Policy Updates Medical Policy & Clinical GuidelinesCommercialJuly 14, 2025

Clinical UM Guidelines notification

We are pleased to provide you with our updated and new medical policies. We 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 to implement a particular Clinical UM Guideline. The link below can be used to confirm whether 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 November 1, 2025

Policy or Guideline number

Title

Explanation of policy

CG-DME-57

Lower Extremity Pressure Gradient Compression Stockings

Addresses the use of lower extremity pressure gradient compression stockings (GCS) used to exert external compression on the lower extremities to prevent or reduce swelling, improve venous circulation, or prevent venous pooling and venous hypertension in individuals with incompetent venous circulation (for example, varicose veins). GCS may also be used to prevent venous thrombosis or to improve healing of extremity wounds by reducing venous pressure and edema. Silicone compression garments may be prescribed to minimize scarring in victims of deep burns. Compression stockings may also be used for the treatment of lymphedema or lipedema. Lymphedema is a condition characterized by the pooling of extracellular fluid in the extremities due to a variety of etiologies. Lipedema is a painful, chronic, incurable condition characterized by abnormal bilateral enlargement of subcutaneous adipose tissue of the legs or arms. The use of GCS for these conditions is intended to apply external pressure to the limbs with the goal of decreasing the pooling of blood lymph fluid, thus relieving the conditions related to such pooling.

Medically necessary under the following indications:

  • An initial purchase of two (2) pairs of individually fitted prescription lower extremity gradient compression stockings are considered medically necessary for individuals who require treatment for any of the following conditions:
    • Edema, stasis, varicose veins, or any other disorder of the lower extremity circulation; or
    • Lipedema; or
    • Lipodermatosclerosis; or
    • Lymphedema; or
    • Postural hypotension; or
    • Prevention or treatment of thrombosis
  • Two (2) pairs of replacement individually fitted prescription gradient compression stockings (for a total of four sets per 12-month period) are considered medically necessary when either of the following criteria have been met:
    • The medically necessary criteria for initial purchase above have been met; and
    • There is documentation of continued benefit derived from use of the device.
  • Additional replacement of individually fitted prescription gradient compression stockings is considered medically necessary when the following criteria have been met:
    • The medically necessary criteria for initial purchase above have been met; and
    • The stockings are no longer providing adequate compression.

Not medically necessary under the following indications:

  • The initial purchase of individually fitted prescription gradient compression stockings is considered not medically necessary when the criteria above have not been met.
  • Replacement of individually fitted prescription gradient compression stockings is considered not medically necessary when the criteria above have not been met, including more than four (4) pairs per 12-month period.

Prior authorization required effective November 1, 2025.

CG-MED-99

Intradialytic Parenteral Nutrition

Addresses intradialytic parenteral nutrition (IDPN). IDPN involves the infusion of intravenous hyperalimentation formula during dialysis with the aim of treating protein calorie malnutrition, which sometimes occurs in individuals with renal failure.

Not medically necessary for all indications.

Prior authorization required effective November 1, 2025.

CG-MED-100

Surface Electrical Stimulation Devices for Headache and Migraine

Addresses low-level electrical stimulation applied to peripheral nerves using a wearable device for the prevention and treatment of headache, especially migraines.

Medically necessary under the following indications:

  • Initial use of the Nerivio® remote electrical neuromodulation (REN) device for the treatment of migraine is considered medically necessary in individuals who meet all the following criteria:
    • 8 years of age or older; and
    • Six-month history of headaches that meet International Classification of Headache Disorders (ICHD 3-beta) diagnostic criteria for migraine with or without aura; and
    • Meets one of the following two criteria:
      • Nerivio is used to treat acute migraine; or
      • Nerivio is used to prevent migraine for individuals with six to 24 headache days (defined as a calendar day with headache regardless of severity or duration) per 28-day period in each of the three months preceding use of Nerivio.
  • Continued use of the Nerivio remote electrical neuromodulation (REN) device for the prevention or treatment of migraines is considered medically necessary in individuals when both the following are demonstrated:
    • Ongoing use (that is, compliance with use); and
    • Clinical benefit (for example, fewer migraines or shorter duration of migraines).

Not medically necessary under the following indications:

  • The Nerivio® remote electrical neuromodulation (REN) device for the treatment of migraine headaches is considered not medically necessary in individuals who do not meet the above criteria, and for all other indications.
  • Surface electrical stimulation devices listed below are considered not medically necessary for the prevention or treatment of headache and migraine:
    1. Cefaly® migraine treatment device
    2. Non-implantable transcutaneous vagus nerve stimulation devices (such as gammaCore-S®)

Moved content related to remote electrical neuromodulation (REN) and supraorbital transcutaneous neurostimulation from DME.00011 to new Clinical UM Guideline.

Moved remote electrical neuromodulation (REN) from investigational and not medically necessary to medically necessary with criteria.

Moved content related to vagus nerve stimulation for migraines from CG-SURG-120 to new Clinical UM Guideline.

Prior authorization required effective November 1, 2025.

CG-MED-101

Home Hospice

Addresses home hospice care. Home hospice care refers to a comprehensive home-based, interdisciplinary care program for individuals with a serious medical illness and a prognosis of six months or less if the disease follows its natural course.

Medically necessary under the following indications when both of the following criteria below are met:

  • The individual requires hospice care, as evidenced by meeting both of the following criteria (1 and 2):
    • The individual is terminally ill (for example, life expectancy is six months or less if illness runs its normal course); and
    • The individual requires services for the management of a terminal illness and related condition(s); and
  • The individual requires either of the following:
    • Routine home hospice services: Services required for less than eight hours of predominantly nursing care during a 24-hour day, which begins and ends at midnight; or
    • Continuous home care services: Services required when both of the following criteria are met:
      • The individual requires a minimum of eight hours of nursing, hospice aide, or homemaker care during a 24-hour day, which begins and ends at midnight.
        and
      • The continuous home care services are provided only during a period of crisis as necessary to maintain an individual at home.

Not medically necessary under the following indication:

  • Home hospice services are considered not medically necessary when the medically necessary criteria above have not been met.

Prior authorization required effective November 1, 2025.

CG-MED-102

Dichoptic Digital Therapy for Amblyopia

Previously titled: Digital Therapy Devices for Treatment of Amblyopia

Addresses dichoptic digital treatment devices for amblyopia. These devices incorporate dichoptic (viewing a separate and independent field through each eye) presentations to improve visual acuity (VA) of individuals with amblyopia.

Medically necessary under the following indications:

  • An initial 12-month trial of dichoptic digital therapy is considered medically necessary when the following criteria are met:
    • Individual is age 4 through 13 years (at least 4 years 0 days and less than 14 years old); and
    • The individual has anisometropic, small-angle (10 prism diopters or less) strabismic amblyopia or mixed-mechanism amblyopia; and
    • There is failure to respond to a six-month trial of patching or atropine (or contraindication/allergy/intolerance to atropine); and
    • For CureSight and RevitalVision, the individual has passed a dedicated 10 minutes in-clinic performance ability test to assure suitable eye tracking performance (validity of eye tracking data > 90% and successful calibration process); and
    • Myopia, if present, is not greater than -6.00 D. spherical equivalent in either eye; and
    • There is no history of light-induced seizures; and
    • There are no conditions documented that prevent the individual from completing a continuous 45 to 90 minutes of treatment per day while sitting in front of a near screen, such as children who don’t like or cannot watch TV or movies for more than 60 minutes every day according to the parent's report.
  • Each additional 12-month interval of dichoptic digital therapy is considered medically necessary when:
    • The clinical records document adherence to therapy; and
    • The amblyopic visual acuity demonstrates continued improvement (note: when amblyopic visual acuity does not improve over two successive measurements at least three months apart, this requirement is not met).

Not medically necessary under the following indication:

  • Dichoptic digital therapy is considered not medically necessary when the criteria above are not met.

Moved content from MED.00145 to new Clinical UM Guideline.
Revised title.

Revised criteria to consider the initial use and continued use of dichoptic digital therapy in the treatment of amblyopia as medically necessary.

Prior authorization required effective November 1, 2025.

CG-SURG-127

Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

Addresses the use of soft tissue (skin, ligament, cartilage, and so on) substitutes in wound healing and surgical procedures.

Medically necessary for the following indications when used for breast reconstruction surgery:

  • AlloDerm Regenerative Tissue Matrix (aseptic or sterile); or
  • Cortiva®; or
  • DermACELL™; or
  • DermaMatrix®; or
  • FlexHD®; or
  • SimpliDerm™; or
  • Strattice™; or
  • SurgiMend®

Medically necessary for the following indications when used for full-thickness or deep partial-thickness burns:

  • Biobrane; or
  • Epicel®; or
  • EZ Derm™; or
  • Fresh frozen unprocessed allograft skin products (for example, AlloSkin™*, TheraSkin®); or
  • Integra™ Bilayer Matrix Wound Dressing; or
  • Integra® Omnigraft Dermal Regeneration Template; or
  • ReCell™ Autologous Harvesting Device; or
  • StrataGraft®

Medically necessary for the following indications when used for complex abdominal wall reconstruction:

  • AlloDerm Regenerative Tissue Matrix (aseptic or sterile); or
  • Strattice; or
  • OviTex™; or
  • Phasix™ Mesh; or
  • Phasix™ ST Mesh.
  • IV. Diabetic foot ulcers

Medically necessary for the following indications when used for the treatment of diabetic foot ulcers, when the clinical criteria below have been met:

  • Products:
    • AmnioBand®, sheet or membrane form; or
    • Apligraf®; or
    • Biovance®; or
    • DermACELL™; or
    • Dermagraft®; or
    • EpiCord®; or
    • EpiFix™; or
    • Grafix® PRIME; or
    • Kerecis®; or
    • mVASC; or
    • NuShield®; or
    • Oasis® Ultra Tri-Layer Wound Matrix; or
    • Oasis® Wound Matrix; or
    • TheraSkin®
  • Clinical Criteria:
    • Ulcers that have not healed with standard conservative therapy (such as surgical debridement, complete off-loading, and standard dressing changes) attempted for at least one month

Medically necessary for the following indications when used for the treatment dystrophic epidermolysis bullosa:

  • Products:
    • Dermagraft®; or
    • OrCel™

Medically necessary for the following indications when used for the treatment of nonhealing wounds (for example, but not limited to, dermal wounds, pressure ulcers, surgical wounds, traumatic wounds, vascular ischemic ulcers, venous stasis ulcers) when the clinical criteria below have been met:

  • Products:
    • AmnioBand, sheet or membrane form; or
    • Apligraf®; or
    • EpiFix™; or
    • GraftJacket™, sheet or membrane form; or
    • Oasis® Ultra Tri-Layer Wound Matrix; or
    • Oasis® Wound Matrix; or
    • PriMatrix™; or
    • TheraSkin®
  • Clinical Criteria:
    • Wounds that have not healed with standard conservative therapy (such as surgical debridement, complete off-loading, standard dressing changes, and compression therapy) attempted for at least one month

Medically necessary for any of the following ocular indications:

  • To facilitate reconstruction of large conjunctival or corneal resections (for example, pterygium excision or excision of conjunctiva related to disease processes); or
  • As therapy for corneal injuries (for example, thermal, chemical, physical trauma); or
  • As treatment for nonhealing or persistent corneal epithelial defects, including ulcers or melts, which have not responded to conservative therapy, including those due to any of the following conditions:
    • Bullous keratopathy; or
    • Dry eye; or
    • Limbal stem cell deficiency; or
    • Neurotrophic keratitis; or
    • Recurrent pterygium; or
    • Stevens-Johnson syndrome

Not medically necessary for any of the following ocular indications:

  • For each proposed use above (breast reconstruction, burns, diabetic foot ulcers, dystrophic epidermolysis bullosa, nonhealing wounds, and ocular indications), use of products other than those explicitly listed for the indication is considered not medically necessary. (For example, the use of an amniotic membrane-derived product considered medically necessary in the Ocular Indications section above is considered not medically necessary for the use in breast reconstructive surgery, treatment of dystrophic epidermolysis bullosa, or other non-ocular indications).

Moved medically necessary and not medically necessary criteria for breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications from SURG.00011 to new Clinical UM Guideline.

Added NuSheild and Oasis Ultra Tri-Layer Wound Matrix as medically necessary for diabetic foot ulcers.

Added Oasis Ultra Tri-Layer Wound Matrix as medically necessary for chronic wounds.

Removed the limit of not more than 52 weeks from the DFU and nonhealing wound criteria.

Revised ocular indications to be agnostic to specific product, as long as it is amnion-derived.

Prior authorization required effective November 1, 2025.

Clinical Guidelines de-adopted effective August 1, 2025

Policy or Guideline number

Title

CG-OR-PR-05

Myoelectric Upper Extremity Prosthetic Devices

Revised Medical Policies and Clinical Guidelines effective November 1, 2025

Policy or Guideline number

Title

Explanation of revision

CG-MED-59

Upper Gastrointestinal Endoscopy in Adults

Reformatted the Clinical Indications section.

Added medically necessary criteria for screening EGD for individuals with Lynch syndrome.

CG-SURG-106

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

Revised medically necessary criteria for congenital heart disease due to stenosis or hypoplasia of a pulmonary artery to remove in a child.

CG-SURG-119

Treatment of Varicose Veins (Lower Extremities)

Revised the Clinical Indications to reflect current nomenclature for AASV/ASV.

Added not medically necessary statement regarding VenoValve device.

LAB.00045

Selected Tests for the Evaluation and Management of Infertility

Removed information regarding endometrial receptivity testing from the Position Statement.

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Revised title and scope.

Moved content related to breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications to new Clinical UM Guideline CG-SURG-127.

Added new products to investigational and not medically necessary statement.

SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis

Revised Position Statement to remove age criterion for POEM and requirement for no previous open surgery.

Added medically necessary criteria for the TIF and G-POEM procedures.

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

Added new medically necessary statement for ReActiv8 Implantable Neurostimulation System.

Revised investigational and not medically necessary statement.

TRANS.00008

Liver Transplantation

Revised formatting in medically necessary statement for Mass Occupying Lesions.

Added new medically necessary criteria for unresectable colorectal cancer with liver metastases (UCLM).

Medical Policies and Clinical Guidelines archived effective April 16, 2025

Policy or Guideline number

Title

Explanation of archive status

CG-SURG-08

Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury

Content for Sacral Nerve Stimulation moved to CG-SURG-95.

LAB.00039

Combined Pathogen Identification and Drug Resistance Testing

N/A

MED.00104

Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin

N/A

MED.00145

Digital Therapy Devices for Treatment of Amblyopia

Content moved to CG-MED-102.

OR-PR.00008

Osseointegrated Limb Prostheses

Content moved to CG-OR-PR-10.

SURG.00061

Presbyopia and Astigmatism-Correcting Intraocular Lenses

Content moved to CG-SURG-128.

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 and 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 the medical necessity criteria set in Anthem’s Medical Policies. Review procedures have been refined to facilitate claim investigation.

Medical Policies and Clinical UM Guidelines are available online

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed at https://www.anthem.com/nv/provider > Commercial provider website > Resources > Medical Policies & Clinical UM Guidelines > Nevada. You can search for a policy by keyword or code. To see recent updates, visit Recent Provider Medical Policy Full List.

   

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.

NVBCBS-CM-086913-25

PUBLICATIONS: August 2025 Provider Newsletter