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 https://www.anthem.com/provider/policies/clinical-guidelines/search.

 

Notes/updates:

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

  • *CG-LAB-20 — Thyroid Testing:
    • Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing
  • *CG-LAB-21 — Serum Iron Testing:
    • Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing
  • *LAB.00043 — Immune Biomarker Tests for Cancer:
    • Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications
  • *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
    • Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications
  • *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
    • The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
      • Endometrial receptivity analysis
      • Sperm-capacitation test
      • Sperm deoxyribonucleic acid (DNA) fragmentation test
      • Sperm penetration assay
      • Uterine natural killer (uNK) cells test
    • *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
      • Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease
      • Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary
      • Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document
    • *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
      • Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications
    • *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
      • Revised Position Statement to include the prevention of lymphedema
    • *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
      • The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications
    • *TRANS.00038 — Thymus Tissue Transplantation:
      • Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue

 

Effective June 11, 2022, Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) will begin using the AIM Specialty Health®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Anthem Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

  • Musculoskeletal guidelines
    • Spine surgery
    • Joint surgery
    • Small joint surgery
    • Sacroiliac joint fusion
  • Sleep disorder management guideline
  • Rehabilitative services
    • Occupational therapy
    • Physical therapy
    • Speech therapy

 

Medical Policies

On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These guidelines take effect
June 11, 2022.

Publish date

Medical policy number

Medical Policy title

New or revised

04/13/2022

*LAB.00043

Immune Biomarker Tests for Cancer

New

04/13/2022

*LAB.00044

Saliva-based Testing to Determine
Drug-Metabolizer Status

New

04/13/2022

*LAB.00045

Selected Tests for the Evaluation and Management of Infertility

New

04/13/2022

*LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

New

04/13/2022

*RAD.00067

Quantitative Ultrasound for Tissue Characterization

New

04/13/2022

*SURG.00160

Implanted Port Delivery Systems to Treat Ocular Disease

New

03/25/2022

*TRANS.00038

Thymus Tissue Transplantation

New

04/13/2022

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

Revised

04/1/2022

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Revised

02/24/2022

SURG.00036

Fetal Surgery for Prenatally Diagnosed Malformations

Revised

04/13/2022

SURG.00096

Surgical and Ablative Treatments for Chronic Headaches

Revised

04/13/2022

*SURG.00154

Microsurgical Procedures for the Prevention or Treatment of Lymphedema

Revised

 

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Nevada Medicaid members on March 24, 2022. These guidelines take effect June 11, 2022.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

04/13/2022

*CG-LAB-20

Thyroid Testing

New

04/13/2022

*CG-LAB-21

Serum Iron Testing

New

04/13/2022

CG-ANC-03

Acupuncture

Revised

04/13/2022

CG-GENE-14

Gene Mutation Testing for Cancer Susceptibility and Management

Revised

04/13/2022

CG-MED-73

Hyperbaric Oxygen Therapy (Systemic/Topical)

Revised

04/13/2022

CG-SURG-36

Adenoidectomy

Revised

02/24/2022

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

Revised

 

 

ANV-NU-0334-22





Featured In:
July 2022 Anthem Provider News - Nevada