State & FederalMedicaidNovember 1, 2018

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Note:

Effective July 30, 2018, InterQual® 2018 and 2018.1 releases will be used. InterQual will continue to be used for home care criteria, long-term care criteria, rehabilitation criteria, and subacute and skilled nursing facilities.

Effective November 1, 2018, MCG Health Care Guidelines will be used for reviews, to include the use of customizations to certain guidelines and:
- o Inpatient and Surgical Care Guidelines.
- o General Recovery Care Guidelines.
- o Recovery Facility Care Guidelines.
- o Chronic Care Guidelines.
- o Behavioral Health Care Guidelines (NEW).

Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

Please share this notice with other members of your practice and office staff.

To search for specific policies or guidelines, visit http://www.anthem.com/cptsearch_shared.html.

Medical Policies

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).

Publish date	Medical Policy number	Medical Policy title	New or revised
6/6/2018	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)	New
6/6/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
5/10/2018	DRUG.00047	Brentuximab Vedotin (Adcetris®)	Revised
5/10/2018	DRUG.00053	Carfilzomib (Kyprolis®)	Revised
6/6/2018	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
6/6/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
5/10/2018	DRUG.00076	Blinatumomab (Blincyto®)	Revised
6/6/2018	DRUG.00111	Monoclonal Antibodies to Interleukin-23	Revised
5/10/2018	SURG.00026	Deep Brain, Cortical and Cerebellar Stimulation	Revised

Clinical UM Guidelines

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
6/6/2018	CG-LAB-12	Testing for Oral and Esophageal Cancer	New
6/6/2018	CG-MED-71	Wound Care in the Home Setting	New
6/28/2018	CG-DME-44	Electric Tumor Treatment Field (TTF)	New
6/28/2018	CG-DRUG-67	Cetuximab (Erbitux®)	New
6/28/2018	CG-DRUG-94	Rituximab (Rituxan®) for Nononcologic Indications	New
6/28/2018	CG-DRUG-95	Belatacept (Nulojix®)	New
6/28/2018	CG-DRUG-96	Ado-trastuzumab emtansine (Kadcyla®)	New
6/28/2018	CG-DRUG-97	Rilonacept (Arcalyst®)	New
6/28/2018	CG-DRUG-98	Bendamustine Hydrochloride	New
6/28/2018	CG-DRUG-99	Elotuzumab (Empliciti™)	New
6/28/2018	CG-DRUG-100	Interferon gamma-1b (Actimmune®)	New
6/28/2018	CG-DRUG-101	Ixabepilone (Ixempra®)	New
6/28/2018	CG-DRUG-102	Olaratumab (Lartruvo™)	New
6/28/2018	CG-MED-72	Hyperthermia for Cancer Therapy	New
6/28/2018	CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty	New
6/28/2018	CG-SURG-77	Refractive Surgery	New
6/28/2018	CG-SURG-78	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies	New
6/28/2018	CG-SURG-79	Implantable Infusion Pumps	New
6/28/2018	CG-SURG-80	Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors	New
5/10/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
6/6/2018	CG-DRUG-60	Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications	Revised
6/6/2018	CG-DRUG-62	Fulvestrant (FASLODEX®)	Revised
6/6/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised

ANV-NL-0038-18 September 2018

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Medical Policies and Clinical Utilization Management Guidelines update

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