PCS codes are considered INV&NMN
| August 1, 2025 |
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‑ANC‑03 Acupuncture | - Revised descriptors for 97811, 97814 effective 1/1/2025
| January 1, 2025 | CG‑MED‑64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins | - Revised descriptor for 93656 effective 1/1/2025
| January 1, 2025 | CG‑MED‑91 Remote Therapeutic and Physiologic Monitoring Services | - Revised descriptors for 98975, 98976, 98977, 98978 effective 1/1/2025
| January 1, 2025 | *CG‑SURG‑61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver | - Added new CPT codes 60660, 60661 effective 1/1/2025 for radiofrequency ablation thyroid considered NMN (was included in NOC 60699)
| January 1, 2025 | CG‑SURG‑120 Vagus Nerve Stimulation | - Added new CPT Category III codes 0908T, 0909T, 0910T, 0911T, 0912T effective 1/1/2025 for a stimulator (not yet FDA approved) for rheumatoid arthritis considered NMN
| January 1, 2025 | LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | - Added new CPT PLA code 0525U effective 1/1/2025 for 3D Predict Ovarian test considered NMN; removed 0564T deleted as of 1/1/2025
| January 1, 2025 | LAB.00015 Detection of Circulating Tumor Cells | - Clarified CPT codes 86152, 86153 considered INV&NMN only for blood specimen; other specimens (eg, CSF) not addressed
| February 1, 2025 | LAB.00026 Pathology Systems and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | - Added MN criteria for ArteraAI Prostate cancer risk stratification test
- Revised INV&NMN statement to remove prostate cancer
- CPT PLA code 0376U will be considered MN when criteria are met (was INV&NMN)
| February 1, 2025 | *LAB.00028 Blood‑based Biomarker Tests for Multiple Sclerosis | - Added new CPT code 83884 effective 1/1/2025 for neurofilament light chain considered INV&NMN
| January 1, 2025 | *LAB.00035 Multi‑biomarker Disease Activity Blood Tests for Rheumatoid Arthritis | - Added new CPT PLA code 0521U effective 1/1/2025 for rheumatoid arthritis panel considered INV&NMN
| January 1, 2025 | *LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia | - Added new CPT PLA code 0524U effective 1/1/2025 for sFlt‑1/PlGF test considered INV&NMN
| January 1, 2025 | LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy | - Added CPT NOC code 81599 replacing PLA code 0456U for PrismRA deleted as of 1/1/2025
| January 1, 2025 | *LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | - Revised formatting and content of MN statement
- Added new CPT codes 82233, 82234, 84393, 84394 for Abeta and pTau considered MN when criteria are met and new CPT code 83884 for neurofilament light chain considered INV&NMN all effective 1/1/2025, removed PLA code 0346U deleted as of 1/1/2025
| January 1, 2025 | *MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications | - Revised INV&NMN to include examples bilateral staged focused ultrasound thalamotomy or pallidotomy, BPH and uterine fibroids
- Added new CPT code 61715 effective 1/1/2025 for intracranial MRgFUS considered MN when criteria are met replacing 0398T deleted as of 1/1/2025
| January 1, 2025 | MED.00132 Autologous Adipose‑derived Regenerative Cell Therapy. Previously titled: Adipose‑derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures | - Revised title, Revised Position Statement
- Revised scope of document to address autologous adipose‑derived regenerative cell therapy
- Moved content related to autologous fat grafting and injectable soft tissue fillers to new document CG‑SURG‑123
- Removed codes 15771‑15774, 11950‑11952, 11954; 31574; C1878; G0429; L8607; Q2026; Q2028 17999; L8699 now addressed in CG‑SURG‑123
| February 1, 2025 | *MED.00135 Gene Therapy for Hemophilia | - Added new HCPCS code J1414 effective 1/1/2025 for Beqvez considered MN when criteria are met replacing C9172 deleted as of 1/1/2025
| January 1, 2025 | MED.00137 Eye Movement Analysis Using Non‑spatial Calibration for the Diagnosis of Concussion | - Revised descriptor for 0615T effective 1/1/2025
| January 1, 2025 | MED.00140 Gene Therapy for Beta Thalassemia | - Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590
| January 1, 2025 | MED.00146 Gene Therapy for Sickle Cell Disease | - Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590
| January 1, 2025 | *SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | - Added new 1/1/2025 CPT and HCPCS codes 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, C8002 for skin cell suspension considered MN when criteria are met, and new HCPCS codes Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353 for products considered INV&NMN
| January 1, 2025 | *SURG.00135 Renal Sympathetic Nerve Ablation | - Added new HCPCS codes C1735, C1736 effective 1/1/2025 for renal denervation catheters considered INV&NMN
| January 1, 2025 | *SURG.00155 Cryoneurolysis | - Added new HCPCS codes C9808, C9809 effective 1/1/2025 for cryoICE and Iovera devices considered INV&NMN
| January 1, 2025 | SURG.00156 Implanted Artificial Iris Devices | - Added new CPT code 66683 effective 1/1/2025 for iris prosthesis implantation considered INV&NMN, replacing category III codes 0616T‑0618T deleted as of 1/1/2025
| January 1, 2025 | SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | - Added new HCPCS code C9807 effective 1/1/2025 for the Sprint device considered INV&NMN
| January 1, 2025 | *SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis | - Added new HCPCS code C8003 effective 1/1/2025 for implantation MISHA knee system considered INV&NMN
| January 1, 2025 | TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors | - Added ICD‑10‑CM diagnosis code C49.3 as MN when criteria are met
| January 1, 2025 |
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. MULTI-BCBS-CM-080572-25 The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policies & Clinical UM Guidelines website. Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 25, 2025. Publish date | Medical Policy number | Medical Policy title | Status | 1/30/2025 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | 1/30/2025 | DME.00053 | Home Video-Assisted Robotic Rehabilitation Systems | New | 1/30/2025 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | Revised | 1/30/2025 | LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | Revised | 1/30/2025 | MED.00151 | Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency | New | 1/30/2025 | MED.00152 | Outpatient Intravenous Insulin Therapy | New | 1/30/2025 | SURG.00165 | Histotripsy | New | 1/30/2025 | TRANS.00029 | Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | Revised | 1/30/2025 | TRANS.00033 | Heart Transplantation | Revised |
Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect May 25, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | Status | 1/30/2025 | CG-DME-06 | Compression Devices for Lymphedema | Revised | 1/30/2025 | CG-MED-98 | Parenteral Antibiotics for the Treatment of Lyme Disease | Conversion New | 1/30/2025 | CG-OR-PR-04 | Cranial Remodeling Bands and Helmets (Cranial Orthoses)
Previously Titled: Cranial Remodeling Bands and Helmets (Cranial Orthotics) | Revised | 1/30/2025 | CG-RAD-26 | Maternity Ultrasound in the Outpatient Setting
Previous category and number: CG-MED-42 | Conversion New | 1/30/2025 | CG-SURG-123 | Autologous Fat Grafting and Injectable Soft Tissue Fillers | Conversion New | 1/30/2025 | CG-SURG-124 | Viscocanalostomy | Conversion New | 1/30/2025 | CG-SURG-125 | Canaloplasty | Conversion New | 1/30/2025 | CG-THER-RAD-07 | Intravascular Coronary and Non-Coronary Brachytherapy
Previously Titled: Intravascular Brachytherapy (Coronary and Non-Coronary) | Revised |
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. MULTI-BCBS-CR-082359-25-CPN81285 Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services. Genetic testingChromosomal microarray analysis: - Added neonatal death to the list of indications considered medically necessary.
- Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.
Whole Exome Sequencing (WES) and Whole Genome Sequencing: - Clarified and restructured the criteria for improved readability.
- Added Medically Necessary criteria for Prenatal and PostNatal testing
- Added Not Medically Necessary statement for early neonatal death
- Added note that WES may include comparator testing.
Pharmacogenomic testing: - Deleted typo (“one” before “genotyping”) in first sentence
- Added “considered medically necessary for genotyping” to title of Table 1
- Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
- Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
- Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
- Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics
Predictive and prognostic polygenic testing: - Updated Description/Scope and Rationale and added References
Musculoskeletal Interventional pain management: - Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
- Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
- Exclusions:
- Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
- Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.
- Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
- Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:
- Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
- Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.
- Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:
- Specified nonsurgical low back pain as an exclusion.
As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management using the following: - Access the Carelon Medical Benefits Management provider portal directly at www.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.
For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. 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. MULTI-BCBS-CRCM-078958-25-CPN78066 Effective June 1, 2025, the following Medicare Part B medication from the current Clinical Criteria Guidelines will be included in our medical step therapy preapproval review process. Step therapy review will apply upon preapproval initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving the medication listed below. Visit our Clinical Criteria page to search for specific criteria. Clinical Criteria | Drug | Status | CC‑0166 | Hercessi (trastuzumab‑strf) | Non‑preferred |
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. MULTI-BCBS-CR-077570-25-CPN77133 Effective for dates of service on and after August 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our preapproval review process. Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over preapproval rules and must be considered first when determining coverage. Claims that do not comply with these new requirements may not be approved. HCPCS code | Medicare Part B drug | Q5136 | Jubbonti; Wyost (denosumab‑bbdz) |
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. MULTI-BCBS-CR-077559-25-CPN77132 |