Policy UpdatesCommercialApril 1, 2024

Medical Policy and Clinical UM Guidelines notification

Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem), 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 or not to implement a particular guideline. The link below can be used to confirm whether the local plan has adopted the 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 policies and clinical guidelines effective July 1, 2024

Policy number

Policy title

Explanation of policy

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Addresses metagenomic sequencing of infectious pathogens in the outpatient setting. Metagenomic testing, which employs next generation sequencing (NGS), analyzes microbial DNA from a clinical sample without reliance on traditional culture or targeted molecular tests. Clinical metagenomic testing is used for comprehensive detection of all pathogens in a single test.

Does not address targeted or multiplex (panel-based) nucleic acid tests (NAAT) or metagenomic sequencing of infectious diseases in the inpatient setting.

Considered investigational and not medically necessary when the criteria are not met.

Prior authorization required effective July 1, 2024.

MED.00146

Gene Therapy for Sickle Cell Disease

Addresses gene therapy for sickle cell disease (SCD), which is a genetic disease involving variations in the human beta-globin gene (HBB) that reduce an individual’s ability to produce functional hemoglobin leading to a shortage of mature red blood cells and a lack of sufficient oxygen circulation. The characteristic sickle-shaped red blood cells are rigid and can block small blood vessels (vaso-occlusion), causing severe pain and organ damage.

Two hematopoietic stem cell-based gene therapy products have been approved by the U.S. Food and Drug Administration (FDA) to treat SCD, exagamglogene autotemcel (Casgevy™) and lovotibeglogene autotemcel (Lyfgenia®). In Casgevy therapy, the BCL11A gene, which encodes a repressor of fetal hemoglobin (HbF) levels, is edited in an individual’s own hematopoietic stem cells using the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) nuclease system to produce high levels of HbF in red blood cells. Lyfgenia therapy involves using a modified lentivirus to deliver a functional copy of the beta-globin HBB gene to the individual’s cells. Both therapies produce functional hemoglobin proteins that may compensate for defective beta-globin, thereby reducing painful and debilitating sickle cell crises for those with SCD:

  • Outlines the medically necessary and investigational and not medically necessary criteria for gene therapy for sickle cell disease.
  • Considered investigational and not medically necessary when the criteria are not met.
  • Prior authorization required effective July 1, 2024.

RAD.00068

Myocardial Strain Imaging

Addresses the use of myocardial strain imaging to detect subclinical cardiac dysfunction. Myocardial strain imaging is an additional analysis performed during conventional cardiac imaging (echocardiography or cardiac MRI). Myocardial strain imaging is theorized to be an improved sensitivity test over ejection fraction (EF) in monitoring ventricular function:

  • Myocardial strain imaging is considered investigational and not medically necessary for all indications.
  • Considered investigational and not medically necessary when the criteria are not met.
  • Prior authorization required effective July 1, 2024.

CG-DME-50

Automated Insulin Delivery Systems

Addresses automated insulin delivery systems for the management of diabetes mellitus. Automated insulin delivery systems combine insulin pumps and continuous interstitial glucose monitors (CGMs). These devices allow management of blood glucose with little to no input by the user. Such devices come in several configurations, including open-loop, hybrid closed-loop, and fully closed-loop systems:

  • Moved content related to automated insulin delivery system from CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps.
  • Considered investigational and not medically necessary when the criteria are not met.
  • Prior authorization required effective July 1, 2024.

Revised Medical Policies and clinical guidelines effective July 1, 2024

Policy or guideline number

Policy or guideline title

Explanation of revision

LAB.00026

Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer

Previously titled: Systems Pathology Testing for Prostate Cancer

Revised title.

Added “Multimodal Artificial Intelligence” to the position statement.

LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

Added medically necessary criteria for measurement of amyloid beta.

Revised investigational and not medically necessary statement.

MED.00057

MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Added medically necessary criteria for Parkinson's Disease.

SURG.00010

Treatments for Urinary Incontinence

Revised medically necessary statements and changed to alphanumeric.

Added not medically necessary statement on periurethral bulking agents and revised existing not medically necessary statement. Removed line on periurethral bulking agents from investigational and not medically necessary statement and changed to alphanumeric.

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

Reformatted position statement and added headers.

Reformatted medically necessary statements to move target treatment areas into criteria.

Revised medically necessary statement for primary dystonia to remove dystonia manifestation types.

Reformatted medically necessary statements for Deep Brain Stimulation (DBS) for Parkinson’s, primary dystonia, and obsessive compulsive disorder.

Reformatted medically necessary statements for epilepsy.

Revised DBS for epilepsy medically necessary statement regarding non-epileptic seizures.

Revised position statement to add revision/replacement medically necessary and investigational and not medically necessary statements for DBS, cortical stimulation, and battery.

Revised and reformatted investigational and not medically necessary statements.

SURG.00097

Scoliosis Surgery

Revision to position statement formatting.

Added medically necessary and investigational and not medically necessary criteria for revision, replacement, or removal of vertebral body tethering to position statement.

SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Revised title.

Added genicular artery embolization to the scope of document.

Revised position statement to add genicular artery embolization as investigational and not medically necessary.

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Added definition of tandem to position statement.

Revised medically necessary criteria for autologous hematopoietic stem cell transplantation for stage IVa and stage IVb retinoblastoma.

Revised investigational and not medically necessary statement for allogeneic (ablative or non-myeloablative [mini transplant]) for retinoblastoma.

CG-DME-44

Electric Tumor Treatment Field (TTF)

Removed criteria requiring treatment begin within 7 weeks of completion of temozolomide and radiotherapy.

Revised criteria to add definition of tumor progression to the Clinical Indications.

Reformatted criteria to limit criteria to one requirement per line.

CG-GENE-13

Genetic Testing for Inherited Diseases

Added additional genes to the table, including those identified as medically actionable by ACMG recommendations, drug-related genes for Leqembi (lecanemab-irmb) associated with Late Onset Alzheimer’s, and Rivfloza (Nedosiran) associated with Primary hyperoxaluria type 1.

CG-GENE-18

Genetic Testing for TP53 Mutations

Added personal or family history of pediatric hypodiploid acute lymphoblastic leukemia as a medically necessary indication for germline testing.

CG-GENE-19

Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing

Removed the words “following transplant” from the medically necessary criteria for multiple myeloma in the Clinical Indications section.

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

Revised formatting of Clinical Indications section.

Revised medically necessary criteria for trial sacral nerve stimulators for urinary incontinence/ urgency/frequency and retention to add new examples of conservative treatments.

Revised permanent sacral nerve stimulators medically necessary criteria for urinary urgency/frequency.

Revised sacral nerve stimulation not medically necessary statement.

Added new medically necessary criteria for percutaneous and implantable tibial nerve stimulation.

Added new medically necessary and not medically necessary criteria for replacement or revision of percutaneous and Implantable tibial nerve stimulators.

Revised percutaneous and implantable tibial nerve stimulation not medically necessary statement.

Archived Medical Policies effective January 3, 2024

Policy or number

Policy title

Explanation of archive status

GENE.00053

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

Content converted to LAB.00050.

Anthem Medical Policies and the 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, anthem.com:

  1. Select For Providers.
  2. Under the Provider Resources heading, select Policies, Guidelines & Manuals.
  3. Select Select a State and choose Nevada.
  4. Select View Medical Policies & Clinical UM Guidelines.
  5. Either enter keyword or code, or select the link for Full List page to search the policy for your inquiry.

To view the list of specific guidelines adopted by Nevada:

  1. Navigate View Medical Policies & Clinical UM Guidelines.
  2. Scroll to the bottom of the page to Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

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-052736-24

PUBLICATIONS: April 2024 Provider Newsletter