Change notification to Clinical UM Guidelines

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.

Clinical Guidelines adopted effective May 1, 2023:

• CG-MED-81 Ultrasound Ablation for Oncologic Indications
• CG-SURG-111 Open Sacroiliac Joint Fusion

Clinical Guidelines de-adopted effective March 1, 2023:

• CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

Clinical Guidelines transferring from post-service to prior authorization effective May 1, 2023:

• CG-MED-23 Home Health

Anthem’s 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

For Nevada

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s website at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select Nevada as your state. Then, select View Medical Policies & Clinical UM Guidelines. Either enter a keyword 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 & Clinical UM Guidelines page. Then, scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.