Policy Updates Medical Policy & Clinical GuidelinesCommercialAugust 14, 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. 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. Refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

New medical policies effective December 1, 2024

Policy or guideline number	Policy title	Explanation of policy
MED.00148	Gene Therapy for Metachromatic Leukodystrophy	Addresses gene therapy for metachromatic leukodystrophy (MLD), a congenital medical condition that affects the nervous system. MLD is caused by having an abnormal variant of the arylsulfatase A (ARSA) gene, which leads to a deficiency of the enzyme ARSA. Gene therapy for individuals with early onset MLD involves ex vivo transduction of CD34+ cells with a lentiviral vector that contains a working copy of the ARSA gene: Considered investigational and not medically necessary when the criteria are not met and in all other situations. Prior authorization required effective December 1, 2024.
RAD.00069	Absolute Quantitation of Myocardial Blood Flow Measurement	Addresses the use of absolute quantitation of myocardial blood flow (AQMBF), an imaging technique that can be used during various modalities of cardiac imaging including positron emission tomography (PET), cardiac magnetic resonance imaging (CMR), single photon emission computed tomography (SPECT) scan imaging: Considered investigational not medically necessary for all indications. Prior authorization required effective December 1, 2024.

Policy or guideline number

Policy title

Explanation of policy

MED.00148

Gene Therapy for Metachromatic Leukodystrophy

Addresses gene therapy for metachromatic leukodystrophy (MLD), a congenital medical condition that affects the nervous system. MLD is caused by having an abnormal variant of the arylsulfatase A (ARSA) gene, which leads to a deficiency of the enzyme ARSA. Gene therapy for individuals with early onset MLD involves ex vivo transduction of CD34+ cells with a lentiviral vector that contains a working copy of the ARSA gene:

Considered investigational and not medically necessary when the criteria are not met and in all other situations.
Prior authorization required effective December 1, 2024.

RAD.00069

Absolute Quantitation of Myocardial Blood Flow Measurement

Addresses the use of absolute quantitation of myocardial blood flow (AQMBF), an imaging technique that can be used during various modalities of cardiac imaging including positron emission tomography (PET), cardiac magnetic resonance imaging (CMR), single photon emission computed tomography (SPECT) scan imaging:

Considered investigational not medically necessary for all indications.
Prior authorization required effective December 1, 2024.

Revised medical policies and clinical guidelines effective December 1, 2024

Policy or guideline number	Policy or guideline title	Explanation of revision
ANC.00009	Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities	Added met for each anatomical region being considered for treatment to lipectomy or liposuction not medically necessary statement. Added Pectus Correction Index to pectus excavatum medically necessary statement.
CG-MED-68	Therapeutic Apheresis	Added medically necessary indications to the cytapheresis section regarding erythrocytapheresis and red blood cell exchange for when used as part of the development of an FDA-approved ex vivo gene therapy.
MED.00055	Wearable Cardioverter Defibrillators	Reformatted language regarding the wearable cardioverter defibrillator and moved punctuation. Added not medically necessary statement when individual has an automated external defibrillator.
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised ocular indications, including the addition of SurSight to medically necessary and not medically necessary section and added new medically necessary criterion addressing non-healing or persistent corneal epithelial defects. Removed VersaWrap from investigational and not medically necessary statement. Removed Phasix Mesh from investigational and not medically necessary statement. Added Phasix Mesh and Phasix ST Mesh to medically necessary and not medically necessary statements.
SURG.00121	Transcatheter Heart Valve Procedures	Revised medically necessary statement for TAVR.

De-adopted clinical guidelines effective July 1, 2024

Policy or guideline number	Policy title
CG-DME-26	Back-Up Ventilators in the Home Setting
CG-DME-47	Noninvasive Home Ventilator Therapy for Respiratory Failure

Archived medical policies effective June 28, 2024

Policy or guideline number	Policy title	Explanation of archive status
DME.00032	Automated External Defibrillators for Home Use	Moved content to CG-DME-55.
MED.00125	Biofeedback and Neurofeedback	Moved content to CG-MED-97.
SURG.00147	Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders	N/A

The 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.

Nevada Medical Policies and Clinical UM Guidelines are available online:

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed at anthem.com > select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as your state. Select View Medical Policies & UM Guidelines (tinyurl.com/26drkr5n). Either enter a keyword or code or select the link Full List page (tinyurl.com/tb3xkwuu) 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 (tinyurl.com/26drkr5n). Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada (tinyurl.com/yc2y4n9t).

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-065153-24

PUBLICATIONS: September 2024 Provider Newsletter

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