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

Material Adverse Change

 

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 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 for service dates on and after October 1, 2022

 

DME.00046 Intermittent abdominal pressure ventilation devices

This document addresses the use of intermittent abdominal pressure ventilation devices.

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

DME.00047 Rehabilitative Devices with Remote Monitoring

This document addresses the use of rehabilitative devices with remote monitoring and adjustment capabilities intended to evaluate and improve muscle strength and range of motion while reporting session data to the individual’s provider.

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

DME.00048 Virtual Reality-Assisted Therapy Systems

This document addresses the use of virtual reality-assisted therapy systems that may be used in the management of pain, cognitive or motor rehabilitation, treatment of procedural anxiety, and promotion of weight control.

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

GENE.00059   Hybrid Personalized Molecular Residual Disease Testing for Cancer

This document addresses hybrid personalized molecular residual disease (MRD) testing for oncologic disease management. This personalized testing occurs in a two-step process. The first step involves whole exome sequencing (WES) of the tumor tissue. In the second step, information about the tumor learned from the WES is used to develop a personalized assay to to detect circulating tumor DNA (ctDNA) that assesses MRD. Commercially available personalized MRD tests include the Signatera™ test (Natera Inc., San Carlos, CA) and the RaDaR™ test (Inivata, Research Triangle Park, NC).

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

LAB.00048 Pain Management Biomarker Analysis

This document addresses a new pain biomarker test, the Foundation Pain Index (FPI) which is a test panel of pain functional biomarkers in urine and is intended to identify sources of chronic pain. The FPI involves analysis of urine by liquid chromatography tandem mass spectrometry (LCM/MS) of a panel of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate,                             3-hydroxypropyl mercapturic acid [3-HPMA], quinolinic acid, kynurenic acid). It is suggested that nutritional deficiencies (such as in Vitamin B12 and B6), oxidative stress and metabolic abnormalities can lead to pain syndromes, and that these abnormalities can be identified through this testing for these pain biomarkers.

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

MED.00139 Electrical Impedance Scanning for Cancer Detection This document addresses the use of electrical impedance scanning for cancer detection.

• Considered investigational and not medically necessary for all indications.
• Prior authorization required effective July 1, 2022.

 

TRANS.00039 Portable Normothermic Organ Perfusion Systems

This document addresses use of a portable normothermic organ machine perfusion and monitoring medical device used to preserve donor organs in a near-normothermic state from retrieval until transplantation. This document does not address static cold storage or other forms of solid organ preservation.

• Considered medically necessary when used for preservation of donor lung pairs initially deemed unacceptable for procurement and transplantation based on limitations of cold storage preservation, that is: age greater than 55, PaO2/FiO2 less than 300 mmHg, donation after cardiac death (DCD) donors, ischemic time greater than 6 hours).
• Considered medically necessary when used for the preservation of an organ initially deemed unacceptable and when criteria (1 or 2) below are met:

1. Organ Care System Liver: Liver allografts from donors after circulatory death (DCD) less than or equal to 55 years old and with less than or equal to 30 minutes of warm ischemic time, macrosteatosis less than or equal to 15%; or
2. OrganOx metra System: liver allografts from donors after DCD less than or equal to 40 years of age, with less than or equal to 20 minutes of functional warm ischemic time, and macrosteatosis less than or equal to 15%.

• Considered investigational and not medically necessary when the above criteria are not met, including but not limited to the preservation of other solid donor organs, including the heart (that is, OCS Heart System), or preservation of standard criteria donor organ.
• Prior authorization required effective July 1, 2022.

 

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

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

• Clarified the criteria for unilateral hearing loss to include conductive, mixed and sensorineural hearing loss
• Clarified the MN criteria for replacement parts and upgrades

 

SURG.00097 Scoliosis Surgery

• Added MN criteria for vertebral body tethering

 

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

CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver

• Revised title
• Removed the reference to glomerular filtration rate from the radiofrequency and cryosurgical ablation treatment of renal cancer
• Added the term “metastatic” to the radiofrequency ablation treatment of metastatic lung cancer to clarify extra-pulmonary disease
• Added NMN statement for laser ablation therapy
• Removed examples from the cryosurgical and radiofrequency ablation NMN statements

 

GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma

• Revised title
• Expanded Scope and Position Statement to include cutaneous squamous cell carcinoma

 

Medical Policies and Clinical Guideline archived May 19, 2022, except where noted

SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent

 

Medical Policies and Clinical Guideline archived June 29, 2022, except where noted

MED.00121 Implantable Interstitial Glucose Monitors

• Moved content into CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps

 

Medical Policies and Clinical Guideline archived July 6, 2022, except where noted

DME.00024 Transtympanic Micropressure

SURG.00137 Focused Microwave Thermotherapy for Breast Cancer

MED.00127 Chelation Therapy

• Transitioned to CG-MED-90 Chelation Therapy

 

Clinical Guidelines de-adopted January 1, 2022

• CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals

 

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 online

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

  

NVBCBS-COMM-001571-22