Medical Policy and clinical UM guidelines notification update (MAC)

Material adverse change (MAC)

 

Please note: The effective date of the upgrade to the 26th Edition of MCG Care Guidelines as relayed in the April 1, 2022 newsletter has changed. 

 

Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (collectively Anthem) are pleased to provide you with our updated and new medical policies.  Anthem will also be implementing changes to the clinical utilization management (UM) guidelines adopted by Nevada.

 

Summarized below are the major new policies and changes. Refer to the specific policy for coding, language, and rationale updates and changes not summarized below.

 

MCG Care Guidelines 26th Edition

Effective September 1, 2022, we will upgrade to the 26th Edition of MCG care guidelines for the following modules:

• Inpatient & Surgical Care (ISC)
• General Recovery Care (GRG)
• Recovery Facility Care (RFC)
• Behavioral Health Care (BHG)
• Chronic Care (CCG)

 

Includes:

• MCG Summary of Guideline Development Policies and Procedures
• MCG 26th Edition Clinically Relevant Changes

 

MPTAC approved the MCG 26th edition GLOS changes that may be considered more restrictive:

• S-1320 [W0133] Aortic Valve Replacement, Transcatheter (Change from 2 days postoperative to 1 day postoperative)
• P-15 Apnea, Neonatal (Non-Preterm Infants) (Change from 3 days to 2 days)
• M-325 Renal Failure, Chronic (Change from 3 days to 2 days)
• M-79 Subarachnoid Hemorrhage, Nonsurgical Treatment (Change from 4 days to 3 days)
• S-410 Craniotomy, Supratentorial (Change from 3 days postoperative to 2 days postoperative)
• S-100 Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF) (Change from Ambulatory or 1 day postoperative to Ambulatory)
• S-560 [W0105] Hip Arthroplasty (Change from Ambulatory or 2 days postoperative to Ambulatory or 1 day postoperative)
• S-632 Humerus Fracture, Closed or Open Reduction (Change from Ambulatory or 1 day postoperative to Ambulatory)
• S-700 [W0081] Knee Arthroplasty, Total (Change from Ambulatory or 2 days postoperative to Ambulatory or 1 day postoperative)
• S-830 [W0100] Lumbar Laminectomy (Change from Ambulatory or 1 day postoperative to Ambulatory)
• S-870 Nephrectomy (Change from 3 days postoperative to 2 days postoperative)
• S-960 Prostatectomy, Radical (Change from 1 day postoperative to Ambulatory or 1 day postoperative)

 

MPTAC approved the MCG 26th edition GLOS changes that may be considered less restrictive:

• M-123 Dehydration (Change from 1 day to 2 days)
• M-550 Esophageal Disease (Change from 1 day to 2 days)
• M-560 Gastritis and Duodenitis (Change from 1 day to 2 days)
• P-355 Pneumothorax, Neonatal (Change from 2 days to 3 days)
• M-327 Seizure (Change from 1 day to 2 days)
• M-63 Back Pain (Change from 1 day to 2 days)

 

MCG GUIDELINES 26th EDITION (New Guidelines)

Inpatient & Surgical Care (ISC) Hospital-at-Home (HaH)

• M-70-HaH Cellulitis: Hospital-at-Home
• M-100-HaH Chronic Obstructive Pulmonary Disease: Hospital-at-Home
• M-190-HaH Heart Failure: Hospital-at-Home
• M-282-HaH Pneumonia: Hospital-at-Home
• M-300-HaH Urinary Tract Infection (UTI): Hospital-at-Home

 

Inpatient & Surgical Care (ISC) Observation Care

• OC-065 Pancreatitis: Observation Care
• OC-066 Renal Failure, Acute: Observation Care
• OC-067 Stroke: Ischemic: Observation Care

 

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 Web site 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 kew 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 Blue Cross and Blue Shield in Nevada.

 

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