Pre-service/prior authorization clinical review update: August 1, 2021

Effective with dates of service on or after November 1, 2021, Anthem Blue Cross and Blue Shield will require review of the below clinical guidelines for medical necessity. Medical necessity review will require prior authorization. Ordering and servicing providers may submit prior authorization requests by contacting the phone number on the back of the members ID card.

 

Clinical guideline name and description:

• CG-DME-06 Pneumatic Compression Devices for Lymphedema: This document addresses the use of pneumatic compression devices for the treatment of lymphedema. This therapy involves the use of an inflatable garment for various body parts and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Pneumatic compression devices are used in clinics or can be purchased or rented for home use. This document addresses the home use of pneumatic compression devices
• CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction: This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

 

Anthem’s Medical Polices and Clinical UM Guidelines are available online on Anthem’s website at anthem.com/providers and can be found using the following path: Providers > State > Review Policies > View Policies and Guidelines > Medical Policies and Clinical UM Guidelines (for Local Plan members).

 

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