Policy Updates Medical Policy & Clinical GuidelinesCommercialJune 10, 2024

Medical Policy and Clinical Utilization Management Guidelines notification

Anthem is 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 and Clinical UM Guidelines effective for service dates on and after October 1, 2024

Policy or guideline number

Policy title

Explanation of policy

CG-SURG-121

Fetal Surgery for Prenatally Diagnosed Malformations

Addresses the use of surgical techniques to correct or treat fetal malformations in utero, including: vesico-amniotic shunting as a treatment of urinary tract obstruction, repair of myelomeningocele as a treatment of neural tube defect, fetoscopic endoluminal tracheal occlusion as a treatment of congenital diaphragmatic hernia, and fetal aortic valvuloplasty as a treatment of critical aortic stenosis. This document does not address surgery to correct placental or uterine abnormalities including, but not limited to, amnioreduction or laser coagulation therapy to address interfetal transfusion syndrome:

  • Considered investigational and not medically necessary when the criteria are not met
  • Prior authorization required effective October 1, 2024

CG-SURG-118

Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Addresses intraocular anterior segment aqueous humor drainage devices (without extraocular reservoir) used in the treatment of glaucoma (open-angle glaucoma; refractory, primary and secondary) to reduce intraocular pressure (IOP):

  • Considered investigational and not medically necessary when the criteria are not met.
  • Prior authorization required effective October 1, 2024.

CG-SURG-119

Treatment of Varicose Veins (Lower Extremities)

Addresses various modalities for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV), anterior accessory great saphenous vein (AAGSV), or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins:

  • Considered investigational and not medically necessary when the criteria are not met
  • Prior authorization required effective October 1, 2024

CG-SURG-120

Vagus Nerve Stimulation

Addresses the indications for use of an implantable vagus nerve stimulation (VNS) device, the electronic analysis of the implanted neurostimulator pulse generator system, and non-implantable (transcutaneous) VNS devices. These devices are used as a treatment of medically and surgically refractory seizures associated with intractable epilepsy. Implantable devices may deliver stimulation in an open-loop fashion with continuous but intermittent (‘ON’ and ‘OFF’ cycles) stimulation of the vagus nerve (a hand-held magnet allows on-demand stimulation to interrupt seizure activity), or may utilize detection of extra-cerebral indicators, for example, cardiac-based seizure detection (also known as “responsive devices”, “devices with an automatic stimulation mode”, or “closed loop devices”) that specifically use tachycardia as a surrogate marker for seizure prediction:

  • Considered investigational and not medically necessary when the criteria are not met
  • Prior authorization required effective October 1, 2024.

OR-PR.00008

Osseointegrated Limb Prostheses

Addresses the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss. A prosthetic device can play an important role in rehabilitation when an upper or lower extremity is lost. The standard type of device used after limb loss is a socket-type prosthesis. The use of a bone-anchored prosthetic device such as the Osseointegrated Prostheses for the Rehabilitation of Amputees system (OPRA™, Integrum, Mölndal, Sweden) has been proposed as an alternative:

  • Considered investigational and not medically necessary when the criteria are not met
  • Prior authorization required effective October 1, 2024

SURG.00162

Implantable Shock Absorber for Treatment of Knee Osteoarthritis

Addresses the use of an implantable shock absorber device (for example, MISHA™ Knee System Moximed, Inc., Fremont, CA) for the treatment of osteoarthritis of the knee:

  • Considered investigational and not medically necessary when the criteria are not met
  • Prior authorization required effective October 1, 2024

Revised Medical Policies effective October 1, 2024

Policy or guideline number

Policy or guideline title

Explanation of revision

LAB.00039

Combined Pathogen Identification and Drug Resistance Testing

Previously titled: Pooled Antibiotic Sensitivity Testing

  • Revised title
  • Revised Position Statement to address “combined pathogen identification and drug resistance” testing

MED.00140

Gene Therapy for Beta Thalassemia

  • Added medically necessary statement on exagamglogene autotemcel
  • Revised not medically necessary statement

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

  • Revised medically necessary statement to include Cortiva and Surgimend for breast reconstruction
  • Revised medically necessary statement to include EPICEL, Integra Omnigraft Dermal Regeneration Template, and ReCell for the treatment of partial and deep thickness burns
  • Revised medically necessary statement to include Biovance and Oasis for the treatment of diabetic foot ulcers
  • Revised not medically necessary statement to align with revisions to medically necessary statements
  • Added new products to the investigational and not medically necessary statement

SURG.00052

Percutaneous Vertebral Disc and Vertebral Endplate Procedures

  • Revised medically necessary criteria for basivertebral nerve ablation (BVNA)

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

  • Revised pVAD criteria to include ECMO as concomitant therapy
  • Revised Total Artificial Heart criteria for simplification

TRANS.00028

Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

  • Updated formatting in Position Statement section
  • In the medically necessary Position Statement section for NHL, created criterion B3
  • In the investigational and not medically necessary section for NHL, updated bullet “A” by adding “when criteria above are not met, including.”

Archived Medical Policies effective March 15, 2024

Policy or guideline number

Policy title

Explanation of archive status

MED.00024

Adoptive Immunotherapy and Cellular Therapy

N/A

Archived Medical Policies and Clinical Guidelines effective April 1, 2024

Policy or guideline number

Policy title

Explanation of archive status

CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

N/A

CG-GENE-10

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies

N/A

CG-GENE-11

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

N/A

CG-GENE-13

Genetic Testing for Inherited Diseases

N/A

CG-GENE-14

Gene Mutation Testing for Cancer Susceptibility and Management

N/A

CG-GENE-15

Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis

N/A

CG-GENE-16

BRCA Genetic Testing

N/A

CG-GENE-18

Genetic Testing for TP53 Mutations

N/A

CG-GENE-19

Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing

N/A

CG-GENE-21

Cell-Free Fetal DNA-Based Prenatal Testing

N/A

CG-GENE-22

Gene Expression Profiling for Managing Breast Cancer Treatment

N/A

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

N/A

CG-SURG-63

Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

N/A

CG-SURG-97

Cardioverter Defibrillators

N/A

GENE.00009

Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer

N/A

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

N/A

GENE.00016

Gene Expression Profiling for Colorectal Cancer

N/A

GENE.00018

Gene Expression Profiling for Cancers of Unknown Primary Site

N/A

GENE.00020

Gene Expression Profile Tests for Multiple Myeloma

N/A

GENE.00023

Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma

N/A

GENE.00025

Proteogenomic Testing for the Evaluation of Malignancies

N/A

GENE.00041

Genetic Testing to Confirm the Identity of Laboratory Specimens

N/A

GENE.00050

Gene Expression Profiling for Coronary Artery Disease

N/A

GENE.00051

Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

N/A

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

N/A

GENE.00054

Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer

N/A

GENE.00055

Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

N/A

GENE.00056

Gene Expression Profiling for Bladder Cancer

N/A

GENE.00057

Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

N/A

GENE.00058

TruGraf Blood Gene Expression Test for Transplant Monitoring

N/A

GENE.00059

Hybrid Personalized Molecular Residual Disease Testing for Cancer

N/A

LAB.00038

Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection

N/A

SURG.00150

Leadless Pacemaker

N/A

TRANS.00025

Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

N/A

TRANS.00041

Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection

N/A

Archived Medical Policies and Clinical Guidelines effective April 10, 2024

Policy or guideline number

Policy title

Explanation of archive status

CG-MED-72

Hyperthermia for Cancer Therapy

N/A

LAB.00043

Immune Biomarker Tests for Cancer

N/A

SURG.00070

Photocoagulation of Macular Drusen

N/A

SURG.00007

Vagus Nerve Stimulation

Content converted to CG-SURG-120.

SURG.00036

Fetal Surgery for Prenatally Diagnosed Malformations

Content converted to CG-SURG-121.

SURG.00037

Treatment of Varicose Veins (Lower Extremities)

Content converted to CG-SURG-119.

SURG.00103

Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Content converted to CG-SURG-118.

Archived Medical Policies and Clinical Guidelines effective June 1, 2024

Policy or guideline number

Policy title

Explanation of archive status

SURG.00105

Bicompartmental Knee Arthroplasty

N/A

Archived Medical Policies and Clinical Guidelines effective September 1, 2024

Policy or guideline number

Policy title

Explanation of archive status

CG-MED-38

Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer

N/A

CG-MED-55

Site of Care: Advanced Radiologic Imaging

N/A

CG-REHAB-10

Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services

N/A

CG-SURG-52

Site of Care: Hospital-based Ambulatory Surgical Procedures and Endoscopic Services

N/A

CG-SURG-86

Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

N/A

Anthem’s 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.
For Nevada:

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 & Clinical 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.

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-060773-24

PUBLICATIONS: July 2024 Provider Newsletter