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 January 1, 2022:

  • 00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis: This document addresses the use of gene expression profiling to assist in the diagnosis or management of idiopathic pulmonary fibrosis
  • The use of gene expression profiling to assist in the diagnosis or management of idiopathic pulmonary fibrosis is considered investigational and not medically necessary in all situations.


  • 00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline: This document addresses the use of artificial intelligence-enabled algorithms which may combine a variety a clinical characteristics such as, biomarkers, genetics, gender or race, to generate prognostic information to enable a more personalized approach to the treatment of chronic kidney disease (e.g., KidneyIntelX).
  • Use of artificial intelligence-enabled algorithms (e.g., KidneyIntelX) to predict progressive kidney function decline in chronic kidney disease is considered investigational and not medically necessary for all indications.


  • 00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion: This document addresses the use of The EyeBOX, the first baseline-free, temporal calibration eye movement analysis device to assist physicians in objectively evaluating individuals with suspected concussion.
  • Eye movement analysis using non-spatial calibration is considered investigational and not medically necessary for the diagnosis of concussion.


Revised Medical Policies and Adopted Clinical UM Guidelines effective January 1, 2022:

  • CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule: This document addresses the use of wireless capsule endoscopy (WCE or video capsule endoscopy [VCE]) devices which have been developed for imaging portions of the gastrointestinal tract and the patency capsule which is intended to ensure that there are no strictures in the digestive tract to impede passage of the wireless endoscopy capsule.
  • Added the use of a magnetically controlled wireless capsule as Not Medically Necessary
  • Reformatted Not Medically Necessary statement


  • 00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography: This document addresses the use of photographic, optical, video, and other imaging technologies for the evaluation of skin lesions.
  • Added electrical impedance spectroscopy for the evaluation of skin lesions as Investigational and Not Medically Necessary


  • 00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection: This document addresses specific noninvasive laboratory tests for the early detection of rejection following a heart transplant.
  • Added noninvasive tests for detection of heart transplant rejection as Investigational and Not Medically Necessary including, but not limited to, AlloSure Heart, AlloSeq cell-free DNA, MMDx Heart, and myTAIHeart


Medical Policies and Clinical Guideline archived July 7, 2021 except where noted

  • CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
  • 00009 Vacuum Assisted Wound Therapy in the Outpatient Setting
  • 00034 Standing Frames
  • 00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
  • 00046 Prothrombin (Factor II) Genetic Testing
  • 00001 Computed Tomography to Detect Coronary Artery Calcification
  • 00127 Sacroiliac Joint Fusion (effective September 12, 2021)



MCG Updates effective August 19, 2021

  • W0118 Musculoskeletal Surgery or Procedure GRG
  • For open sacroiliac joint fusion, see CG-SURG-111 Open Sacroiliac Joint Fusion
  • For elective, non-emergent, sacroiliac joint fusion (percutaneous/minimally invasive techniques), see Musculoskeletal Program Clinical Appropriateness Guidelines


  • W0174 BHG Transcranial Magnetic Stimulation
  • Revised Clinical Indications for Procedure
    • “Major depressive disorder (severe)” changed to “Treatment resistant major depressive disorder”
    • “Relapse of symptoms after remission” changed to “Relapse of symptoms after virtual absence of depressive symptoms”
    • Updated footnote with timeframe for Remission, Relapse, and Recovery statements


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 Anthem’s Web site at the Provider Resources heading, select Policies and Guidelines.  Select Nevada as Your State.  Select View Medical Policies & UM Guidelines. Either enter key word or code, or select the link for Full List page to search the policy for your inquiry. 


Open the attachment titled “Guided Access HMO additional details NV.pdf” to view the Revised Medical Policies and Clinical Guidelines for Nevada.


Featured In:
October 2021 Anthem Provider News - Nevada