Policy Updates Medical Policy & Clinical GuidelinesCommercialDecember 18, 2024

Clinical UM Guidelines Notification

Anthem 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 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 Clinical Guidelines effective for service dates on and after April 1, 2025

Policy Number

Policy Title

Explanation of Policy

DME.00052

Brain Computer Interface Rehabilitation Devices

Addresses brain computer interface (BCI) rehabilitation devices. These are non‑invasive devices designed to enable individuals, particularly those with neurological conditions such as stroke, to control external devices using their brain signals.

Considered investigational and not medically necessary for the following procedure code, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary. (E0738 upper extremity rehabilitation system providing active) assistance to facilitate muscle re‑education, include microprocessor, all components, and accessories.

Prior authorization required effective April 1, 2025.

LAB.00051

Per‑ and Polyfluoroalkyl Substances PFAS Testing

Addresses testing for per‑ and polyfluoroalkyl substances (PFAS). PFAS are a large group of synthetic chemicals that have been used by numerous industrial and commercial sectors for products that benefited from PFAS' unique properties, including their chemical and thermal stability, water‑, heat‑, grease‑, and oil‑resistant qualities. PFAS have been shown to bioaccumulate and biomagnify in wildlife as well as readily accumulate in human tissues such as the lungs, liver, brain, and circulatory system of humans. Because PFAS do not fully biodegrade in the environment, they have been referred to as “forever chemicals.” Research has revealed possible associations between human exposures to certain PFAS and some adverse health outcomes.

Considered investigational and not medically necessary for all indications.

Prior authorization required effective April 1, 2025.

MED.00150

Hepzato Kit™ (melphalan hepatic delivery system)

Addresses Hepzato Kit™ (Delcath® Systems; Wilmington, DE), a liver‑directed therapy designed to administer high‑dose melphalan via a hepatic arterial delivery system. This document does not address other injectable administration routes of melphalan (e.g., Alkeran®; Apotex, Inc, Toronto, Canada) or other hepatic delivery methods for chemotherapy administration.

Considered investigational and not medically necessary when the criteria above are not met, and for all other indications.

Prior authorization required effective April 1, 2025.

Revised Medical Policies effective April 1, 2025

Policy or Guideline Number

Policy or Guideline Title

Explanation of Revision

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Revised investigational and not medically necessary statement, adding external lower extremity nerve stimulator.

LAB.00026

Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions

Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer

Revised title.

Added precancerous lesions with Barrett’s esophagus as an example to Position Statement.

SURG.00032

Patent Foramen Ovale and Left Atrial Appendage Closure Devices

Previously titled: Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention

Revised title.

Revised medically necessary statement.

Added not medically necessary statements for PFO and LAAA closure.

Added an investigational and not medically necessary statement for PFO.

TRANS.00023

Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias

Reformatted allogeneic stem cell transplantation for multiple myeloma criteria.

Revised medically necessary statements for autologous stem cell transplantation for initial treatment of primary amyloidosis.

Removed criteria requiring LVEF of 45% or greater.

Added repeat autologous stem cell transplantation as a medically necessary treatment of relapsed amyloidosis when criteria are met.

Revised investigational and not medically necessary statement to reflect medically necessary changes.

De‑Adopted Clinical Guidelines effective December 1, 2024

Policy or Guideline Number

Policy Title

CG‑MED-23

Home Health

De‑Adopted Clinical Guidelines effective March 1, 2025

Policy or Guideline Number

Policy Title

CG‑ANC-06

Ambulance Services: Ground; Non‑Emergent

The Medical Policies and Clinical UM Guidelines for Anthem are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes medical directors and representatives from practicing physician groups for Anthem, 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 our medical policies. Review procedures have been refined to facilitate claim investigation.

Our 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 our web site 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 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.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

PCTS-1031, NVBCBS-CM-074834-24

PUBLICATIONS: January 2025 Provider Newsletter