Policy Updates Medical Policy & Clinical GuidelinesCommercialJune 1, 2025

Medical Policies and Clinical Utilization Management Guidelines are now available

Our new and revised Clinical Utilization Management (UM) Guidelines and Medical Guidelines, effective for service dates on and after September 1, 2025. Anthem will also implement changes to our Clinical UM Guidelines, which were adopted for Nevada. Anthem Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee (MPTAC). The MPTAC, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

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 UM Guidelines and Medical Guidelines

Policy or Guideline Number

Policy or Guideline Title

Explanation of Policy or Guideline

CG-SURG-125

Canaloplasty

  • Addresses canaloplasty, which is a form of non-penetrating glaucoma surgery. Canaloplasty is proposed as an alternative to trabeculectomy, the traditional surgical treatment of primary open-angle glaucoma (POAG).
  • Considered investigational and not medically necessary for all indications.
  • Prior authorization required effective September 1, 2025.

DME.00053

Home Video-Assisted Robotic Rehabilitation Systems

  • Addresses home use of video‑assisted robotic rehabilitation systems such as the Motus Hand or Motus Foot devices. The HCPCS code associated with this revised coverage guideline is E0739.
  • Considered investigational and not medically necessary for all indications.
  • Prior authorization required effective September 1, 2025.

MED.00151

Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency

  • Addresses gene therapy for aromatic l-amino acid decarboxylase (AADC) deficiency, which is a genetic disease involving variations in the human dopa decarboxylase (DDC) gene that reduce an individual’s ability to synthesize dopamine and serotonin from their precursor molecules. These chemicals are essential neurotransmitters that control many vital physiological functions such as sleep, memory, learning, brain development and cardiovascular function. A gene therapy product to treat AADC deficiency has been approved by the U.S. Food and Drug Administration (FDA), eladocagene exuparvovec-tneq (Kebilidi™). In Kebilidi therapy, an adeno-associated virus vector containing a functional copy of the human DDC gene is delivered directly into the brain through stereotactic injections. The viral vector infects the brain’s cells and causes a switch in the target genetic code, with the goal of allowing nerve cells to produce the missing enzyme.
  • Considered investigational and not medically necessary for all indications.
  • Prior authorization required effective September 1, 2025.

MED.00152

Outpatient Intravenous Insulin Therapy

  • Addresses outpatient intravenous insulin therapy, also referred to as the following:
    • Chronic intermittent intravenous insulin infusion therapy (CIIIT)
    • Hepatic activation
    • Metabolic activation therapy (MAT)
    • Outpatient intravenous insulin therapy (OIVIT)
    • Physiologic insulin resensitization (PIR)
    • Pulsatile intravenous insulin therapy (PIVIT)
    • Pulse insulin therapy (PIT)
  • Outpatient intravenous insulin therapy has been proposed as an adjunctive or alternative therapy for the treatment of type 1 diabetes.
  • Considered investigational and not medically necessary for all indications.
  • Prior authorization required effective September 1, 2025.

SURG.00165

Histotripsy

  • Addresses the use of histotripsy to ablate tissue. Histotripsy is an incisionless non-thermal procedure that uses ultrasound to induce mechanical cavitation resulting in the transformation of targeted tissue into acellular debris. The mechanism of action for histotripsy differs from that for high intensity focused ultrasound (HIFU). In HIFU, the heat produced by high intensity focused ultrasound directly destroys tissue. The spread of this heat can damage adjacent tissue. Histotripsy uses minimal heat to create microbubbles within tissue and it is these bubbles that destroy the tissue. Histotripsy has been proposed as a treatment for malignant tissue, including liver lesions and renal cancer. This treatment has also been proposed for treatment of nonmalignant conditions such as benign prostatic hypertrophy (BPH).
  • Considered investigational and not medically necessary for all indications.
  • Prior authorization required effective September 1, 2025.

Revised Medical Policies and Clinical UM Guidelines

Policy or Guideline Number

Policy or Guideline Title

Explanation of Revision

CG-OR-PR-04

Cranial Remodeling Bands and Helmets (Cranial Orthoses)

Previously Titled: Cranial Remodeling Bands and Helmets (Cranial Orthotics)

  • Revised title.
  • Revised criterion regarding cervical motion restriction.
  • Revised Cranial Vault Asymmetry Index criteria.

CG-THER-RAD-07

Intravascular Coronary and Non-Coronary Brachytherapy

Previously Titled: Intravascular Brachytherapy (Coronary and Non-Coronary)

  • Revised title.
  • Revised medically necessary and not medically necessary statements.

DME.00011

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

  • Revised investigational and not medically necessary statement, adding bimodal (acoustic and peripheral nerve electrical stimulation) neuromodulation therapy.

LAB.00026

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

  • Added medically necessary criteria for ArteraAI Prostate cancer risk stratification test.
  • Revised investigational and not medically necessary statement to remove prostate cancer.

LAB.00037

Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

  • Revised investigational and not medically necessary statement to remove proprietary names and "for all other indications."

TRANS.00029

Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias

  • Removed age requirements for HSCT for aplastic anemia, SCD, and thalassemia from medically necessary criteria.

TRANS.00033

Heart Transplantation

  • Reformatted medically necessary statement.
  • Revised medically necessary CPET criteria.
  • Added medically necessary criteria related to history of malignancy.
  • Added Note regarding 2024 ISHLT listing guidelines.
  • Added new Pediatric medically necessary criteria related to PVR.
  • Revised Relative Contraindications for Transplant Recipients related to PVR.
  • Revised formatting in Absolute Contraindications for Transplant Recipients.

Medical Policies and Clinical UM Guidelines archived effective January 30, 2025

Policy or Guideline Number

Policy Title

Explanation of Archive Status

CG-MED-42

Maternity Ultrasound in the Outpatient Setting

  • Content moved to CG-RAD-26

MED.00013

Parenteral Antibiotics for the Treatment of Lyme Disease

  • Content moved to CG-MED-98

MED.00097

Neural Therapy

N/A

MED.00128

Insulin Potentiation Therapy

N/A

SURG.00095

Viscocanalostomy and Canaloplasty

  • Content for Viscocanalostomy moved to CG-SURG-124
  • Content for Canaloplasty moved to CG-SURG-125

SURG.00116

High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus

N/A

Medical Policies and Clinical UM Guidelines archived effective April 1, 2025

Policy or Guideline Number

Policy Title

Explanation of Archive Status

CG-MED-64

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins

N/A

CG-MED-74

Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

N/A

CG-SURG-111

Open Sacroiliac Joint Fusion

N/A

CG-SURG-55

Cardiac Electrophysiological Studies (EPS) and Catheter Ablation

N/A

CG-SURG-93

Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

N/A

SURG.00152

Wireless Left Ventricular Pacing for Cardiac Resynchronization Therapy

N/A

THER-RAD.00008

Neutron Beam Radiotherapy

N/A

View the Medical Policies and Clinical UM Guidelines online

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed online. Enter the keyword or code or select Full List Page to search for the policy relevant to your inquiry.

The Clinical UM guidelines published on the 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 above 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.

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 medically necessary criteria set in Anthem medical policies. Review procedures have been refined to facilitate claim investigation.

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-083459-25

PUBLICATIONS: June 2025 Provider Newsletter