Material adverse change (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 July 1, 2022:

  • 00043 Immune Biomarker Tests for Cancer: This document addresses immune response algorithmic tests for oncologic disease management. At least one test, Immunoscore® (Veracyte Inc.), which has been investigated for management of colon cancer, is commercially available. The test, which is performed on tissue samples, assesses immune response at the tumor site.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective July 1, 2022.

 

  • 00044 Saliva-based Testing to Determine Drug-Metabolizer Status: This document addresses the use of saliva-based testing to determine drug-metabolizer status.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective July 1, 2022.

 

  • LAB00045 Selected Tests for the Evaluation and Management of Infertility: This document addresses selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment.
    • 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; and
      • Uterine natural killer (uNK) cells test.
    • Prior authorization required effective July 1, 2022.

 

  • 00067 Quantitative Ultrasound for Tissue Characterization: This document addresses quantitative ultrasound to evaluate visceral organs and other anatomic structures by using imaging data and software to analyze tissue characteristics. This technology is being explored as a noninvasive means to identify tissue traits without performing biopsies or using contrast agents.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective July 1, 2022.

 

  • 00160 Implanted Port Delivery Systems to Treat Ocular Disease: A port delivery system is a novel type of drug delivery platform using a permanent drug-eluting implant inserted into and through the sclera of the eye to allow delivery of drugs to the intravitreal space. Such systems consist of a transscleral device that includes a reservoir and release control element to distribute drugs within the eye. A self-sealing extrascleral flange, which is visible through the conjunctiva, allows refilling of the reservoir as needed. Port delivery systems have been proposed as an alternative to monthly intravitreal injections in the treatment of retinal and potentially other ocular diseases.
    • Considered investigational and not medically necessary for all indications.
    • Prior authorization required effective July 1, 2022.

 

  • 00038 Thymus Tissue Transplantation: This document addresses thymus tissue transplantation using allogeneic processed thymus tissue-agdc (RETHYMIC®, Enzyvant Therapeutics, Inc. Cambridge, MA) a regenerative therapy used for immune reconstitution in children with congenital athymia.
    • Considered investigational and not medically necessary for all uses, including but not limited to immune reconstitution in children with congenital athymia.
    • Prior authorization required effective July 1, 2022.

 

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

  • CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management Previously titled: “Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management"
    • Revised title
    • Expanded scope of document to address solid and non-solid tumors
    • Updated Table A and Table B
    • Moved content of CG-GENE-01 Janus Kinase 2, CALR and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document.

 

  • CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
    • Added Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) with criteria to MN statement
    • Removed ISSHL from NMN statement.

 

  • CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
    • Revised stance for fenestrated and branched endovascular/endoluminal stent graft devices to be considered MN when criteria are met.

 

  • 00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
    • Added polygenic risk score testing to the scope as INV&NMN
    • Clarified criteria for Lynch Syndrome to add “containing 5-50 genes” and “at a minimum
    • Added MN statement for gene panel testing for initial evaluation of myelodysplastic syndromes
    • Added MN statement for gene panel testing for initial evaluation of acute myeloid leukemia
    • Added MN statement for gene panel testing for initial evaluation of acute lymphoblastic leukemia
    • Clarified criteria for Whole Exome Sequencing (WES) to state “live” fetus
    • Revised MN criteria for gene panel testing for prostate cancer to remove “Lynparza” and add “a poly (ADP-ribose) polymerase (PARP) inhibitor”

 

  • 00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
    • "Moved StrataGraft from INV&NMN section to MN section for burns”
    • Added mVASC to MN section for treatment of DFUs
    • Clarified product terminology regarding AlloDerm products                 
    • “Added new products to INV&NMN statement."

 

  • 00036 Fetal Surgery for Prenatally Diagnosed Malformations
    • Clarified unit of measurement for BMI in MN criteria
    • “Added MN criteria for fetoscopic endoluminal tracheal occlusion (FETO)."

 

  • 00096 Surgical and Ablative Treatments for Chronic Headaches
    • Removed criteria addressing nasal and sinus surgery from INV&NMN statement.

 

  • 00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema
    • Previously titled: “Microsurgical Procedures for the Treatment of Lymphedema"
    • Revised title: “Revised Position Statement to include the prevention of lymphedema."

 

Procedure Codes to Require Prior Authorization Effective July 1, 2022

  • 93656 – As addressed in CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins, currently adopted
  • 93613 – As addressed in CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation, currently adopted
  • 58575 – As addressed in MCG W0010 Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-Assisted

 

Medical Policies and Clinical Guideline archived April 13, 2022 except where noted

  • CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays
    • Content added to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.
  • CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome
    • Content added to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.
  • CG-GENE-09 Genetic Testing for CHARGE Syndrome
    • Content added to CG-GENE-13 Genetic Testing for Inherited Diseases.
  • CG-MED-44 Holter Monitors
    • Content added to CG-MED-40 External Ambulatory Cardiac Monitors.
  • 00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
    • Content split into CG-GENE-13 Genetic Testing for Inherited Diseases and LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease.

 

MCG Care Guidelines 26th Edition

Effective July 1, 2022, we will upgrade to the 26th Edition of MCG care guidelines for the following modules:

  • Inpatient & Surgical Care (ISC)                            
  • General Recovery Care (GRG)
  • Recovery Facility Care (RFC)
  • Behavioral Health Care (BHG)
  • Chronic Care (CCG)

 

Includes:

  • MCG Summary of Guideline Development Policies and Procedures
  • MCG 26th Edition Clinically Relevant Changes

 

MPTAC approved the MCG 26th edition GLOS changes that may be considered more restrictive:

  • S-1320 [W0133] Aortic Valve Replacement, Transcatheter (Change from 2 days postoperative to 1 day postoperative)
  • P-15 Apnea, Neonatal (Non-Preterm Infants) (Change from 3 days to 2 days)
  • M-325 Renal Failure, Chronic (Change from 3 days to 2 days)
  • M-79 Subarachnoid Hemorrhage, Nonsurgical Treatment (Change from 4 days to 3 days)
  • S-410 Craniotomy, Supratentorial (Change from 3 days postoperative to 2 days postoperative)
  • S-100 Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF) (Change from Ambulatory or 1 day postoperative to Ambulatory)
  • S-560 [W0105] Hip Arthroplasty (Change from Ambulatory or 2 days postoperative to Ambulatory or 1 day postoperative)
  • S-632 Humerus Fracture, Closed or Open Reduction (Change from Ambulatory or 1 day postoperative to Ambulatory)
  • S-700 [W0081] Knee Arthroplasty, Total (Change from Ambulatory or 2 days postoperative to Ambulatory or 1 day postoperative)
  • S-830 [W0100] Lumbar Laminectomy (Change from Ambulatory or 1 day postoperative to Ambulatory)
  • S-870 Nephrectomy (Change from 3 days postoperative to 2 days postoperative)
  • S-960 Prostatectomy, Radical (Change from 1 day postoperative to Ambulatory or 1 day postoperative)

 

MPTAC approved the MCG 26th edition GLOS changes that may be considered less restrictive:

  • M-123 Dehydration (Change from 1 day to 2 days)
  • M-550 Esophageal Disease (Change from 1 day to 2 days)
  • M-560 Gastritis and Duodenitis (Change from 1 day to 2 days)
  • P-355 Pneumothorax, Neonatal (Change from 2 days to 3 days)
  • M-327 Seizure (Change from 1 day to 2 days)
  • M-63 Back Pain (Change from 1 day to 2 days)

 

MCG GUIDELINES 26th EDITION (New Guidelines)

 

Inpatient & Surgical Care (ISC) Hospital-at-Home (HaH)

  • M-70-HaH Cellulitis: Hospital-at-Home
  • M-100-HaH Chronic Obstructive Pulmonary Disease: Hospital-at-Home
  • M-190-HaH Heart Failure: Hospital-at-Home
  • M-282-HaH Pneumonia: Hospital-at-Home
  • M-300-HaH Urinary Tract Infection (UTI): Hospital-at-Home

 

Inpatient & Surgical Care (ISC) Observation Care

  • OC-065 Pancreatitis: Observation Care
  • OC-066 Renal Failure, Acute: Observation Care
  • OC-067 Stroke: Ischemic: Observation Care

 

Clinical Guidelines de-adopted February 1, 2022

  • CG-MED-63 Treatment of Hyperhidrosis
  • CG-MED-69 Inhaled Nitric Oxide
  • CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
  • CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-18 Septoplasty
  • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
  • CG-SURG-34 Diagnostic Infertility Surgery
  • CG-SURG-59 Vena Cava Filters
  • CG-SURG-70 Gastric Electrical Stimulation
  • CG-SURG-73 Balloon Sinus Ostial Dilation
  • CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
  • CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
  • CG-SURG-94 Keratoprosthesis
  • CG-SURG-104 Intraoperative Neurophysiological Monitoring
  • CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies

 

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 Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.

 

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April 2022 Anthem Provider News - Nevada