State & FederalMedicaidAugust 17, 2018

Clinical Utilization Management Guidelines update

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Anthem. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

 

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit http://www.anthem.com/cptsearch_shared.html.

 

Please note:

  • Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
  • For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

5/1/2018

CG-DME-42

Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices

New

5/1/2018

CG-DME-43

High-Frequency Chest Compression Devices for Airway Clearance

New

5/1/2018

CG-DRUG-82

Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension

New

5/1/2018

CG-DRUG-83

Growth Hormone

New

5/1/2018

CG-DRUG-84

Belimumab (Benlysta®)

New

5/1/2018

CG-DRUG-85

Tesamorelin (Egrifta®)

New

5/1/2018

CG-DRUG-86

Ocriplasmin (Jetrea®) Intravitreal Injection Treatment

New

5/1/2018

CG-DRUG-87

Vedolizumab (Entyvio®)

New

5/1/2018

CG-DRUG-88

Dupilumab (Dupixent®)

New

5/1/2018

CG-SURG-70

Gastric Electrical Stimulation

New

5/1/2018

CG-SURG-71

Reduction Mammaplasty

New

5/1/2018

CG-SURG-72

Endothelial Keratoplasty

New

7/1/2018

CG-THER-RAD-03

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

New

7/1/2018

CG-THER-RAD-04

Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors

New

5/1/2018

CG-DRUG-29

Hyaluronan Injections

Revised

2/28/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

2/28/2018

CG-DRUG-59

Testosterone Injectable

Revised

2/28/2018

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

Revised

2/28/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

2/28/2018

CG-MED-39

Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Revised

2/28/2018

CG-MED-53

Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing

Revised

2/28/2018

CG-SURG-33

Lumbar Fusion and Lumbar Total Disc Arthroplasty

Revised

 

ANVPEC-0669-18 July 2018

PUBLICATIONS: August 2018 Anthem Provider Newsletter - NV