Medical Policy and clinical UM guidelines notification (MAC)
Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (collectively “Anthem”) are pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to the clinical utilization management (UM) guidelines adopted by Nevada.
Summarized below are the major new policies and changes. Refer to the specific policy for coding, language, and rationale updates and changes not summarized below.
New medical policies effective for service dates on and after May 1, 2022:
- 00044 Wheelchair Mounted Robotic Arm Attachment: This document addresses the use of a wheelchair mounted robotic arm attachment intended for use in individuals with upper extremity disability, to create a sense of independence with mobility restraints and gain autonomy due to neurologic conditions, trauma, or other problems.
- Considered Investigational and Not Medically Necessary
- Prior authorization required effective May 1, 2022
- 000138 Wearable Devices for Stress Relief and Management: Wearable devices for stress relief are typically small and inconspicuous sensors worn on the wrist, waist, skin, or clothes to aid wearers in identifying stressful triggers. Stress relief wearables often include biofeedback to help wearers learn to modify their physiologic response and may contain a therapeutic intervention, such as a calming vibration, activated by device-detected physiologic stressful stimuli.
- Considered investigational and not medically necessary in all situations.
- Prior authorization required effective May 1, 2022
Revised Medical Policies and Adopted Clinical UM Guidelines effective May 1, 2022:
- CG-MED-53 Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing: This document addresses cervical cancer screening and testing for human papillomavirus (HPV) to assess cervical cancer risk. Currently cervical cancer screening comprises cervical cytology with Papanicolaou testing (also known as a ‘Pap test’), and testing for HPV DNA. Pap tests are used to identify pre-cancerous or cancerous tissues present on the cervix. Screen for HPV aids in identifying individuals at higher risk for developing cervical cancer.
- Removed criteria addressing chronically immunosuppressed individuals.
- CG-SURG-78 Locoregional and Surgical Techniques for Treatment Primary and Metastatic Liver Malignancies: This document addresses surgical excision and locoregional therapies to treat primary or metastatic cancer of the liver. Treatment focuses on excising tumors or inducing tumor necrosis and can be used as a curative or palliative therapy, as a bridge to liver transplantation, or in those who may become eligible for liver transplantation with treatment. Local regional therapies may include any of the following ablative and arterially directed therapies:
- Ablative Therapy
- Cryosurgical ablation or cryotherapy
- Microwave ablation (MWA)
- Percutaneous ethanol injection (PEI)
- Radiofrequency ablation (RFA)
- Arterially directed therapy
- Selective internal radiation therapy (SIRT); also known as transarterial radioembolization (TARE)
- Transcatheter arterial chemoembolization (TACE)
- Transcatheter arterial embolization (TAE)
- Revised the clinical indications to add a NMN statement for histotripsy
- Ablative Therapy
- 00099 Navigational Bronchoscopy: This document addresses the use of navigational bronchoscopy (NB) devices as an aid in accessing peripheral lung lesions and masses, which may be inaccessible by standard bronchoscopy. ENB has also been proposed as a means of placing fiducial markers for surgical and radiological procedures.
- Revised title
- Removed the word “electromagnetic” in the position statement.
- 00010 Treatments for Urinary Incontinence: This document addresses the following for urinary incontinence:
- Vaginal weight training;
- Injection of periurethral bulking agents;
- Transvaginal radiofrequency bladder neck suspension;
- Transurethral radiofrequency energy collagen micro-remodeling;
- Artificial urinary sphincter devices;
- Intraurethral valve-pump implantation;
- Adjustable balloon system implantation.
- Added new criterion to INV&NMN statement on endovaginal cryogen-cooled, monopolar radiofrequency remodeling.
- Added “as treatment for urinary incontinence” to INV&NMN statement and removed wording on urinary incontinence.
- 00097 Scoliosis Surgery: This document addresses vertebral body stapling and vertebral body tethering as surgical treatments of scoliosis.
- Revised title.
- Added “minimally invasive deformity correction system” to the scope and position statement.
Medical policies to require prior authorization effective May 1, 2022:
DME.00032 Automated External Defibrillators for Home Use
LAB.00011 Analysis of Proteomic Patterns
MED.00002 Selected Sleep Testing Services
MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
MED.00099 Navigational Bronchoscopy
MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
OR-PR.00005 Upper Extremity Myoelectric Orthoses
OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
RAD.00053 Cervical and Thoracic Discography
SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
SURG.00071 Percutaneous and Endoscopic Spinal Surgery
SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
SURG.00107 Prostate Saturation Biopsy
SURG.00119 Endobronchial Valve Devices
SURG.00126 Irreversible Electroporation
SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease
SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
SURG.00150 Leadless Pacemaker
SURG.00151 Balloon Dilation of Eustachian Tube
TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
TRANS.00008 Liver Transplantation
TRANS.00009 Lung and Lobar Transplantation
TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation
TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
TRANS.00026 Heart/Lung Transplantation
TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
TRANS.00033 Heart Transplantation
TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
TRANS.00035 Other Adult Stem Cell Therapy
Medical policies and clinical guidelines archived November 18, 2021 (except where noted)
- 00095 Anterior Segment Optical Coherence Tomography
- 00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
- OR-PR.00004 Partial-Hand Myoelectric Prosthesis
- Content moved to CG-OR-PR-05
Medical policies and clinical guidelines archived December 29, 2021 (except where noted)
- CG-BEH-01 Assessment of Autism Spectrum Disorders and Rett Syndrome Medical
- CG-MED-32 Ancillary Services for Pregnancy Complications
- CG-MED-77 SPECT/CT Fusion Imaging
- CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- 00036 Genetic Testing for Hereditary Pancreatitis
- Content moved to CG-GENE-13
- 00047 Methyenetetrahydrofolate Reductase Mutation Testing
- Content moved to CG-GENE-13
- 00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium
- Content moved to TRANS.00035
Clinical Guidelines de-adopted January 1, 2022
- CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
- CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
- CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
- CG-SURG-30 Tonsillectomy for Children With or Without Adenoidectomy
- CG-SURG-72 Endothelial Keratoplasty
- CG-SURG-77 Refractive Surgery
- CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
- CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)
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 on the Policies and Guidelines page under the Provider Resources heading on our anthem.com/provider website. From there, 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 & UM Guidelines page. Scroll to the bottom of the page to the link titled .
February 2022 Anthem Provider News - Nevada