Beginning with claims processing on or after August 31, 2024, Anthem will implement revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, care providers are encouraged to use ICD-10-CM coding guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the category level that a code can be billed with another range of codes, it is imperative to look for Excludes1 notes that may prohibit billing a specific code combination.

The concept of Excludes1 notes is one of the unique attributes of the ICD-10-CM code set and coding conventions. An Excludes1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes1 note. These notes appear below the affected codes; if the note appears under the category (the first three characters of a code), it applies to the entire series of codes within that category. If the Excludes1 note appears beneath a specific code (three, four, five, six, or seven characters in length) then it applies only to that specific code.

In ICD-10-CM, when a category includes an Excludes1 note, it outlines what codes should not be billed together. Examples of this code scenario would include but are not limited to the following:

Reporting Z01.419 with Z12.4:
- 41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix).
Reporting Z79.891with F11.2X:
- 891 (long-term use of opiates) has an Excludes1 note after it for F11.2X (opioid dependence).
Reporting M54.2 with M50.XX:
- 2 (cervicalgia) has an Excludes1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder).
Reporting M54.5 with S39.012X and/or M54.4x:
- 5 (low back pain) has an Excludes1 note below it, which includes S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain), and M51.2X (lumbago due to intervertebral disc disorder).
Reporting J03.XX with J02.XX, J35.1, J36, J02.9:
- Acute tonsillitis has an Excludes1 note below it, which includes J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), and J36 (peritonsillar abscess).
- Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2N89 (other inflammatory disorders of the vagina) has an Excludes1 note below the category for R87.62X (abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623 (HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis), and A59.00 (trichomonal leukorrhea).

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM code book to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process to indicate why the billed diagnoses codes are appropriately used together.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

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.

MULTI-BCBS-CR-063312-24-CPN63181

AdministrativeCommercialAugust 1, 2024

Device-dependent procedures — facility editing update

Effective for all dates of service on and after November 1, 2024, Anthem is updating its outpatient facility editing system to implement a device-dependent procedure edit.

When a device is necessary to perform a specific procedure, both the device and the device-dependent procedure code must be submitted on the same claim and rendered on the same service date. Please visit the Centers for Medicare & Medicaid Services (CMS) Outpatient Code Editor at cms.gov for the most current lists of device-dependent procedure codes and device category codes. These lists may also be found in Appendix 3A and 3B of the Uniform Billing Editor. These lists may be updated to align with CMS changes.

In addition to the CMS-provided device-dependent procedure codes, we are adding CPT^® codes 52441 and 52442 to the device-dependent procedure list for this edit.

If you believe you have received a claim denial in error, please follow the claim dispute process for Anthem.

MULTI-BCBS-CM-063147-24

AdministrativeCommercialAugust 1, 2024

Incidental services — facility editing update

Effective for all claims received on or after November 1, 2024, Anthem is updating its outpatient facility editing system to deny claim lines billed with general revenue code 0250 when billed on the same claim with a radiology or diagnostic revenue code. Claims billed with surgical revenue codes 036X or 049X are not subject to this edit.

Per industry standard coding resources, including the Uniform Billing Editor and the National Uniform Billing Committee, care providers should use the more detailed revenue code subcategory when applicable and available rather than revenue codes that end in 0 (General) or 9 (Other). Claims must be coded to the highest level of specificity. As a reminder, unclassified CPT^® code J3490 should only be submitted when there is no specific HCPCS or CPT code for the submitted National Drug Code.

If you believe you have received a claim denial in error, please follow the claim dispute process for Anthem.

MULTI-BCBS-CM-063149-24

AdministrativeCommercialAugust 1, 2024

CAA: Providers required to verify their online provider directory information

Summary:

The Consolidated Appropriations Act (CAA) requires care providers to validate their online directory details every 90 days to remain listed.
Anthem's provider data management (PDM) on Availity Essentials enables care providers to verify and update their information efficiently.
Care providers can submit data updates through the PDM's Roster Automation solution using a standard Microsoft Excel document.

The CAA of 2021 requires care providers to review and verify the accuracy of the following information in the online provider directory every 90 days:

Provider/facility name
Address
Specialty
Phone number
Digital contact information

Providers who fail to verify their information every 90 days may be removed from the online provider directory.

Providers will be reinstated to the online provider directory once verification is complete.

Review, verify, and update your directory information

To review, verify, and update your online directory information, Anthem uses the provider data management (PDM) capabilities of Availity Essentials to update provider or facility data. Using the Availity PDM application meets the verification requirement to validate provider demographic data set by the CAA.

PDM features include:

Updating provider demographic information for all assigned payers in one location.
Verifying and managing current provider demographic information.
Monitoring submitted demographic updates in real-time with a digital dashboard.
Reviewing the history of previously verified data.

To access the PDM application, log on to Availity and go to My Providers > Provider Data Management Administrators are automatically granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. View the Availity PDM quick start guide here (PDF).

Use Roster Automation to submit provider demographic changes

Within the PDM application, providers also have the choice and flexibility to request data updates using our Roster Automation solution by submitting a spreadsheet via a roster upload.

Provider data additions, changes, and terminations are submitted on a standardized Microsoft Excel document. The resources for this process are available on our website. Visit anthem.com > For Providers > Forms and Guides. The following two resources appear under the Digital Tools category:

Roster Automation Rules of Engagement: This is a reference document available to ensure error-free submissions for accurate and timely updates through automation.
Roster Automation Standard Template: Use this template to submit your information. More detailed instructions on formatting and submission requirements can be found on the first tab of the template, the tab named User Reference Guide.

MULTI-BCBS-CM-064396-24-SRS64386

AdministrativeMedicaidAugust 1, 2024

Keeping your provider directory information current: inactive providers

We have previously asked you to review your online provider directory information to help ensure Anthem members can locate the most current information for in-network providers and facilities.

In support of this effort, we are identifying providers who have not submitted any claims within the last 12 months. The inactive providers are likely not treating Anthem members. To that end, the following actions will be taking place over the next month and will be repeated, at least twice a year, going forward.

Active group agreement with individual providers identified as inactive:

If the group has additional active providers, just the individual providers identified as inactive will be terminated.
If the group does not have any additional active providers, and Anthem has not received claims from this provider within 12 months, the provider and associated group will be terminated.

Active group agreement with no remaining individual providers identified:

If the group does not have any additional active providers, and Anthem has received claims from this group within 12 months, a termination letter will be mailed in accordance with the terms of the active group agreement.

To submit updates to your provider data, please use Availity Essentials PDM. Availity Essentials PDM has replaced all previous intake channels for demographic change requests and roster submissions as of January 1, 2024.

What if I need assistance?

Contact your provider relationship management representative or refer to the Contact Us section at the bottom of our provider website (https://providers.anthem.com/nv) for up-to-date contact information.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NVBCBS-CD-061922-24

AdministrativeMedicaidAugust 1, 2024

Mutually exclusive places of service

Beginning with claims processing on or after September 1, 2024, Anthem will update their claims editing process for professional claims to support mutually exclusive places of service edits.

According to CMS policy, the place of service (POS) code used should indicate the setting in which the patient received a face-to-face encounter or where the technical component of a service was rendered in the case of an interpretation. However, when a patient is in a registered inpatient status, all services billed by all providers should reflect and acknowledge the patient's inpatient status. A physician/practitioner/supplier furnishing services to a patient who is a registered inpatient shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient receives the face-to-face encounter.

For additional information, please visit CMS.gov:

CMS Transmittal 2679; R2679CP | CMS.
CMS Transmittal 1170; R1170OTN | CMS.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

NVBCBS-CD-061219-24-CPN61097

AdministrativeCommercialAugust 1, 2024

Evaluation and management services correct coding (professional)

Anthem continues to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, Anthem is taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional care providers. On September 1, 2021, we began using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.

Care providers should report E/M services in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The coded service should reflect and not exceed the level needed to manage the member's condition(s).

Claims are selected from care providers who are identified as coding at a higher E/M level compared to their peers with similar risk-adjusted members. Prior to payment, Anthem will review the selected E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, Anthem reserves the right to:

Deny the claim and request resubmission of the claim with the appropriate E/M level.
Pend the claim and request documentation supporting the E/M level billed.
Adjust reimbursement to reflect the lower E/M level supported by the claim.

The maximum level of service for E/M codes is based on the complexity of the medical decision-making or time and is reimbursed at the supported E/M code level and fee schedule rate.

This initiative does not impact every level four or five E/M claim. Care providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.

Care providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).

If you have questions about this program, contact your local network consultant. With your help, we can continually build towards a future of shared success.

NVBCBS-CM-061845-24

Digital SolutionsCommercialJuly 24, 2024

Expansion of Carelon Medical Benefits Management, Inc. programs

As a reminder, effective October 1, 2024, Carelon Medical Benefits Management will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — additional outpatient utilization management (UM) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.

The Clinical UM Guidelines and Medical Policies (also known as coverage guidelines in Virginia) by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard^®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program^® (FEP^®). For more information, please contact the phone number on the back of the member ID card.

Pre-service review requirements

For procedures that are scheduled to begin on or after October 1, 2024, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including, but not limited to, the following non-emergency modalities. Please refer to the Clinical Guidelines at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care. Please note some services below are effective March 1, 2025.

Program	Services	Medical Policies or Clinical Guidelines
Cardiovascular	Intracardiac ischemia monitoring OP cardiac hemodynamic monitoring w/wireless sensor for heart failure management Non-invasive heart failure and arrhythmia monitoring system	MED.00111 MED.00115 MED.00134
Musculoskeletal	US bone growth stim Manipulation under anesthesia Anesthesia for interventional pain procedures Facet joint allograft implants for facet disease Electrothermal shrinkage of joint capsules, ligaments, and tendons Implant of nerve stim. devices Radiofrequency neurolysis and pulsed radiofrequency therapy for trigeminal neuralgia	CG-DME-45 CG-MED-65 SURG.00043 CG-MED-78 CG-SURG-08 CG-SURG-89 SURG.00114
Radiology	Magnetic source imaging and magnetoencephalography Dynamic spinal visualization (including digital motion X-ray and cineradiography/ videofluoroscopy) Cervical and thoracic discography	CG-MED-76 RAD.00034 RAD.00053
Radiation oncology	Neutron beam radiotherapy	THER-RAD.00008
Sleep	Electronic positional devices for Tx of OSA Neuromuscular electrical training for Tx of OSA	DME.00042 DME.00043
Surgical GI	High resolution anoscopy screening Doppler-guided transanal hemorrhoidal de-arterialization	SURG.00116 SURG.00141

Update to previous notice: The services additional outpatient utilization management and base surgical below are effective March 1, 2025.

Program	Services	Medical Policies or Clinical Guidelines
Additional outpatient utilization management services (effective 3/1/2025)	Fertility Therapeutic apheresis Hyperbaric oxygen therapy Physiologic record of tremor Home parenteral nutrition Imaging evaluation of skin lesions Ambulance services (not applicable to Connecticut) Virtual reality-assisted therapy systems Quantitative sensory testing Automated nerve conduction testing Bioimpedance spectroscopy Autonomic testing Continuous monitoring of intraocular pressure Seizure monitoring Electronic home visual field monitoring Eye movement analysis for diagnosis of concussion High-volume colonic irrigation Electrical stimulation as a treatment for pain and other conditions Sensory stimulation for brain-injured individuals in coma or vegetative state Automated evacuation of meibomian gland Selected sleep testing		CG-MED-68 MED.00101 CG-MED-89 CG-MED-73 CG-MED-73 DME.00011 DME.00048 MED.00011 MED.00082 MED.00092 MED.00103 MED.00105 MED.00112 MED.00118 MED.00130 MED.00131 MED.00137 MED.00141 MED.00002 MED.00004 CG-MED-66 CG-MED-88 CG-SURG-35 LAB.00045 CG-ANC-04 CG-ANC-06
Cardiovascular services effective 3/1/2025	Intravascular stent Angioplasty Central venous access device Sclerotherapy Endovenous therapy Vascular embolization/occlusion organ/venous Echosclerotherapy Balloon dilatation Balloon angioplasty Transcath stent Dialysis circuit with angiography Carotid sinus procedures Carotid sinus neurostimulator		CG-SURG-106 CG-SURG-119 CG-SURG-28 CG-SURG-76 CG-SURG-83 CG-SURG-93 RAD.00059 SURG.00062 SURG.00124
Base surgical effective 3/1/2025	Anesthesia for dental services Skin-related cosmetic and reconstructive services Balloon dilation of eustachian tubes Functional endoscopic sinus surgery Bronchial thermoplasty Balloon sinus ostial dilation Cochlear and auditory brainstem implants Implantable hearing aids Surgical treatment for obstructive sleep apnea and snoring Drug-eluting devices to maintain sinus ostial patency Minimally invasive treatment of posterior nasal nerve for rhinitis MRI guided high-intensity focused ultrasound ablation for non-oncologic indications Uterine fibroid ablation Sacral nerve stimulation as a treatment of neurogenic bladder secondary to spinal cord injury Vagus nerve stimulation Ablation for solid tumors outside the liver Irreversible electroporation Corneal collagen cross linking Intraocular telescope Automated evacuation of meibomian gland Presbyopia and astigmatism-correcting intraocular lenses Viscocanalostomy and canaloplasty Intraocular anterior segment aqueous drainage devices Implanted artificial iris devices Implanted port delivery systems for ocular disease Implantable infusion pumps Treatments for urinary and fecal incontinence, urinary retention Reduction mammaplasty Mastectomy for gynecomastia Panniculectomy and abdominoplasty Adipose-derived regenerative cell therapy and soft tissue augmentation Products for wound healing and soft tissue grafting Surgical and ablative treatments for chronic headaches Intraoperative assessment of surgical margins during breast-conserving surgery with radiofrequency spectroscopy or optical coherence tomography Mandibular/maxillary surgery Blepharoplasty, repair, and brow lift Internal rib fixation systems Prostate saturation biopsy Focal laser ablation for the treatment of prostate cancer Penile prosthesis implantation Diaphragmatic/phrenic nerve stimulation and pacing systems High intensity focused ultrasound ablation for oncologic indications Renal sympathetic nerve ablation Hysterectomy Laparoscopic gynecologic surgery Myomectomy Transurethral destruction, prostate tissue Temporomandibular disorders (SURG-09) Septoplasty (SURG-18) Bariatric surgery and other treatment for clinically severe obesity (SURG-81) Nasal valve repair (SURG.00079) Bone-anchored and bone conduction hearing aids (SURG-82)	ANC.00007 CG-MED-41 CG-MED-79 CG-MED-81 CG-SURG-03 CG-SURG-08 CG-SURG-09 CG-SURG-105 CG-SURG-12 CG-SURG-117 CG-SURG-118 CG-SURG-120 CG-SURG-18 CG-SURG-24 CG-SURG-61 CG-SURG-71 CG-SURG-73 CG-SURG-79 CG-SURG-81 CG-SURG-82 CG-SURG-83 CG-SURG-84 CG-SURG-88 CG-SURG-95 CG-SURG-96 CG-SURG-99 MED.00057 MED.00103 MED.00132 SURG.00010 SURG.00011 SURG.00118 SURG.00061 SURG.00077 SURG.00079 SURG.00084 SURG.00095 SURG.00096 SURG.00107 SURG.00116 SURG.00120 SURG.00126 SURG.00129 SURG.00132 SURG.00135 SURG.00139 SURG.00141 SURG.00156 SURG.00157 SURG.00159 SURG.00160 MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal MCG: ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy

To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management provider portal. The provider portal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your local network relations representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

MULTI-BCBS-CM-063152-24-CPN62856

Digital SolutionsCommercialMedicare AdvantageMedicaidAugust 1, 2024

Save time and get better results with optimized CPT code search in Availity Essentials

Improvements in search capabilities in Availity Essentials now result in faster and more accurate results.

To help save you more time upfront while receiving more detailed eligibility & benefits information, we’ve expanded the Current Procedural Terminology^® (CPT) code search capabilities in Availity Essentials’ Eligibility and Benefit tool.

These optimizations enable the use of up to eight specific CPT or Healthcare Common Procedure Coding System (HCPCS) codes per transaction for faster, more accurate, and personalized search results, which include:

Authorization requirement notifications — so you know up-front if an authorization is needed.
Additional plan-level benefit limitations details.
Cost-share information displayed by places of service and procedure codes.

Making these details available on the search results pages can help you save time and effort by giving you access to the right information you need when you need it. Additionally, it reduces the need to contact us, resulting in fewer calls and chats over time.

Watch the recorded training to see how you can start saving time today. Learning sessions show step-by-step how you can use the CPT code search capabilities in Availity Essentials to help increase your productivity. We're dedicated to supporting your success through digital solutions that help reduce your administrative burden and streamline your interactions with us.

If you have any questions, contact your provider relationship management representative.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. 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-CDCRCM-062273-24-CPN60904

Digital SolutionsMedicare AdvantageMedicaidAugust 1, 2024

Admission, discharge, and transfer information is now available for Medicare Advantage and Medicaid members

If you and your organization are focused on promoting evidence-based medicine and clinical quality performance, our Alerts Hub clinical notification tool, accessed through Availity Essentials, can help drive your success.

Our clinical notification application, Alerts Hub, offers admission, discharge, and transfer (ADT) notifications for Medicare Advantage and Medicaid members. For those members, Alerts Hub offers a simple way to view a list of patients who have been admitted to the hospital or visited the emergency room.

Discover what users across the country already know.

Alerts Hub offers timely, actionable information to help your organization reach out to patients who can benefit from transitions in care planning or other interventions following inpatient or emergency care.

Viewing and responding to ADT notifications with outreach to patients can help drive your organizations’ clinical quality and cost of care performance in value-based care arrangements —More importantly, it helps drive better outcomes for your patients.

Get started today.

We are committed to finding solutions that help our care provider partners offer quality services to our members. To access Alerts Hub, log on to Availity Essentials, select Payer Spaces, then select Alerts Hub. New users will need to register and set preferences. Registered users will receive daily notification emails with a summary of relevant alerts and a reminder to view details in Alerts Hub. Be sure to check your junk or spam folders if you aren’t receiving messages in your inbox.

Need more help? The Availity Custom Learning Center offers a range of training materials that can help you get up to speed quickly so that you can take advantage of all Alerts Hub has to offer.

Contact us.

Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website.

NVBCBS-CDCR-060639-24-CPN59897

Behavioral HealthMedicaidAugust 1, 2024

Learn to Live: A Digital Mental Health Beneﬁt for Anthem members!

Did you know your Anthem patients can access no cost internet based cognitive behavioral therapy (iCBT) programs online 24/7?

The programs help with:

Resilience
Stress, Anxiety & Worry
Social Anxiety
Depression
Insomnia
Substance Use
Panic

Improve equity and access to Mental Health Programs and services for your patients with Learn to Live. Here are some important tips to share with patients so they get the most out of it.

The self-directed programs are conﬁdential and convenient. Learn to Live is accessible via a web browser or the app. Members can use the programs anytime - day or night.

Stick with it

Research shows the most signiﬁcant improvement is seen after completing three or more lessons. In the ﬁrst few lessons members may still be ﬁguring out their goals, learning about iCBT, and learning basic tools. The more lessons they complete, the more likely they'll stick with it and feel improvement.

Work with a coach

One of the best ways to maximize the beneﬁts of a Learn to Live program is to work with a personal coach. And it’s free! Users who work with a coach see 44% more improvement compared to those who go it alone.

Live and on-demand webinars

Learn to Live creates webinars on a wide variety of topics. They can be accessed on-demand for convenience. Watching webinars is an easy way for members to learn about mental health topics from experts.

Encourage your patients to check out our online mental health programs!

Available at no cost to members, ages 13+

To access, patients should visit:

www.learntolive.com/welcome/nvanthem and enter code: NVAnthem

NVBCBS-CD-059984-24-CPN59137

Education & TrainingCommercialMedicare AdvantageAugust 1, 2024

August is National Breastfeeding Month

On August 6, 2011, the U.S. Breastfeeding Committee (USBC) officially declared August as National Breastfeeding Month.¹

In recognition of August as National Breastfeeding Month, we are introducing resources published by numerous trusted sources, including My Diverse Patients. The first is an eLearning experience, developed for care providers, nurses, office staff, and other healthcare professionals. It is titled Promoting Birth Equity. You can find it on the Maternal Health Disparities page. In addition, within the Current Trends section, we offer access to an education resource via an externally published special series called Lost Mothers: Maternal Mortality In The U.S. It includes a resource by the National Public Radio entitled Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why.

Further and in accordance, the U.S. Centers for Disease Control and Prevention (CDC) offers these key points about breastfeeding:

Breastfeeding is the best source of nutrition for most infants.
Breastfeeding can reduce the risk of certain health conditions for both infants and mothers.
Only one in four infants are exclusively breastfed as recommended until they are six months old.
CDC supports and promotes breastfeeding across the United States.

Infants who are breastfed and mothers who breastfeed have reduced risk of:

Asthma and severe lower respiratory disease.
Obesity.
Type 1 diabetes.
Acute otitis media (ear infections).
Sudden infant death syndrome (SIDS).
Gastrointestinal infections, which can cause diarrhea and vomiting.
Necrotizing enterocolitis (NEC) (death of intestinal tissue) for preterm infants.

Mothers who breastfeed also have reduced risk of high blood pressure, Type 2 diabetes, ovarian cancer, and breast cancer.²

Whole health

We are taking a holistic view that can transform health. Maternal-child health includes the entire pre‑pregnancy, pregnancy, delivery, and postpartum journey of a parent and child up to one year after birth.³

Healthy babies start with healthy pregnancies. The United States has a robust healthcare infrastructure, spending more per capita on healthcare than any other nation, but maternal health in the U.S. has lagged behind that of other developed countries.⁴

Certified doula care can help improve maternal and infant health outcomes

Research shows that doulas — trained professionals who counsel pregnant people before, during, and after their babies are born — can help improve maternal health outcomes by offering information and education, as well as physical, social, and emotional support. Such care has been found to reduce the rate of cesarean births, preterm births, and postpartum depression, while also improving breastfeeding rate.⁴

We look forward to working together to deliver high-quality, equitable healthcare. If you have any questions about this communication, visit the Contact Us section of our provider website.

National Breastfeeding Month. U.S. Breastfeeding Committee. (n.d.). https://www.usbreastfeeding.org/national-breastfeeding-month.html
Centers for Disease Control and Prevention. (2023, December 18). About breastfeeding. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/php/about/index.html
Maternal Health. Elevance Health. (n.d.). https://www.elevancehealth.com/our-approach-to-health/maternal-health
Elevance Health Impact. (2023, April 30). Certified Doula Care Can Help Improve Maternal and Infant Health Outcomes Video. Elevance Health. https://www.elevancehealth.com/our-approach-to-health/whole-health/certified-doula-care-can-help-improve-maternal-and-infant-health-outcomes

MULTI-ALL-CRCM-062148-24-CPN61848

Policy UpdatesMedicaidJuly 25, 2024

Update: Use 59 Modifier for increased multiple birth reimbursements

Summary

We recently sent you a communication notifying you that Anthem increased reimbursements as of November 1, 2013, for multiple births (for example, twins, triplets, etc.) occurring via the same delivery method billed with a 51 modifier. That communication was incorrect. To receive the higher reimbursement for multiple births, you will need to bill with the 59 modifier and not with the 51 modifier as previously instructed. When you bill with a 59 modifier and use the diagnosis and procedure code combinations below for multiple births with the same delivery method (for example, vaginal to vaginal, cesarean section to C-section), we will reimburse at 125% of the Nevada Medicaid fee schedule.

What this means to you

No immediate action necessary — Pass this information to your office staff.

Why is this change necessary?

An earlier communication on this topic incorrectly listed the affected modifier as 51. We are correcting that mistake and informing you that the correct modifier to use when submitting multi delivery claims is 59.

Do I need to refile claims?

Previously submitted claims affected by this update may be resubmitted for review and, if applicable, adjusted reimbursement.

What is the impact of the change on coding?

Obstetrical providers who bill using the 59 modifier for same-delivery-method multiple births will be reimbursed at 125% of the Nevada Medicaid fee schedule.

Codes affected by this change

Code	Modifier	Description	Delivery type	Services
59400		Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care	Vaginal	Global
59409	59	Vaginal delivery only (with or without episiotomy and/or forceps)	Vaginal	Delivery only
59510		Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care	C-section	Global
59514	59	Cesarean delivery only	C-section	Delivery only

Code	Modifier	Description	Delivery type	Services
59610		Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care after previous cesarean delivery	Vaginal	Global
59612	59	Vaginal delivery only after previous cesarean delivery (with or without episiotomy and/or forceps)	Vaginal	Delivery only
59618		Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care following attempted vaginal delivery after previous cesarean delivery	C-section	Global
59620	59	Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery	C-section	Delivery only

Billing examples

Say you deliver twins (same method) for a member. To receive appropriate reimbursement, proper billing entails:

Twin A: vaginal delivery code with postpartum care and no modifier; one unit — will reimburse 100% of Nevada Medicaid fee schedule
Twin B: vaginal delivery only code with a 59 modifier; 1 unit — will reimburse 25 percent of Nevada Medicaid fee schedule

What is the impact of the change on medical record review requirements?

Medical record review is not required with the use of the 59 modifier for multiple deliveries (for example, twins, triplets). The modifier 22 for increased procedural services requires medical records and should not be used to be reimbursed for multiple births using the same delivery method at 125% of the Nevada Medicaid fee schedule.

What if I need help?

If you have questions about this communication, received this communication in error or need help with anything else, contact your provider relationship management representative or call Provider Services at 844-396-2330.

NVBCBS-CD-057177-24

Policy UpdatesMedicaidJune 26, 2024

Clinical Criteria updates — November 2023

Summary

On February 24, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

New: newly published criteria
Revised: addition or removal of medical necessity requirements, new document number
Updates (marked with an asterisk *): notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date	Clinical Criteria number	Clinical Criteria title	New or revised
August 1, 2024	*CC-0252	Adzynma (ADAMTS13, recombinant-krhn)	New
August 1, 2024	*CC-0253	Aphexda (motixafortide)	New
August 1, 2024	*CC-0254	Zilbysq (zilucoplan)	New
August 1, 2024	CC-0130	Imfinzi (durvalumab)	Revised
August 1, 2024	CC-0223	Imjudo (tremelimumab-actl)	Revised
August 1, 2024	*CC-0059	Selected Injectable NK-1 Antiemetic Agents	Revised
August 1, 2024	CC-0074	Akynzeo (fosnetupitant and palonosetron) for injection	Revised
August 1, 2024	*CC-0065	Agents for Hemophilia A and von Willebrand Disease	Revised
August 1, 2024	CC-0124	Keytruda (pembrolizumab)	Revised
August 1, 2024	CC-0150	Kymriah (tisagenlecleucel)	Revised
August 1, 2024	CC-0187	Breyanzi (lisocabtagene maraleucel)	Revised
August 1, 2024	CC-0133	Aliqopa (copanlisib)	Revised
August 1, 2024	CC-0205	Fyarro (sirolimus albumin bound)	Revised
August 1, 2024	CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
August 1, 2024	*CC-0226	Elahere (mirvetuximab)	Revised
August 1, 2024	CC-0125	Opdivo (nivolumab)	Revised
August 1, 2024	CC-0058	Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents	Revised
August 1, 2024	*CC-0009	Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis	Revised
August 1, 2024	*CC-0014	Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis	Revised
August 1, 2024	*CC-0011	Ocrevus (ocrelizumab)	Revised
August 1, 2024	*CC-0174	Kesimpta (ofatumumab)	Revised
August 1, 2024	*CC-0020	Natalizumab Agents (Tysabri, Tyruko)	Revised
August 1, 2024	*CC-0032	Botulinum Toxin	Revised
August 1, 2024	*CC-0068	Growth Hormone	Revised
August 1, 2024	*CC-0173	Enspryng (satralizumab-mwge)	Revised
August 1, 2024	*CC-0170	Uplizna (inebilizumab-cdon)	Revised
August 1, 2024	*CC-0199	Empaveli (pegcetacoplan)	Revised
August 1, 2024	*CC-0041	Complement Inhibitors	Revised
August 1, 2024	*CC-0071	Entyvio (vedolizumab)	Revised
August 1, 2024	*CC-0064	Interleukin-1 Inhibitors	Revised
August 1, 2024	*CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
August 1, 2024	*CC-0066	Monoclonal Antibodies to Interleukin-6	Revised
August 1, 2024	*CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
August 1, 2024	*CC-0078	Orencia (abatacept)	Revised
August 1, 2024	*CC-0063	Ustekinumab Agents	Revised
August 1, 2024	*CC-0062	Tumor Necrosis Factor Antagonists	Revised
August 1, 2024	CC-0003	Immunoglobulins	Revised
August 1, 2024	*CC-0002	Colony Stimulating Factor Agents	Revised
August 1, 2024	CC-0247	Beyfortus (nirsevimab)	Revised
August 1, 2024	CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised
August 1, 2024	CC-0010	Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors	Revised
August 1, 2024	CC-0209	Leqvio (inclisiran)	Revised
August 1, 2024	*CC-0086	Spravato (esketamine) Nasal Spray	Revised

NVBCBS-CD-050624-24-CPN49889

Policy UpdatesMedicare AdvantageJuly 10, 2024

Clinical Criteria updates

Effective August 12, 2024

Summary: On May 17, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or for additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

New: newly published criteria
Revised: addition or removal of medical necessity requirements, new document number
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective date	Clinical Criteria number	Clinical Criteria title	New or revised
August 12, 2024	*CC-0262	Tevimbra (tislelizumab-jsgr)	New
August 12, 2024	*CC-0162	Tepezza (teprotumumab-trbw)	Revised
August 12, 2024	*CC-0111	Nplate (romiplostim)	Revised
August 12, 2024	CC-0165	Trodelvy (sacituzumab govitecan)	Revised
August 12, 2024	*CC-0002	Colony Stimulating Factor Agents	Revised
August 12, 2024	CC-0128	Tecentriq (atezolizumab)	Revised
August 12, 2024	*CC-0098	Doxorubicin Liposome (Doxil, Lipodox)	Revised
August 12, 2024	*CC-0101	Torisel (temsirolimus)	Revised
August 12, 2024	*CC-0107	Bevacizumab for Non-Ophthalmologic Indications	Revised
August 12, 2024	CC-0143	Polivy (polatuzumab vedotin-piiq)	Revised
August 12, 2024	*CC-0092	Adcetris (brentuximab vedotin)	Revised
August 12, 2024	CC-0106	Erbitux (cetuximab)	Revised
August 12, 2024	*CC-0105	Vectibix (panitumumab)	Revised
August 12, 2024	CC-0145	Libtayo (cemiplimab-rwlc)	Revised
August 12, 2024	CC-0160	Vyepti (eptinezumab)	Revised
August 12, 2024	CC-0102	GNRH Analogs for Oncologic Indications	Revised
August 12, 2024	CC-0201	Rybrevant (amivantamab-ymjw)	Revised
August 12, 2024	*CC-0188	Imcivree (setmelanotide)	Revised
August 12, 2024	*CC-0124	Keytruda (pembrolizumab)	Revised
August 12, 2024	CC-0041	Complement C5 Inhibitors	Revised
August 12, 2024	CC-0199	Empaveli (pegcetacoplan)	Revised
August 12, 2024	*CC-0130	Imfinzi (durvalumab)	Revised
August 12, 2024	CC-0240	Zynyz (retifanlimab-dlwr)	Revised
August 12, 2024	CC-0123	Cyramza (ramucirumab)	Revised
August 12, 2024	CC-0187	Breyanzi (lisocabtagene maraleucel)	Revised
August 12, 2024	CC-0158	Enhertu (fam-trastuzumab deruxtecan-nxki)	Revised
August 12, 2024	CC-0226	Elahere (mirvetuximab)	Revised
August 12, 2024	CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
August 12, 2024	*CC-0066	Monoclonal Antibodies to Interleukin-6	Revised
August 12, 2024	CC-0221	Spevigo (spesolimab-sbzo)	Revised
August 12, 2024	CC-0071	Entyvio (vedolizumab)	Revised
August 12, 2024	*CC-0063	Ustekinumab Agents	Revised

MULTI-BCBS-CR-061721-24-CPN61521

Policy UpdatesMedicaidJuly 10, 2024

Carelon Medical Benefits Management, Inc. updates effective October 20, 2024

This article was updated as of September 11, 2024.

Effective on October 20, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review will apply for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements:

Cardiology:
- Cardiac Resynchronization Therapy
- Endovascular Revascularization
- Imaging of the Heart
- Implantable Cardioverter Defibrillators
- Percutaneous Coronary Intervention
- Permanent Implantable Pacemakers
Genetic testing:
- Pharmacogenomic Testing
- Predictive and Prognostic Polygenic Testing
- Chromosomal Microarray Analysis
- Whole Exome Sequencing and Whole Genome Sequencing
- Somatic Tumor Testing
Musculoskeletal:
- Spine Surgery
- Sacroiliac Joint Fusion
Sleep:
- Sleep Disorder Management

NVBCBS-CD-056104-24-CPN54674, NVBCBS-CD-063772-24

Medical Policy & Clinical GuidelinesCommercialAugust 1, 2024

MCG Care Guidelines 28th edition

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines. Along with this upgrade, there will be some changes as to how transcranial magnetic stimulation (TMS) will be approved.

A specific change will be noted for Behavioral Health Care (BHG): Transcranial Magnetic Stimulation B-801-T. An annotation for motor threshold redetermination after initiation of treatment has been added to the Inconclusive or non-supportive evidence section of the evidence summary with new references to support it.

Any requests for CPT^® code 90869 will be referred for peer clinical review to determine medical necessity.

If you have questions, please contact Provider Services by calling the number on the back of the member's ID card.

MULTI-BCBS-CM-062483-24-SRS62339

Medical Policy & Clinical GuidelinesCommercialJune 25, 2024

Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Effective for dates of service on and after November 17, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Cell-free DNA testing (liquid biopsy) for the management of cancer:

Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)

Prenatal testing (changed to screening) using cell-free DNA:

Expanded criteria to include follow-up screening for abnormal maternal serum screen results in viable singleton/twin pregnancies when diagnostic testing is declined
Expanded criteria to include screening for pregnancies with multiple anomalies when diagnostic testing is not possible

Somatic testing of solid tumors:

Tissue-agnostic testing for patients with advanced solid tumors:
- Clarification about TMB testing by FDA-approved test with reporting threshold ≥ 10 mutations/megabase (mut/Mb)
Bladder cancer:
- Expansive changes for microsatellite instability/mismatch repair deficiency (MSI/dMMR)
Brain cancer:
- New clinical criteria considered clarifications for what may have otherwise been reviewed using general (umbrella) criteria
Breast cancer, metastatic:
- Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)
Colorectal cancer (CRC), localized and metastatic:
- Newly diagnosed localized or metastatic CRC — expanded criteria for MSI/dMMR testing to allow in individuals with de novo metastatic disease
- Metastatic CRC — expanded POLE/POLD1 testing
Endometrial carcinoma:
- Expanded routine testing for MSI/dMMR; also expanded POLE and p53 testing
- Panel size limited to ≤ 50 genes
Non-small cell lung cancer, metastatic:
- New criteria for metastatic squamous cell carcinoma
- Allowance for repeat next-generation sequencing (NGS) testing in the setting of progressive disease, if a progressing lesion is being used for the repeat testing
Ovarian (epithelial):
- Added statement that homologous recombination deficiency (HRD) testing must include evaluation of genomic instability through an FDA approved test
Pancreatic adenocarcinoma:
- Added criteria for targeted (50 or fewer genes) somatic testing beyond MSI/dMMR in locally advanced, metastatic, or recurrent pancreatic adenocarcinoma
Prostate cancer, metastatic:
- Specified appropriateness of MSI/dMMR testing is in metastatic prostate cancer
- Moved ataxia-telangiectasia mutated (ATM) from required to "may be included" genes in approvable NGS panels
Thyroid cancer:
- Testing of indeterminate thyroid nodules (ITN) — Afirma GSC added as a gene expression classifier that may be used
- Somatic testing of thyroid malignancy — modified language so that BRAF V600E, ALK, NTRK, and RET testing can be done in anaplastic thyroid cancer at any stage, or in unresectable, locally advanced, recurrent, or metastatic thyroid cancer

Somatic testing of hematologic malignancies:

Acute lymphocytic leukemia:
- Added statement about NGS testing on bone marrow specimen which specifies time points where testing is appropriate (such as end of initial induction, end of initial consolidation)
Acute myelogenous leukemia:
- Added an indication for focused testing using RT-qPCR to measure minimal residual disease (MRD)
Chronic myeloid leukemia:
- Modified the timing for BCR-ABL1 quantification for monitoring in the first year after completion of tyrosine kinase inhibitor (TKI) therapy
- Added allowance for BCR-ABL1 quantification for monitoring patients at three-month intervals beyond one year after completion of TKI therapy
Myeloproliferative neoplasms:
- Added allowance for additional focused testing for initial risk stratification if a specific myeloproliferative neoplasm is diagnosed on initial diagnostic workup
Myelodysplastic syndrome (MDS):
- Clarified that testing can be pursued for diagnosis or risk stratification and clarified the list of genes that may be associated with MDS

Musculoskeletal

Joint surgery:

Reverse shoulder arthroplasty:
- Added a requirement for impaired function for six months for consistency with total shoulder arthroplasty
- Removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
Shoulder arthroscopy and open procedures:
- Removal of loose body — removed requirement for specific findings on exam
- Rotator cuff repair and revision — added an exclusion for subacromial balloon spacer due to lack of supporting evidence
- Labrum repair — removed Bankart lesion broadening MRI findings to allow for any labral tear
- Chronic shoulder instability or laxity — broadened exam findings to include any evidence of instability rather than just the apprehension/relocation test
- Tendinopathy of the long head of the biceps — removed specific exam findings related to long head of biceps pathology
Primary total hip arthroplasty:
- Removed the requirements for conservative management and three-month duration of symptoms when radiographs show severe osteoarthritis
Primary partial hip arthroplasty:
- Combined criteria for partial hip arthroplasty and partial hip resurfacing
Hip arthroscopy:
- Removal of loose body — removed requirement for specific findings on exam
Knee arthroplasty:
- Added exclusion for the use of an implantable shock absorber due to lack of supporting evidence
Knee arthroscopy:
- Anterior cruciate ligament (ACL) reconstruction — removed standalone scenario of physically demanding occupation/pattern of activities
- Excision of popliteal cyst — added imaging requirement
- Repair of subchondral bone defects (subchondroplasty) — added exclusion for use of engineered calcium phosphate mineral or similar compounds due to lack of supporting evidence
Osteochondral grafts:
- Juvenile osteochondritis dissecans — expanded allowances to include either failed conservative management or unstable lesion
- Added exclusion for use of particulated juvenile articular cartilage due to lack of evidence supporting its use

Small joint surgery:

Hallux rigidus surgery:
- First metatarsophalangeal joint arthrodesis — removed three-month requirement for conservative management (not needed with severe osteoarthritis)
- First metatarsophalangeal joint arthroplasty — removed three-month requirement for conservative management; added allowance for failed prior hallux rigidus surgery
Ankle arthritis:
- Ankle arthrodesis and total ankle arthroplasty — removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
- Revision total ankle arthroplasty — added requirement for reconstruction after the management of periprosthetic infection to be consistent for staged reconstructions of infected total ankle

Surgical site of care:

Criteria have been reformatted to align with general categories that are used across all Carelon Medical Benefits Management Site of Care Guidelines.
Background, Scope, and Rationale sections have been updated and aligned with all Carelon Medical Benefits Management Site of Care Guidelines.
Clinical comorbidities have been broadened to include any American Society of Anesthesiologists (ASA) Class III or greater condition with specific examples updated as below:
- The following cardiac comorbidity examples were removed and replaced with “documented history of myocardial infarction or acute coronary syndrome”:
  - “Acute coronary syndrome within the prior three months”
  - Currently taking dual antiplatelet therapy which cannot be temporarily discontinued safely for the proposed surgical procedure
  - Ongoing ischemic symptoms
- The cerebrovascular example was changed from “Stroke or transient ischemic attack (TIA) within the prior three months” to “Documented history of stroke or transient ischemic attack (TIA).”
The criteria “mental status change” was removed due to redundancy with existing criteria of “intellectual disability or cognitive impairment.”
Criteria added for “when performing a procedure outside the Hospital Outpatient Department (HOPD) would reasonably be expected to create clinically significant delays in care.”
Criteria added for “Absence of a geographically accessible alternative non-HOPD facility capable of performing the requested procedure.”

Advanced imaging site of care:

Background, Scope, and Rationale sections have been updated and aligned with all Carelon Medical Benefits Management Site of Care Guidelines.
Criteria was added for “Additional resources required to establish and/or maintain IV access in patients with previous difficulty.”

How to submit prior authorization requests, ask questions, or get more information

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

Access the Carelon Medical Benefits Management provider portal directly at providerportal.com:
- Online access is available seven days a week, 24 hours a day to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website.

MULTI-BCBS-CM-061669-24

Medical Policy & Clinical GuidelinesMedicaidJuly 11, 2024

MCG Care Guidelines 28th edition

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

Behavioral Health Care (BHG):
- The goal length of stay (GLOS) has been changed in two guidelines in the 28th edition of Behavioral Health Care.
Inpatient & Surgical Care (ISC):
- The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines, in the 28th edition of Inpatient & Surgical Care.
General Recovery Care (GRG):
- Benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
Chronic Care (CCG):
- A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

If you have questions, please contact the Provider Services number on the back of the member's ID card.

NVBCBS-CD-056530-24-CPN55821

Medical Policy & Clinical GuidelinesMedicare AdvantageJuly 5, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Effective August 8, 2024

This article was updated as of September 11, 2024.

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Quarter 1, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider and select Change State and pick appropriate state. Then Providers > Policies, Guidelines & Manuals.

Notes/Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

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

OR-PR.00008 - Osseointegrated Limb Prostheses
- Outlines the Medically Necessary and Not Medically Necessary criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss
SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- Revised Medically Necessary criteria for basivertebral nerve ablation (BVNA)
SURG.00162 - Implantable Shock Absorber for Treatment of Knee Osteoarthritis
- Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered Investigational & Not Medically Necessary
CG-DME-53 - Biomechanical Footwear Therapy
- Biomechanical footwear therapy is considered Not Medically Necessary for all indications
CG-LAB-32 - Cancer Antigen 125 Testing
- Outlines the Medically Necessary and Not Medically Necessary criteria for the tumor marker cancer antigen 125 (CA-125) testing
CG-MED-94 - Vestibular Function Testing
- Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests
CG-MED-96 - Prefabricated External Infant Ear Molding Systems
- Outlines the Medically Necessary, Reconstructive and Cosmetic & Not Medically Necessary criteria for the use of prefabricated external infant ear molding systems to treat external ear malformations and deformations

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 8, 2024.

Publish Date	Medical Policy Number	Medical Policy Title	New or Revised
4/10/2024	*LAB.00039	Combined Pathogen Identification and Drug Resistance Testing Previously Titled: Pooled Antibiotic Sensitivity Testing	Revised
2/22/2024	MED.00140	Gene Therapy for Beta Thalassemia	Revised
4/10/2024	*OR-PR.00008	Osseointegrated Limb Prostheses	New
4/1/2024	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
4/10/2024	*SURG.00052	Percutaneous Vertebral Disc and Vertebral Endplate Procedures	Revised
4/10/2024	SURG.00145	Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)	Revised
4/10/2024	*SURG.00162	Implantable Shock Absorber for Treatment of Knee Osteoarthritis	New
4/10/2024	TRANS.00028	Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma	Revised

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare members on March 28, 2024. These guidelines take effect August 8, 2024.

Publish Date	Clinical UM Guideline Number	Clinical UM Guideline Title	New or Revised
4/10/2024	CG-DME-50	Automated Insulin Delivery Systems	Revised
4/10/2024	*CG-DME-53	Biomechanical Footwear Therapy	New
4/10/2024	*CG-LAB-32	Cancer Antigen 125 Testing	New
4/10/2024	CG-MED-68	Therapeutic Apheresis	Revised
4/10/2024	*CG-MED-94	Vestibular Function Testing	Revised
4/10/2024	*CG-MED-96	Prefabricated External Infant Ear Molding Systems	New
4/10/2024	CG-SURG-118	Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)	Conversion New
4/10/2024	CG-SURG-119	Treatment of Varicose Veins (Lower Extremities)	Conversion New
4/10/2024	CG-SURG-120	Vagus Nerve Stimulation	Conversion New
4/10/2024	CG-SURG-121	Fetal Surgery for Prenatally Diagnosed Malformations	Conversion New
4/1/2024	CG-SURG-78	Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies	Revised

MULTI-BCBS-CR-061533-24-CPN60990, MULTI-ALL-CRMMP-066285-24

Prior AuthorizationCommercialAugust 1, 2024

Notification of authorization fax number changes

Anthem is in the process of shutting down specific authorization fax channels. This is to notify you the below fax numbers will be decommissioned as of August 30, 2024.

Look for additional notifications as other authorization fax lines are retired.

Availity Authorizations is the preferred method for authorization intakes. If you cannot use Availity Authorizations, call our contact center at 833-545-9102, and we will work with you to determine the best submission method.

Available resources

Registering and accessing Availity is easy. If your organization is not registered for Availity, start here.

If you are not already familiar with Availity Authorization, training is available. Register for training today and learn about the simple workflow for submitting digital authorizations.

These fax numbers will be turned off as of August 30, 2024.

MULTI-BCBS-CM-063748-24-CPN63063

Reimbursement PoliciesCommercialAugust 1, 2024

New reimbursement policy: Intraoperative Neuromonitoring — Professional

Beginning with dates of service on or after November 1, 2024, Anthem will implement a new reimbursement policy titled Intraoperative Neuromonitoring — Professional based on guidelines from the American Academy of Neurology. This reimbursement policy will allow reimbursement for intraoperative neuromonitoring (IONM) when billed by a professional provider with a place of service 19, 21, 22, or 24.

When reporting IONM, providers are required to bill on a CMS-1500 form and use the appropriate place of service. Services must be performed in a hospital setting using the place of service where the member is located even if the monitoring physician is in an office. The following place of service codes are appropriate for use by the monitoring physician:

Off campus-outpatient hospital (19)
Inpatient hospital (21)
On campus-outpatient hospital (22)
Ambulatory surgical center (24)

For specific policy details, visit reimbursement policy page at anthem.com.

MULTI-BCBS-CM-062863-24-SRS62734

Reimbursement PoliciesCommercialAugust 1, 2024

Reimbursement policy update: Modifiers 26 and TC — Professional

Anthem updated the Modifiers 26 and TC — Professional reimbursement policy in October 2023. The statement below was inadvertently removed from the Nonreimbursable section of the policy, but remained in the policy Definition section:

There is a separate standalone code that describes the professional component only, technical component only, or global test only of a selected diagnostic test.

No claims were impacted by the omission of this statement. The Nonreimbursable section of the policy has been updated to include this statement.

For specific policy details, visit the reimbursement policy page at anthem.com.

MULTI-BCBS-CM-061251-24

Reimbursement PoliciesMedicare AdvantageAugust 1, 2024

Reimbursement policy update: Modifier 78

(Policy G-06016, effective 07/01/2024)

Past system limitations prevented us from reimbursing Modifier 78 in complete alignment with Centers for Medicare & Medicaid Services (CMS). New system updates will now allow Anthem to closer align with the CMS Medicare Physician Fee Schedule Data Base (MPFSDB).

For claims processed on and after 07/01/2024, you may see a slight adjustment in reimbursement which will reflect this configuration update.

For specific policy details visit the reimbursement policy page at anthem.com/medicareprovider.

MULTI-BCBS-CR-048996-23-CPN45239

Reimbursement PoliciesCommercialAugust 1, 2024

Reimbursement policy update: Professional Anesthesia Service

Beginning with dates of service on or after November 1, 2024, Anthem will update the Anesthesia Modifiers list in the Related Coding section of the Professional Anesthesia Service reimbursement policy as follows:

Updated modifier QZ reimbursement from 100% to 85%.
Added modifiers QK, QX, or QY language (removed from the policy body section).
Removed diagnosis codes not eligible for reimbursement when reported with add-on code 99140 code list.
Added the following statement to the Comments column for modifiers G8, G9, and QS column:
- May be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).
Updated physical status modifiers P3, P4, and P5 language to indicate reimbursement for the applicable additional time unit.

Section V., Qualifying Circumstances for Anesthesia will be updated to indicate that Anthem will consider qualifying circumstances to be always bundled when reported in addition to the anesthesia procedure or service provided.

For specific policy details, visit reimbursement policy page at anthem.com.

MULTI-BCBS-CM-063134-24-SRS62776

Reimbursement PoliciesCommercialAugust 1, 2024

Reimbursement policy update: Bundled Services and Supplies — Facility

Beginning with dates of service on or after November 1, 2024, Anthem will update the Bundled Services and Supplies — Facility reimbursement policy as follows:

Addition of categories of services considered integral to the primary service, or included in the facility fee that are not allowed for separate reimbursement when billed by a facility provider
Addition of the following code to the Related Coding section:

G2211 — visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition

For specific policy details, visit the reimbursement policy page and select the appropriate state.

MULTI-BCBS-CM-062760-24

Reimbursement PoliciesCommercialAugust 1, 2024

Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility

Beginning with dates of service on or after November 1, 2024, Anthem will update the related coding section of the Outpatient Facility Revenue Code Billing Requirements — Facility reimbursement policy. The policy requires HCPCS or CPT^®codes to be submitted for reimbursement when submitted with certain revenue codes. The policy is updated to include the following revenue codes that require a corresponding HCPCS or CPT code:

0270 Medical/Surgical Supplies and Devices — General
0271 Medical/Surgical Supplies and Devices — Nonsterile
0272 Medical/Surgical Supplies and Devices — Sterile
0273 Medical/Surgical Supplies and Devices — Take-home supplies
0274 Medical/Surgical Supplies and Devices — Prosthetic/orthotic devices
0275 Medical/Surgical Supplies and Devices — Pacemaker
0276 Medical/Surgical Supplies and Devices — Intraocular lens
0277 Medical/Surgical Supplies and Devices — Take-home oxygen
0279 Medical/Surgical Supplies and Devices — Other supplies/devices
0280 Oncology — General
0920 Other diagnostic services — General
0940 Other therapeutic services — General

For specific policy details, visit the reimbursement policy page at anthem.com.

MULTI-BCBS-CM-062881-24-SRS62741

Reimbursement PoliciesMedicare AdvantageAugust 1, 2024

Reimbursement policy update: Nurse Practitioner and Physician Assistant Services

(Policy G-20002, effective 11/01/2024)

Beginning with dates of service on or after 11/01/2024, Anthem will update the Nurse Practitioner and Physician Assistant Services reimbursement policy as indicated below.

The following services will be removed as physicians’ services:

Preventive Services
Radiology Services

The following services will be included as physicians’ services:

Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
Laboratory Services and Screening Services

For specific policy details, visit the reimbursement policy page at Anthem.com/provider.

MULTI-BCBS-CR-050463-24-CPN49984

Reimbursement PoliciesMedicaidAugust 1, 2024

Reimbursement policy update: Nurse Practitioner and Physician Assistant Services

(Policy G-20002, effective 11/01/2024)

Beginning with dates of service on or after 11/01/2024, Anthem will update the Nurse Practitioner and Physician Assistant Services reimbursement policy as indicated below.

The following services will be removed as physicians’ services:

Preventive Services
Radiology Services

The following services will be included as physicians’ services:

Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
Laboratory Services and Screening Services

For additional information, please review the Nurse Practitioner and Physician Assistant Services reimbursement policy at providers.anthem.com/nv.

NVBCBS-CD-050440-24-CPN49984

PharmacyCommercialJuly 25, 2024

Specialty pharmacy updates — February 2024

Note: This article corrects the Clinical Criteria for Spravato (esketamine), which was incorrectly listed in a February 2024 article.

Specialty pharmacy updates for Anthem are listed below

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Update: In the May 2023 edition of Provider News, we announced prior authorization for Adstiladrin would be effective August 2023. Review of Adstiladrin is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

Clinical Criteria	Drug	HCPCS or CPT® code(s)
CC-0252	Adzynma (ADAMTS13, recombinant-krhn)	C9399
CC-0253*	Aphexda (motixafortide)	J3490, J3590, J9999
CC-0042	Bimzelx (bimekizumab-bkzx)	J3490
CC-0032	Daxxify (daxibotulinumtoxinA-lanm)	C9160
CC-0050	Omvoh (mirikizumab-mrkz)	J3590
CC-0066*	Tofidence (tocilizumab-bavi)	J3490, J3590
CC-0254	Zilbysq (zilucoplan)	J3490
CC-0062	Zymfentra (infliximab-dyyb)	J3590

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0042	Bimzelx (bimekizumab-bkzx)	J3490
CC-0032	Daxxify (daxibotulinumtoxinA-lanm)	C9160
CC-0050	Omvoh (mirikizumab-mrkz)	J3590
CC-0086	Spravato (esketamine)	G2082, G2083, S0013
CC-0066	Tofidence (tocilizumab-bavi)	J3490, J3590
CC-0254	Zilbysq (zilucoplan)	J3490
CC-0062	Zymfentra (infliximab-dyyb)	J3590

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-061803-24-CPN61620

PharmacyCommercialAugust 1, 2024

Specialty pharmacy updates — August 2024

Specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of a national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after November 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria at anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these prior authorization updates.

Clinical Criteria	Drug	HCPCS or CPT^® code(s)
CC-0262*	Tevimbra (tislelizumab-jsgr)	J3590, J9999
CC-0066*	Tyenne (tocilizumab-aazg)	C9399, J3590
CC-0063	Wezlana (ustekinumab-auub)	Q5137, Q5138]

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Access our Clinical Criteria at anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these quantity limit updates.

Clinical Criteria	Drug	HCPCS or CPT code(s)
CC-0066	Tyenne (tocilizumab-aazg)	C9399, J3590
CC-0063	Wezlana (ustekinumab-auub)	Q5137, Q5138

MULTI-BCBS-CM-063401-24-CPN63195

August 2024 Provider Newsletter

Contents

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Summary:

Review, verify, and update your directory information

Use Roster Automation to submit provider demographic changes

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Active group agreement with individual providers identified as inactive:

Active group agreement with no remaining individual providers identified:

What if I need assistance?

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Members included in the new program

Pre-service review requirements

For more information

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Discover what users across the country already know.

Get started today.

Contact us.

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Stick with it

Work with a coach

Live and on-demand webinars

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Whole health

Certified doula care can help improve maternal and infant health outcomes

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Summary

What this means to you

Why is this change necessary?

Do I need to refile claims?

What is the impact of the change on coding?

Codes affected by this change

Billing examples

What is the impact of the change on medical record review requirements?

What if I need help?

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Summary

Please note:

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Please note:

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Genetic testing

Musculoskeletal

Surgical site of care:

Advanced imaging site of care:

How to submit prior authorization requests, ask questions, or get more information

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Notes/Updates:

Medical Policies

Clinical UM Guidelines

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Available resources

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Specialty pharmacy updates for Anthem are listed below

Prior authorization updates

Quantity limit updates

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Prior authorization updates

Quantity limit updates

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