Change notification to Medical Policies and Clinical UM Guidelines: (MAC)

Material adverse change

Anthem Blue Cross and Blue Shield (Anthem) in Nevada is 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 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 for service dates effective September 1, 2023:

• MED.00145 Digital Therapy Devices for Treatment of Amblyopia:This document addresses digital therapy devices for the treatment of amblyopia. These devices incorporate dichoptic (viewing a separate and independent field through each eye) presentations to improve visual acuity of individuals with amblyopia:
  • Considered investigational and not medically necessary
  • Prior authorization required effective September 1, 2023

Revised Medical Policies and Clinical Guidelines effective September 1, 2023:

• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone:
  • Added new medically necessary criterion for idiopathic intracranial hypertension (IIH)
• GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy):
  • Added new medically necessary statement for panels that assess tumor mutation burden (TMB) and revised investigational and not medically necessary statement
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting:
  • Revised medically necessary statement to include SimpliDerm for breast reconstruction
  • Revised medically necessary statement to include Kerecis and TheraSkin for diabetic foot ulcers
  • Revised medically necessary statement to include medically necessary ioBand for venous stasis ulcers
  • Revised medically necessary statement to include OviTex for complex abdominal wall wounds
  • Revised formatting in several medically necessary statements
  • Revised not medically necessary statement to align with revisions to medically necessary statements
  • Added new products to the investigational and not medically necessary statement
• SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir):
  • Revised medically necessary and investigational and not medically necessary Position Statements to address iStent infinite Trabecular Micro-Bypass Stent System, model iS3

Adopted Medical Policies and Clinical Guidelines effective September 1, 2023:

• CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Medical Policiesand Clinical Guidelines archived April 12, 2023:

• RAD.00052 Positional MRI
• SURG.00053 Unicondylar Interpositional Spacer

Medical Policiesand Clinical Guidelines archiving August 1, 2023:

• RAD.00036 MRI of the Breast

Anthem Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee (MPTAC). The committee, which includes 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 website at anthem.com, Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as your state, then 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.

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.