Material Adverse Change (MAC)

 

Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem) are pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to our clinical utilization management (UM) guidelines that are adopted for Nevada. The clinical UM guidelines published on our website represent the clinical UM guidelines currently available to all Plans for adoption throughout our organization. Because local practice patterns, claims systems and benefit designs vary, a local Plan may choose whether or not to implement a particular clinical UM guideline. The link below can be used to confirm whether or not the local Plan has adopted the clinical UM guideline(s) in question. Adoption lists are created and maintained solely by each local Plan. 

 

The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

 

New medical policies and effective for service dates on and after September 1, 2021:

  • 00056 Gene expression profiling for bladder cancer: This document addresses gene expression profiling to diagnose bladder cancer, predict response to therapy in individuals with bladder cancer, and monitor individuals with a history of bladder cancer.
  • Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary.
  • 00038 Cell-free DNA testing to aid in the monitoring of kidney transplants for rejection: This document addresses the use of cell-free DNA (cfDNA) as a method of detecting kidney transplant recipients at risk for transplant rejection.
  • Cell-free DNA testing is considered investigational and not medically necessary as a non-invasive method of determining the risk of rejection in kidney transplant recipients.
  • 00039 Pooled antibiotic sensitivity testing: This document addresses pooled antibiotic sensitivity testing (P-AST) of urine in combination with a multiplex polymerase chain reaction (M-PCR) assay for the identification of susceptible urine pathogens and antibiotic resistance genes.
  • Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications.
  • 00159 Focal laser ablation for the treatment of prostate cancer: This document addresses the use of focal laser ablation, also known as laser interstitial therapy or laser interstitial photocoagulation, to treat localized prostate cancer.
  • Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer.
  • 00037 Uterine transplantation: This document addresses uterine transplantation, which has been proposed as a treatment of uterine factor infertility.
  • Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus.
  • Prior authorization will be required effective September 1, 2021


Revised medical policies and adopted clinical UM guidelines effective September 1, 2021:

  • 00008 Cosmetic and reconstructive services of the head and neck: This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of procedures addressing the treatment of abnormalities of the head and neck.
  • Removed the word “physical” from the term “physical functional impairment” in facial plastic surgery, otoplasty, rhinophyma, rhinoplasty or rhinoseptoplasty and cranial nerve procedures position statements.
  • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary.


CG-OR-PR-04 Cranial remodeling bands and helmets (cranial orthotics):
This document addresses the use of the adjustable band or helmet cranial orthoses as a treatment of craniosynostosis, non-synostotic plagiocephaly (asymmetrically shaped posterior head), scaphocephaly (abnormally shaped narrow head), and brachycephaly (abnormally shaped head; shortened in antero-posterior dimension without asymmetry) in infants.

  • Removed condition requirement from reconstructive criteria
  • Replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
  • Updated formatting in the clinical indications section

CG-SURG-78 Locoregional and surgical techniques for treating primary and metastatic liver malignancies:
This document addresses surgical excision and locoregional therapies to treat primary or metastatic cancer of the liver.
  • Added transcatheter arterial chemoembolization (TACE) using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications.

CG-SURG-82 Bone-anchored and bone conduction hearing aids: This document addresses the use of implantable bone-anchored hearing aids, transcutaneously worn, non-surgical application of a bone-anchored hearing aid using a headband or softband, partially-implantable magnetic bone conduction hearing aids, and an intraoral bone conduction hearing aid.
  • Removed reorganized clinical indications section
  • Reorganized and clarified bilateral hearing loss medically necessary criteria
  • Clarified medically necessary criteria for transcutaneously-worn bone conduction hearing aids for both bilateral and unilateral hearing loss
  • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
  • Moved device-specific threshold information to the discussion section
  • Clarified medically necessary criteria for transcutaneously worn and fully- or partially-implantable bone conduction hearing aids for unilateral hearing loss
  • Added not medically necessary statement for when medically necessary criteria have not been met
  • Clarified not medically necessary statement regarding replacement parts or upgrades
  • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications

 

Medical policy converted to clinical guideline effective April 7, 2021

MP number

Title

CG number

GENE.00011

Gene expression profiling for managing breast cancer treatment

CG-GENE-22

GENE.00007

Cardiac ion channel genetic testing

CG-GENE-23

GENE.00017

Genetic testing for diagnosis and management of hereditary cardiomyopathies (including arrhythmogenic right ventricular dysplasia/ cardiomyopathy)

CG-GENE-23

 

Clinical guidelines to be archived and added to other existing clinical guidelines effective April 1, 2021 (except where noted)

CG number

Title

Moved into CG number

CG-GENE-02

Analysis of RAS status

CG-GENE-14

CG-GENE-03

BRAF mutation analysis

CG-GENE-14

CG-GENE-12

PIK3CA mutation testing for malignant conditions

CG-GENE-14

CG-GENE-20

Epidermal growth factor receptor (EGFR) testing

CG-GENE-14

      

Medical policies to be archived

  • 00077 In-vivo analysis of gastrointestinal lesions – effective April 7, 2021
  • 00022 Lung volume reduction surgery – effective June 25, 2021

 

Anthem medical policies and clinical UM guidelines are developed by our national medical policy and technology assessment committee. The committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

 

All coverage written or administered by Anthem excludes from coverage, services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s medical policies.  Review procedures have been refined to facilitate claim investigation.

 

Anthem’s medical policies and clinical UM guidelines are available online

The complete list of our medical policies and clinical UM guidelines may be accessed on our anthem.com/provider website. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select Nevada as Your State.  Select View Medical Policies & Clinical UM Guidelines. Either enter key word or code, or select the link for full list page to search the policy for your inquiry. 

 

To view the list of specific clinical UM guidelines adopted by Nevada, navigate to the View Medical Policies & Clinical UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.

 

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. 

 

1150-621-PN-NV



Featured In:
June 2021 Anthem Provider News - Nevada