Medical Policy and Clinical UM Guidelines updates

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. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

 

New Medical Policies effective for service dates on and after February 1, 2022:

• 00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring: This document addresses the use of neuromuscular electrical training of the tongue muscles as a treatment of obstructive sleep apnea (OSA) or snoring.
• Considered Investigational and Not Medically Necessary
• 00058 TruGraf Bleed Gene Expression Test for Transplant Monitoring: This document addresses the TruGraf® blood gene expression test is a blood-based gene expression assay designed to identify transplant recipients who are inadequately immunosuppressed.
• Considered Investigational and Not Medically Necessary
• 00040 Serum Biomarker Tests for Risk of Preeclampsia: This document addresses biomarker testing to identify individuals at increased risk of preeclampsia during pregnancy.
• Considered Investigational and Not Medically Necessary
• 00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy: This document addresses molecular signature testing (PrismRA, Schipher Medicine, Durham, NC) to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy.
• Considered Investigational and Not Medically Necessary
• OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis: This document addresses the use of a microprocessor controlled knee-ankle-foot orthosis (for example, the C-Brace®, Ottobock HealthCare LP, Austin, TX) that provides support for individuals with lower extremity weakness.
• Provides Clinical Indications for Medically Necessary and Not Medically Necessary criteria

 

Revised Adopted Clinical UM Guideline effective February 1, 2022:

• CG-DME-44 Electric Tumor Treatment Field (TTF): This document addresses electrical fields known as “tumor treatment fields (TTF)” that are created by low-intensity, intermediate frequency (100–200 kilohertz [kHz]) electric currents delivered to the malignant tumor site by insulated electrodes placed on the skin surface.
• Added Medically Necessary indications for continuation therapy

 

Medical Policies archived October 6, 2021

• 00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis
• 00085 Antineoplaston Therapy
• 00037 Whole Body Computed Tomography Scanning

 

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.

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 a keyword or code or select the link for the Full List page to search the policy for your inquiry. 

Open the attached PDF titled "Nevada Revised Medical Policies and Clinical Guidelines 12.1.21.pdf" to view Nevada's revised medical policies and clinical guidelines

1433-1121-PN-NV