Change notification to Medical Policies and Clinical UM Guidelines

Anthem Blue Cross and Blue Shield (Anthem) and our subsidiary company, HMO Nevada, 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 effective on and after June 1, 2023:

• MED.00135 Gene Therapy for Hemophilia: This document addresses gene therapy for hemophilia, a congenital medical condition in which the blood does not clot normally due to lack of sufficient blood-clotting proteins known as clotting factors. There are several forms of hemophilia, the most common of which are hemophilia A, which involves a deficiency in clotting factor VIII, and hemophilia B, which involves a deficiency in clotting factor IX. Gene therapy products for hemophilia use a virus vector with a working copy of the missing gene attached (factor VIII and factor IX for hemophilia A and B, respectively):
  • Outlines the medically necessary and investigational and not medically necessary criteria for a one- time infusion of etranacogene dezaparvovec-drlb for select individuals with hemophilia B.
  • Considered investigational and not medically necessary for all indications.
  • Preauthorization required effective June 1, 2023.
• MED.00143 Ingestible Devices for the Treatment of Constipation: This document addresses the use of ingestible devices as a nonpharmacological treatment of constipation. The capsule shaped devices mechanically stimulate the colon via vibrations with the goal of triggering a bowel movement. Internal mechanical stimulation has been proposed as an alternative second-line treatment of constipation following failure of laxative therapy:
  • Considered investigational and not medically necessary for all indications.
  • Post service review required effective June 1, 2023.

Revised Medical Policies and Adopted Clinical UM Guidelines effective June 1, 2023:

• CG-DME-31 Powered Wheeled Mobility Devices:
  • Added not medically necessary statement for powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT Personal Mobility Device) for all indications.
• CG-DME-44 Electric Tumor Treatment Field (TTF):
  • Added medically necessary criteria for recurrent glioblastoma multiforme.
  • Revised compliance requirement medically necessary criteria from 18 hours per day to 18 hours per day, on average.
  • Revised reference to see rationale for discussion about tumor progression criteria without change in intent.
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document.
  • Added chromosome conformation signatures to scope of document and investigational and not medically necessary statement.
• MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring Previously titled: Surface Electromyography Devices for Seizure Monitoring:
  • Revised title.
  • Revised Position Statement by adding electrodermal activity sensor devices.
• SURG.00097 Scoliosis Surgery:
  • Added magnetically controlled growing rods to scope of document in investigational and not medically necessary statement.
• TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias:
  • Expanded scope of document to address autologous hematopoietic stem cell mobilization and pheresis for the treatment of genetic diseases as part of the development of an FDA-approved ex vivo gene therapy (for example, betibeglogene autotemce or elivaldogene autotemcel).
  • Added medically necessary, investigational, and not medically necessary criteria for autologous hematopoietic stem cell mobilization and pheresis.

Medical Policies archived November 6, 2022, except where noted:

• SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy

Medical Policies archived November 17, 2022, except where noted:

• SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

Medical Policies and Clinical Guidelines archived December 28, 2022, except where noted:

• CG-GENE-07 BCR-ABL Mutation Analysis
  • Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.
• CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
  • Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.
• CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions
  • Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases and GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling.
• GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
  • Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases.
• GENE.00037 Genetic Testing for Macular Degeneration
  • Content merged into GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling and CG-GENE-13 Genetic Testing for Inherited Diseases.
• GENE.00038 Genetic Testing for Statin-Induced Myopathy
  • Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases.
• GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
  • Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases.

Medical Policies archived January 4, 2023, except where noted:

• MED.00065 Hepatic Activation Therapy
• MED.00099 Navigational Bronchoscopy
  • Content converted to CG-MED-93 Navigational Bronchoscopy.
• REHAB.00003 Hippotherapy
  • Transitioned to Carelon.
• SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
  • Content converted to CG-SURG-115 Mechanical Embolectomy for Treatment of Stroke.

Medical Policies and Clinical UM Guidelines, for Anthem, are developed by our national Medical Policy and Technology Assessment Committee (the 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 the medical policies for Anthem. Review procedures have been refined to facilitate claim investigation.

Medical Policies and Clinical UM Guidelines, for Anthem, are available online:

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the website for Anthem at anthem.com and select For Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & Clinical UM Guidelines. Either enter 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 ViewMedical 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.