MedicaidOctober 31, 2019
March 2019 Medical Policies and Clinical Utilization Management Guidelines update
Category: Medicaid
The Medical Policies and Clinical Utilization Management (UM) Guidelines 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www11.anthem.com/search.html.
Notes/updates:
- CG-DME-44 -- Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
- CG-MED-72 -- Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.
- CG-SURG-09 -- Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
- CG-SURG-30 -- Tonsillectomy for Children with or without Adenoidectomy was revised to:
- Spell out number of episodes of throat infections in MN criteria (A1, A2, A3).
- Clarify criterion addressing parapharyngeal abscess (B4) to say two or more.
- Add “asthma” as potential condition improved by tonsillectomy in MN criteria (C1b).
- The following AIM Specialty Health® updates took effect on March 31, 2019:
- Advanced Imaging
- Imaging of the Brain
- Imaging of the Extremities
- Imaging of the Spine
Medical Policies
On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).
|
Publish date |
Medical Policy number |
Medical Policy title |
New or revised |
|
4/24/2019 |
MED.00127 |
Chelation Therapy |
New |
|
4/24/2019 |
GENE.00050 |
Gene Expression Profiling for Coronary Artery Disease |
New |
|
4/24/2019 |
MED.00128 |
Insulin Potentiation Therapy |
New |
|
4/24/2019 |
SURG.00152 |
Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing |
New |
|
3/28/2019 |
DRUG.00088 |
Atezolizumab (Tecentriq®) |
Revised |
|
3/28/2019 |
DRUG.00053 |
Carfilzomib (Kyprolis®) |
Revised |
|
4/24/2019 |
GENE.00045 |
Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers |
Revised |
|
4/24/2019 |
GENE.00010 |
Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status |
Revised |
|
4/24/2019 |
SURG.00139 |
Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography |
Revised |
|
4/24/2019 |
GENE.00012 |
Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent |
Revised |
|
4/24/2019 |
SURG.00121 |
Transcatheter Heart Valve Procedures |
Revised |
Clinical UM Guidelines
On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations Committee for members on May 7, 2019.
|
Publish date |
Clinical UM Guideline number |
Clinical UM Guideline title |
New or revised |
|
3/28/2019 |
CG-ANC-07 |
Inpatient Interfacility Transfers |
Revised |
|
3/28/2019 |
CG-DRUG-50 |
Paclitaxel, protein-bound (Abraxane®) |
Revised |
|
3/28/2019 |
CG-DRUG-96 |
Ado-trastuzumab emtansine (Kadcyla®) |
Revised |
|
3/28/2019 |
CG-GENE-04 |
Molecular Marker Evaluation of Thyroid Nodules |
Revised |
|
4/24/2019 |
CG-DME-44 |
Electric Tumor Treatment Field (TTF) |
Revised |
|
4/24/2019 |
CG-DRUG-68 |
Bevacizumab (Avastin®) for Non-Ophthalmologic Indications |
Revised |
|
4/24/2019 |
CG-GENE-01 |
Janus Kinase 2, CALR, and MPL Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays |
Revised |
|
4/24/2019 |
CG-GENE-05 |
Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy) |
Revised |
|
4/24/2019 |
CG-MED-82 |
Intravenous versus Oral Drug Administration in the Outpatient and Home Setting |
New |
|
4/24/2019 |
CG-MED-83 |
Level of Care: Specialty Pharmaceuticals |
New |
|
4/24/2019 |
CG-SURG-30 |
Tonsillectomy for Children with or without Adenoidectomy |
Revised |
|
5/9/2019 |
CG-DRUG-113 |
Inotuzumab ozogamicin (Besponsa®) |
New |
|
5/9/2019 |
CG-GENE-06 |
Preimplantation Genetic Diagnosis Testing |
New |
|
5/9/2019 |
CG-GENE-07 |
BCR-ABL Mutation Analysis |
New |
|
5/9/2019 |
CG-GENE-08 |
Genetic Testing for PTEN Hamartoma Tumor Syndrome |
New |
|
5/9/2019 |
CG-GENE-09 |
Genetic Testing for CHARGE Syndrome |
New |
|
5/9/2019 |
CG-MED-81 |
High Intensity Focused Ultrasound (HIFU) for Oncologic Indications |
New |
|
5/9/2019 |
CG-SURG-98 |
Prostate Multiparametric Magnetic Resonance Imaging |
New |
|
5/9/2019 |
CG-SURG-99 |
Panniculectomy and Abdominoplasty |
New |
|
6/24/2019 |
CG-SURG-97 |
Cardioverter Defibrillators |
New |
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