Medicaid

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 anthem.com/search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • *CG-LAB-17 - molecular gastrointestinal pathogen panel (GIPP) testing for infectious diarrhea in the outpatient setting
    • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
  • *GENE.00056 - gene expression profiling for bladder cancer
    • Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary
  • *LAB.00038 - cell-free DNA testing to aid in the monitoring of kidney Transplants for 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
  • *LAB.00039 - pooled antibiotic sensitivity testing
    • Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications
  • *SURG.00159 - focal laser ablation for the treatment of prostate cancer
    • Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer
  • *TRANS.00037 - uterine transplantation
    • 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
  • *ANC.00008 - cosmetic and reconstructive services of the head and neck
    • 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)
    • Removed condition requirement from reconstructive criteria and 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
  • *CG-SURG-78 - locoregional and surgical techniques for treating primary and metastatic liver malignancies
    • Added 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
    • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
    • Added not medically necessary statement for when medical necessity criteria have not been met and 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
  • CG-GENE-22 - gene expression profiling for managing breast cancer treatment
    • A new clinical guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
  • CG-GENE-23 - genetic testing for heritable cardiac conditions
    • A new clinical guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
  • CG-SURG-110 - lung volume reduction surgery
    • A new clinical guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

 

AIM Specialty Health®* clinical appropriateness guideline updates.

To view AIM guidelines, visit the AIM Specialty Health page.

  • The Small Joint Surgery Guideline has been revised and will be effective on March 14, 2021.
  • The following Guidelines have been revised and will be effective on July 1, 2021:
  • * Joint Surgery
  • * Spine Surgery

 

Medical policies

On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions

(Anthem). These guidelines take effect on July 1, 2021.

Publish date

Medical policy number

Medical policy title

New or revised

4/1/2021

*GENE.00056

Gene Expression Profiling for Bladder Cancer

New

4/7/2021

*LAB.00038

Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection

New

4/7/2021

*LAB.00039

Pooled Antibiotic Sensitivity Testing

New

4/7/2021

*SURG.00159

Focal Laser Ablation for the Treatment of Prostate Cancer

New

4/7/2021

*TRANS.00037

Uterine Transplantation

New

4/7/2021

*ANC.00008

Cosmetic and Reconstructive Services of the Head and Neck

Revised

4/7/2021

MED.00087

Optical Detection for Screening and Identification of Cervical Cancer

Revised

2/18/2021

SURG.00121

Transcatheter Heart Valve Procedures

Revised

2/18/2021

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

Revised

 

Clinical UM guidelines

On February 11, 2021, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect on July 1, 2021.

Publish date

Clinical UM guideline number

Clinical UM guideline title

New or revised

4/7/2021

*CG-LAB-17

Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting

New

2/18/2021

CG-GENE-21

Cell-Free Fetal DNA-Based Prenatal Testing

Revised

4/7/2021

CG-MED-26

Neonatal Levels of Care

Revised

2/18/2021

CG-MED-87

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

4/7/2021

*CG-OR-PR-04

Cranial Remodeling Bands and Helmets (Cranial Orthotics)

Revised

2/18/2021

CG-SURG-55

Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation

Revised

4/7/2021

CG-SURG-71

Reduction Mammaplasty

Revised

4/7/2021

*CG-SURG-78

Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies

Revised

4/7/2021

*CG-SURG-82

Bone-Anchored and Bone Conduction Hearing Aids

Revised

4/7/2021

CG-SURG-97

Cardioverter Defibrillators

Revised

 

 

ANV-NU-0231-21



Featured In:
July 2021 Anthem Provider News - Nevada