Medical Policy and Clinical UM Guidelines notification

Anthem and our subsidiary company, HMO Nevada are 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, 2024:

• CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output: This document addresses augmentative and alternative communication (AAC) devices with digitized or synthesized speech output. Digitized speech output refers to natural speech that is recorded and stored, and then reproduced by the device. In contrast, synthesized speech devices translate user input into machine-generated speech and thus are not dependent on pre-stored messages. These devices are aids to improve the functional communication needs of individuals with severe speech impairment or absent speech. Associated functional disabilities may limit an individual’s ability to use alternative natural methods of communication such as writing notes, using sign language, or even to manipulate a low technology augmentative communication system:
  • Considered investigational and not medically necessary as indicated in the guideline.
  • Prior authorization required effective April 1, 2024.
• CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight: This document addresses criteria for ultra-lightweight wheelchairs. Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs, and physical deficits. An ultra- lightweight manual wheelchair is constructed of high strength materials and weighs less than 30 lbs:
  • Considered investigational and not medically necessary as indicated in the guideline.
  • Prior authorization required effective April 1, 2024.

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, 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 Anthem’s Medical Policies. Review procedures have been refined to facilitate claim investigation.

Anthem’s Medical Policies and Clinical UM Guidelines are available online:

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s website 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 in Nevada.