Medical Policies and Clinical UM Guidelines update - September 2023

Anthem Blue Cross and Blue Shield (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 effective for service dates on and after January 1, 2024:

• SURG.00161  Nanoparticle-Mediated Thermal Ablation: This document addresses the use of nanoparticle-mediated thermal ablation to treat solid tumors. Nanoparticles are instilled into tumor tissue and then exposed to an energy source. Nanoparticle vibration induced by the energy source increases temperature to ablate the targeted tissue. Nanoparticle-mediated thermal ablation is purported to achieve homogeneous heat distribution in tumor tissue while protecting surrounding healthy tissue:
  • Considered investigational and not medically necessary for all indications
  • Prior authorization required effective January 1 ,2024

Revised Medical Policies and Clinical UM Guidelines effective January 1, 2024:

• CG-ANC-06 Ambulance Services: Ground; Non-Emergent:
  • Revised medically necessary and not medically necessary statements regarding mileage
  • Revised not medically necessary statement to remove list of non-covered indications
• CG-DME-31 Powered Wheeled Mobility Devices:     
  • Revised hierarchy and formatting in the medically necessary statement addressing power seating systems
  • Added new medically necessary and not medically necessary criteria to address power seat elevation systems when individuals meet criteria for (uneven) transfers
• CG-GENE-16 BRCA Genetic Testing:           
  • Revised Clinical Indications to include homologous recombination deficiency pathways to PARP inhibitor criteria 
• CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment:       
  • Revised criteria regarding tumor size
• CG-MED-59 Upper Gastrointestinal Endoscopy in Adults:
  • Revised Clinical Indications section to remove references to “life-limiting comorbidities”
• CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue:
  • Revised medically necessary criteria for cryopreservation of mature oocytes to include: (1) medical and surgical treatment, gonadotoxic therapy and bilateral oophorectomy as possible causes of anticipated infertility; (2) Criterion which states “individual is a candidate based on ovarian reserve and likelihood for successful oocyte cryopreservation (for example, age 45 years or less)”
  • Revised criteria so cryopreservation of ovarian tissue is considered medically necessary when criteria are met
  • Revised not medically necessary statement to indicate cryopreservation of ovarian tissue is considered not medically necessary when the criteria above are not met
• CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus:
  • Revised formatting and hierarchy in the Clinical Indications section
  • Removed 1 year life expectancy from the Clinical Indications section
  • Removed requirement for absence of comorbid conditions from the medically necessary statement
• CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver:
  • Removed criteria that individual must a be high renal or surgical risk from the cryoablation and radiofrequency ablation criteria for clinically localized, suspected renal malignancies. 
• CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants:
  • Reformatted the medically necessary criteria for cochlear implants.
  • Revised cochlear implantation criteria to include unilateral sensorineural deafness (Published on 5/25/23).
• CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention. Previously Titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention:
  • Revised title.
  • Added medically necessary criteria for temporary SNS for urinary and fecal conditions.
  • Reformatted medically necessary criteria for permanent SNS for urinary and fecal conditions.
  • Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices.
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Reformatted hierarchy for gene panel testing for inherited diseases, testing for cancer susceptibility, testing for cancer management, and molecular profiling for the evaluation of malignancies.
  • Revised panel testing criteria to remove 50 gene parameter.
  • Revised acute myeloid leukemia medically necessary statement to include “newly diagnosed or relapsed.”
  • Added circulating tumor DNA to scope of document (moved content from GENE.00049 into this document and added new criteria for prostate cancer and advance non-small cell lung cancer).
  • Revised molecular profiling criteria to remove “progressed following prior treatment” language.
  • Revised not medically necessary statement for Whole Exome Sequencing to address repeat testing."
• MED.00004 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions. Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography):
  • Revised title.
  • Added additional technologies to investigational and not medically necessary section.
• MED.00135 Gene Therapy for Hemophilia:   
  • Revised medically necessary statement on etranacogene dezaparvovec-drlb. 
  • Added medically necessary statement on valoctocogene roxaparvovec-rvox.
  • Revised first investigational and not medically necessary statement and deleted second investigational and not medically necessary statement (Published on 7/18/2023).
• SURG.00121 Transcatheter Heart Valve Procedures:
  • Revised text and formatting in the medically necessary statement for transcutaneous aortic valve replacement (TAVR).
  • Revised medically necessary statement for transcatheter pulmonary valve to remove right ventricular outflow tract (RVOT) conduit diameter criteria and added criteria for native and patched RVOT.
  • Added a new investigational and not medically necessary statement addressing TAVR cerebral protection devices.
  • Revised the investigational and not medically necessary statement regarding valve-in-valve repair to address replacement instead of repair.
• TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection:  
  • Revised medically necessary criteria regarding the time frame for AlloMap testing post HT.
  • Removed the word, “Non Invasive” from the Investigational and not medically necessary statement about AlloSure Heart, AlloSeq cell-free DNA, MMDx Heart and myTAIHeart.
• LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

Anthem Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee (MPTAC). 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

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed by visiting Home | Anthem Blue Cross and Blue Shield Healthcare Solutions. Under the Resources heading, select Policies and Guidelines, and then select Medical Policies and Clinical UM Guidelines.