Medical Policy and Clinical Utilization Management (UM) Guidelines update notification letter (MAC)

Material adverse change

Anthem Blue Cross and Blue Shield (Anthem) and our subsidiary company, HMO Nevada, 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.

 

On July 1, 2022, Anthem sent notification of the new medical policies listed effective for service dates on or after October 1, 2022. The notification also indicated effective July 1, 2022; prior authorization (PA) was required for these policies. Please note, the revisions to the July 1, 2022, notification as follows: 

• October 1, 2022: Effective date for policies requiring PA
• October 1, 2022: Effective date for policies to be reviewed post-service.
• Post-service review is required at the point of claim submission for not otherwise classified codes.

 

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

 

DME.00046 Intermittent Abdominal Pressure Ventilation Devices

This document addresses the use of intermittent abdominal pressure ventilation devices:

• Considered investigational and not medically necessary for all indications.
• PA required effective October 1, 2022.

 

DME.00047 Rehabilitative Devices with Remote Monitoring

This document addresses the use of rehabilitative devices with remote monitoring and adjustment capabilities intended to evaluate and improve muscle strength and range of motion while reporting session data to the individual’s provider:

• Considered investigational and not medically necessary for all indications.
• Post service review required effective October 1, 2022.

 

DME.00048 Virtual Reality-Assisted Therapy Systems

This document addresses the use of virtual reality-assisted therapy systems that may be used in the management of pain, cognitive or motor rehabilitation, treatment of procedural anxiety, and promotion of weight control:

• Considered investigational and not medically necessary for all indications.
• Post service review required effective October 1, 2022.

 

GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer

This document addresses hybrid personalized molecular residual disease (MRD) testing for oncologic disease management. This personalized testing occurs in a two-step process. The first step involves whole exome sequencing (WES) of the tumor tissue. In the second step, information about the tumor learned from the WES is used to develop a personalized assay to detect circulating tumor DNA (ctDNA) that assesses MRD. Commercially available personalized MRD tests include the Signatera™ test (Natera Inc.,* San Carlos, CA) and the RaDaR™ test (Inivata,* Research Triangle Park, NC):

• Considered investigational and not medically necessary for all indications.
• PA required effective October 1, 2022.

 

LAB.00048 Pain Management Biomarker Analysis

This document addresses a new pain biomarker test, the Foundation Pain Index (FPI), which is a test panel of pain functional biomarkers in urine and is intended to identify sources of chronic pain. The FPI involves analysis of urine by liquid chromatography tandem mass spectrometry (LCM/MS) of a panel of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid [3-HPMA], quinolinic acid, kynurenic acid). It is suggested that nutritional deficiencies (such as in Vitamin B12 and B6), oxidative stress and metabolic abnormalities can lead to pain syndromes, and that these abnormalities can be identified through this testing for these pain biomarkers:

• Considered investigational and not medically necessary for all indications.
• PA required effective October 1, 2022.

 

MED.00139 Electrical Impedance Scanning for Cancer Detection

This document addresses the use of electrical impedance scanning for cancer detection:

• Considered investigational and not medically necessary for all indications.
• Post-service review required effective October 1, 2022.

 

TRANS.00039 Portable Normothermic Organ Perfusion Systems

This document addresses use of a portable normothermic organ machine perfusion and monitoring medical device used to preserve donor organs in a near-normothermic state from retrieval until transplantation. This document does not address static cold storage or other forms of solid organ preservation:

• Considered medically necessary when used for preservation of donor lung pairs initially deemed unacceptable for procurement and transplantation based on limitations of cold storage preservation, that is: age greater than 55, PaO2/FiO2 less than 300 mmHg, donation after cardiac death (DCD) donors, ischemic time greater than 6 hours).
• Considered medically necessary when used for the preservation of an organ initially deemed unacceptable and when criteria (1 or 2) below are met:

1. Organ Care System Liver: Liver allografts from donors after circulatory death (DCD) less than or equal to 55 years old and with less than or equal to 30 minutes of warm ischemic time, macrosteatosis less than or equal to 15%
2. OrganOx metra System: liver allografts from donors after DCD less than or equal to 40 years of age, with less than or equal to 20 minutes of functional warm ischemic time, and macrosteatosis less than or equal to 15%.

• Considered investigational and not medically necessary when the above criteria are not met, including but not limited to the preservation of other solid donor organs, including the heart (that is, OCS Heart System), or preservation of standard criteria donor organ.
• Post-service review effective October 1, 2022.

 

Procedure codes to require PA, effective December 1, 2022:

• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications:
  • Code 0398T — Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed.
• SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir):
  • Code 0450T — Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (list separately in addition to code for primary procedure).
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures:
  • Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
• ANC.00007 Cosmetic and Reconstructive Services: Skin Related:
  • Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
  • Code 15787 — Abrasion; Add'l 4 Lesions/<.
• CG-SURG-27 Gender Affirming Surgery:
  • Code 11922 — Tattooing, intradermal introduction of insoluble opaque pigments to correct defects of skin, including micropigmentation.
• SURG.00121 Transcatheter Heart Valve Procedures:
  • Code 33419 — Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (list separately in addition to code for primary procedure).
• SURG.00037 Treatment of Varicose Veins (Lower Extremities):
  • Code 36474 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (list separately in addition to code for primary procedure).
• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone:
  • Code 37239 — Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (list separately in addition to code for primary procedure).
  • Code 37249 — Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (list separately in addition to code for primary procedure).
• SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis:
  • Code 43192 — Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance.
  • Code 43201 — Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance.
  • Code 43210 — Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches:
  • Code 64787 — Implantation, nerve end into bone/muscle.

 

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

The complete list of our Medical Policies and Clinical UM Guidelines can be accessed on Anthem’s website. Visit https://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 the keyword, 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.

 

* Natera, Inc. is an independent company providing personalized MRD tests on behalf of Anthem Blue Cross and Blue Shield. Inivata is an independent company providing personalized MRD tests on behalf of Anthem Blue Cross and Blue Shield.

 

NVBCBS-CM-004409-22