 Provider News NevadaJuly 1, 2024 July 2024 Provider Newsletter Contents
NVBCBS-CDCRCM-061284-24 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). To ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis for our pediatric members, we review clinical information (including treatment and medical management) and laboratory and diagnostic procedure findings in the medical records submitted for review. To conduct the review accurately and consistently, our review process for pediatric sepsis applies coding and documentation guidelines. Beginning with admission dates of July 1, 2024, and later for members aged 29 days through 17 years of age, we will also apply the updated and most recent publication of the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force criteria known as the Phoenix Sepsis Criteria, published in the Journal of the American Medical Association (JAMA) in January 2024. Clinicians and facilities should apply the Phoenix Sepsis Criteria when determining at discharge if the pediatric patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the Phoenix Sepsis Criteria. Together, we can work towards improved outcomes. jamanetwork.com/journals/jama/article-abstract/2814297 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-056038-24-CPN55116 Beginning with claims processing on or after August 1, 2024, Anthem will use coding policies to support the use of anatomical modifiers. These policies were developed to promote national correct coding methods and to control improper coding that leads to incorrect payment. This update is part of continuing efforts to process claims accurately without having to request additional documentation from care providers. What are the policies for using anatomical modifiers in procedure coding?CPT® and HCPCS Level II guidelines supporting the use of anatomic-specific modifiers were used to develop these policies, which validate the area or part of the body on which a procedure is performed. Procedure codes that do not specify right or left require the appropriate anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied. Action neededCPT and HCPCS Level II guidelines support the following set of anatomical modifiers to facilitate correct coding for claims processing. Care providers are encouraged to follow these guidelines and append the modifiers relevant to the procedure code on the service line. The anatomical modifiers, which must be reported, are: Modifier | Description | E1–E4 | Eyelids | FA, F1–F9 | Fingers | TA, T1–T9 | Toes | LC | Left circumflex, coronary artery | LD | Left anterior descending, coronary artery | LM | Left main coronary artery | RC | Right coronary artery | RI | Ramus intermedius | LT | Left side | RT | Right side | 50 | Bilateral |
We are committed to a future of shared success. 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 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-059553-24-CPN58952 Effective for all claims received on and after August 1, 2024, Anthem is updating its outpatient facility editing system to deny revenue code 0710 (recovery room services) when billed without revenue code 037X (anesthesia services), on the same claim. Per industry-standard coding resources, including the UB04 editor and the National Uniform Billing Committee (NUBC), “an anesthesia charge (revenue code category 037X) should be billed with a revenue code from category 071X, recovery room charge.” If you believe you have received a denial in error, follow the Anthem claim dispute process. 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-CM-061118-24-SRS60998 Effective for all claims received on and after August 1, 2024, Anthem is updating its professional claims editing system to deny anesthesia services billed without the required anesthesia modifiers. According to industry-standard coding resources including the American Society of Anesthesiologists and AMA CPT® coding manuals, and the Anthem current commercial professional anesthesia services reimbursement policy, anesthesia modifiers are necessary to identify whether a procedure was personally performed, medically directed, or medically supervised. The required modifiers to be reported by provider type are as follows: Provider type
| Required modifier(s)
| Anesthesiologist | AA, AD, QK, or QY | CRNA or anesthesiologist assistant — medically directed | QX | CRNA — not medically directed | QZ |
If you believe you have received a claim denial in error, follow the Anthem claim dispute process. 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-CM-061114-24 When working with another carrier, submit documentation from the other carrier when you send the claim to Anthem to help avoid the claim from denying for timely filing. You can submit the documentation and the claim through Availity Essentials using the Claims and Payments application. If we are the secondary payer, we will need to receive an Explanation of Benefits (EOB) along with the claim submission to determine our payment amount. To avoid a timely filing denial, the documentation must demonstrate that submission to the other insurer was within Anthem’s timely filing limit and must reflect that it was received within the timely filing limit starting from the date of the remittance advice or Explanation of Payments. If you submit to the other carrier first and receive a rejection, submit the denial letter from the other insurance carrier along with the claim. To avoid a timely filing denial, the denial letter must be dated and printed on letterhead, and the claim and documentation must be submitted to Anthem within the timely filing limit starting from the date of the denial letter. When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can delay your receiving payment and can also cause you to miss the timely filing guideline. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners. ResourceCoordination of benefits — how to avoid timely filing denial 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-CM-061117-24 ATTACHMENTS (available on web): Coordination of benefits — how to avoid timely filing denials (pdf - 0.32mb) Effective October 1, 2024, Anthem is enhancing its claims editing system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate Federal Drug Administration (FDA) approved indicators for on- and off-label use. These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with the FDA indicator for on-/off-label use. If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record that is relevant to the drug provided. If you have questions about this notification, contact your contract manager or provider relationship management account 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-CM-061244-24 Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/provider. Then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information has changed. Updating your informationAnthem uses the provider data management (PDM) capability available on Availity Essentials to update your care provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA). PDM features include:- Updating care provider demographic information for all assigned payers in one location.
- Attesting to and managing current care provider demographic information.
- Monitoring submitted demographic updates in real-time with a digital dashboard.
- Reviewing the history of previously verified data.
Accessing the PDM applicationLog on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be 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. PDM training PDM training is available: - Log on to Availity.com to learn about and attend one of our training opportunities.
- On Availity.com, you can view the Availity PDM quick start guide.
- Roster Automation Standard Template and Roster Automation Rules of Engagement training:
- Listen to our recorded webinar on Availity.com.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your care providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY. We are focused on reducing administrative burdens, so you can do what you do best — care for our members. 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-CM-060917-24-SRS60902 Beginning August 1, 2024, the mailing address for submitting paper claims and claims-related correspondence will change. The current post office box in Colorado is being decommissioned and replaced by a post office box in California. This box is used for receiving provider inquiries related to claims, appeals, and other related inquiries. The current mailing address is: P.O. Box 5747
Denver, CO 80217-5747 On August 1, 2024, this will change to: P.O. Box 60007
Los Angeles, CA 90060-0007 Please make note of this address change. While the Colorado post office box will be shut down by the beginning of August 2024, there will be premium forwarding set up for one year to help ensure mail is not lost. 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-CM-060171-24 Routinely, the CMS issues revisions to the average sales price (ASP) fee schedules regarding drug pricing. The CMS third quarter fee schedule has been released and is effective on July 1, 2024. This will go into effect with Anthem on August 1, 2024. To view the ASP fee schedule, please visit the CMS website at tinyurl.com/2u9am6cv. We are committed to a future of shared success. 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-CM-059947-24 In our previous communications, we shared information about using the Authorizations and Referrals application on Availity Essentials to receive digital notifications for your authorization cases and related decision letters, and we introduced the Preference Center for Authorization and Referrals where you can select your preferred method of communication. We are excited to announce that we launched the Preference Center for Authorization and Referrals in April and will start using your preferences there in July. Here is a quick recap on how to receive digital notifications and set your preferred communication method for the status of your authorization cases. Use the Authorizations and Referrals application for digital notifications:- Retrieve cases submitted digitally and non-digitally by your organization through Auth/Referral Inquiry; use the Pin to Dashboard feature to keep these cases on the Auth/Referral Dashboard, saving you from repeating the search in the future.
- Find the most recent statuses of cases submitted by your organization on the Auth/Referral Dashboard — Select View Details in the Actions menu for case details, including decision letters. For pinned cases, select the case card to get the latest status and case details.
Access the Preference Center and set your preferences:- After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile.
- Select your organization and then set your communication preference (your default is Digital Access (Default) or if you prefer to receive paper surface mail, you can select Digital + Mail) for Authorization and Referrals:
- Adjust the preference for the tax IDs and NPIs of your organization to fit your business needs.
- You can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs.
Manage preferences (Availity administrators)Availity Administrators can learn more about managing preferences related to Authorization Decision letters. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters. With your help, we can continually build towards a future of shared success. 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-CM-060250-24-CPN60234 For those providers and their corresponding vendors (either billing services or clearinghouses) who submit corrected claims through EDI, we’re enhancing the 277CA to notify you of submission errors discovered during our claims processing. Although you’ll continue to receive physical mail notifications related to claims processing issues, the 277CA notifications can expedite the turnaround time by highlighting submission issues upfront. Now, the 277CA will also communicate the following messages: - Tax ID and NPI are not registered.
- Billed place of treatment doesn’t correspond with the place of service.
- Rendering provider isn’t valid for the service date.
- Billing NPI doesn’t align with the claim’s tax ID.
Despite the addition of this new feature, there will be no reductions in the services we already provide. Our hope is that this change will augment the speed and communication of our service. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners. 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-CM-060850-24-CPN59863 We hope you are finding our monthly observance articles helpful and informative. We will continue to feature these monthly articles to keep you informed about our resources that are here to support you in caring for all of our members. We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers. In recognition of July as Disability Awareness Month, and to commemorate the signing of the Americans with Disabilities Act (ADA) in 1990 that promotes equal rights and accessibility for people with disabilities, we are introducing three eLearning resources and tools on My Diverse Patients. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address disparities. Availability of multiple free continuing medical education (CME) courses with CMEs are offered through the American Academy of Family Physicians (AAFP). For the month of July, our featured eLearning Resources & Tools are: - Health Equity Framework for People with Disabilities:
- This policy brief provides the rationale for the need for an all-of-government approach to achieve health equity in the United States and its territories for the largest unrecognized minority group in this country — the over 61 million people with disabilities — and sets forth a framework to achieve health equity for all people with disabilities. Disability is a natural part of the human condition, which occurs across all ages, genders, races, ethnicities, languages, and social groups.
- Health Equity for People with Disabilities:
- The CDC’s Division of Human Development and Disability (DHDD) works to promote health and reduce health inequities for people with disabilities of all ages so they can participate fully in all aspects of their communities throughout their lives and have the opportunity to achieve all they set out to do.
- Connections Between Health Equity and Disability:
- When it comes to healthcare, significant disparities abound between people with disabilities and able-bodied people. From physical barriers and discrimination to financial hurdles and a lack of available resources, access to healthcare is alarmingly inequitable for people with disabilities around the world.
We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare. 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-ALL-CRCM-060725-24-CPN60345 When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim. - For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:
- In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
- It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.
- For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:
- In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
- It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.
We’ve also developed a training video that can help you reduce duplicate claims along with a training guide called Making the Claims Process Work for You to help you properly submit a corrected claim. Access the video and download the guide here. Provider information is required to view this training; however, you will only be prompted to enter this information the first time viewing this training. If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report. 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-CM-049145-23-CPN48099, MULTI-BCBS-CM-061597-24-CPN61590 We have enhanced functionality on the eLearning platform MyDiversePatients.com. This new functionality identifies learners and supports our ongoing commitment to health equity and cultural competency. When a care provider (doctor, nurse, health professional, office staff) starts an online continuing medical education (CME) course, they now have the option to register a National Provider Identifier (NPI): - Flexibility: Self-paced learning gives the learner the freedom to decide when and where to take the trainings.
- Multi-device accessibility: The course site is fully responsive and designed to work with multiple devices, including smartphone, tablet, and desktop. This means you can learn from the comfort of your home, while on the go, in the office, or any location of your choosing.
- Progress tracking: The NPI registration allows the platform to monitor and track learning progress and achievements, helping health professionals to meet their CME requirements efficiently.
- Credit management: Upon completion of a CME course and review of the recommended materials, the user has the opportunity to fill in a certificate of completion with the information they wish to appear on the document itself.
- Find Care provider search tool: If the eLearner chooses to register their NPI when they take a CME course, progress is tracked to completion. The NPI number allows for a cultural competency indicator to appear beside the provider’s name in directories (Find Care). This is designed to support referring practitioners and members by being able to identify providers who have received certificates in cultural competency.
Goals of My Diverse Patients:- Offer a comprehensive repository of resources for care providers to help support the needs of diverse patients and address disparities.
- Provide cultural competency for relevant resources from external sources (such as medical journals and medical/quality organizations.)
Benefits:- Availability of multiple free CME resources — CME courses are offered through the American Academy of Family Physicians.
- Real life stories about diverse patients and the unique challenges they face.
- Tips for working with diverse patients to promote improvement in health outcomes.
New courses with CME credits and nursing continuing education units will be added in 2024. We look forward to working together to deliver equitable healthcare. 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-055981-24-CPN54448 Effective July 4, 2024, Anthem will transition to the InterQual® 2024 criteria, to include updates from March 2024. InterQual criteria used by this market: - Long-term Care Criteria
- Rehabilitation Criteria
- Subacute and Skilled Nursing Facility (SNF) Criteria
If you have any questions, please contact Provider Services at 844-396-2330. 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-056486-24-CPN55035 Effective June 29, 2024 Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 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 need 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 | June 29, 2024 | *CC-0258 | iDoseTR (travoprost Implant) | New | June 29, 2024 | *CC-0259 | Amtagvi (lifleucel) | New | June 29, 2024 | *CC-0260 | Nexobrid (anacaulase-bcdb) | New | June 29, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised | June 29, 2024 | *CC-0041 | Complement Inhibitors | Revised | June 29, 2024 | CC-0128 | Tecentriq (atezolizumab) | Revised | June 29, 2024 | CC-0116 | Bendamustine agents | Revised | June 29, 2024 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised | June 29, 2024 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised | June 29, 2024 | CC-0157 | Padcev (enfortumab vedotin) | Revised | June 29, 2024 | CC-0230 | Adstiladrin (nadofaragene firadenovec-vncg) | Revised | June 29, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised | June 29, 2024 | *CC-0119 | Yervoy (ipilimumab) | Revised | June 29, 2024 | *CC-0099 | Abraxane (paclitaxel, protein bound) | Revised | June 29, 2024 | *CC-0093 | Docetaxel (Taxotere) | Revised | June 29, 2024 | *CC-0094 | Pemetrexed (Alimta, Pemfexy, Pemrydi) | Revised | June 29, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised | June 29, 2024 | *CC-0088 | Elzonris (tagraxofusp-erzs) | Revised | June 29, 2024 | *CC-0118 | Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin) | Revised | June 29, 2024 | *CC-0112 | Xofigo (Radium Ra 223 Dichloride) | Revised | June 29, 2024 | *CC-0123 | Cyramza (ramucirumab) | Revised | June 29, 2024 | *CC-0131 | Besponsa (inotuzumab ozogamicin) | Revised | June 29, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised | June 29, 2024 | CC-0122 | Arzerra (ofatumumab) | Revised | June 29, 2024 | CC-0232 | Lunsumio (mosunetuzumab-axgb) | Revised | June 29, 2024 | CC-0109 | Zaltrap (ziv-aflibercept) | Revised | June 29, 2024 | CC-0135 | Melanoma Vaccines | Revised | June 29, 2024 | *CC-0096 | Asparagine Specific Enzymes | Revised | June 29, 2024 | CC-0120 | Kyprolis (carfilzomib) | Revised | June 29, 2024 | *CC-0117 | Empliciti (elotuzumab) | Revised | June 29, 2024 | *CC-0126 | Blincyto (blinatumomab) | Revised | June 29, 2024 | CC-0113 | Sylvant (siltuximab) | Revised | June 29, 2024 | CC-0132 | Mylotarg (gemtuzumab ozogamicin) | Revised | June 29, 2024 | CC-0097 | Vidaza (azacitidine) | Revised | June 29, 2024 | CC-0129 | Bavencio (avelumab) | Revised | June 29, 2024 | *CC-0090 | Ixempra (ixabepilone) | Revised | June 29, 2024 | CC-0110 | Perjeta (pertuzumab) | Revised | June 29, 2024 | *CC-0115 | Kadcyla (ado-trastuzumab) | Revised | June 29, 2024 | *CC-0108 | Halaven (eribulin) | Revised | June 29, 2024 | CC-0089 | Mozobil (plerixafor) | Revised | June 29, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised | June 29, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised | June 29, 2024 | *CC-0212 | Tezspire (tezepelumab-ekko) | Revised | June 29, 2024 | *CC-0033 | Xolair (omalizumab) | Revised | June 29, 2024 | *CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised | June 29, 2024 | *CC-0029 | Dupixent (dupilumab) | Revised | June 29, 2024 | *CC-0208 | Adbry (tralokinumab) | Revised | June 29, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | June 29, 2024 | *CC-0067 | Prostacyclin Infusion and Inhalation Therapy | Revised | June 29, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | June 29, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised | June 29, 2024 | *CC-0057 | Krystexxa (pegloticase) | Revised | June 29, 2024 | *CC-0068 | Growth Hormones | Revised | June 29, 2024 | *CC-0047 | Trogarzo | Revised | June 29, 2024 | *CC-0078 | Orencia (abatacept) | Revised | June 29, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised | June 29, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised | June 29, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
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-059008-24-CPN57972 SummaryOn November 17, 2023, and March 21, 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. For 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 | July 6, 2024 | *CC-0261 | Winrevair (sotatercept-csrk) | New | July 6, 2024 | *CC-0125 | Opdivo (nivolumab) | Revised | July 6, 2024 | *CC-0003 | Immunoglobulins | Revised | July 6, 2024 | CC-0033 | Xolair (omalizumab) | Revised | July 6, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | July 6, 2024 | CC-0121 | Gazyva (obinutuzumab) | Revised | July 6, 2024 | CC-0201 | Rybrevant (amivantamab-ymjw) | Revised | July 6, 2024 | *CC-0251 | Ycanth (cantharidin) | Revised |
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-059942-24-CPN59599 Summary: On February 24, 2023, September 11, 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. For 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 | July 7, 2024 | *CC-0252 | Adzynma (ADAMTS13, recombinant-krhn) | New | July 7, 2024 | *CC-0253 | Aphexda (motixafortide) | New | July 7, 2024 | *CC-0254 | Zilbysq (zilucoplan) | New | July 7, 2024 | CC-0130 | Imfinzi (durvalumab) | Revised | July 7, 2024 | CC-0223 | Imjudo (tremelimumab-actl) | Revised | July 7, 2024 | *CC-0059 | Selected Injectable NK-1 Antiemetic Agents | Revised | July 7, 2024 | CC-0074 | Akynzeo (fosnetupitant and palonosetron) for injection | Revised | July 7, 2024 | *CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised | July 7, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised | July 7, 2024 | CC-0150 | Kymriah (tisagenlecleucel) | Revised | July 7, 2024 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised | July 7, 2024 | CC-0133 | Aliqopa (copanlisib) | Revised | July 7, 2024 | CC-0205 | Fyarro (sirolimus albumin bound) | Revised | July 7, 2024 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised | July 7, 2024 | *CC-0226 | Elahere (mirvetuximab) | Revised | July 7, 2024 | CC-0125 | Opdivo (nivolumab) | Revised | July 7, 2024 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised | July 7, 2024 | *CC-0009 | Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis | Revised | July 7, 2024 | *CC-0014 | Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis | Revised | July 7, 2024 | *CC-0011 | Ocrevus (ocrelizumab) | Revised | July 7, 2024 | *CC-0174 | Kesimpta (ofatumumab) | Revised | July 7, 2024 | *CC-0020 | Natalizumab Agents (Tysabri, Tyruko) | Revised | July 7, 2024 | *CC-0032 | Botulinum Toxin | Revised | July 7, 2024 | *CC-0068 | Growth Hormone | Revised | July 7, 2024 | *CC-0173 | Enspryng (satralizumab-mwge) | Revised | July 7, 2024 | *CC-0170 | Uplizna (inebilizumab-cdon) | Revised | July 7, 2024 | *CC-0199 | Empaveli (pegcetacoplan) | Revised | July 7, 2024 | *CC-0041 | Complement Inhibitors | Revised | July 7, 2024 | *CC-0071 | Entyvio (vedolizumab) | Revised | July 7, 2024 | *CC-0064 | Interleukin-1 Inhibitors | Revised | July 7, 2024 | *CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | July 7, 2024 | *CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | July 7, 2024 | *CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised | July 7, 2024 | *CC-0078 | Orencia (abatacept) | Revised | July 7, 2024 | *CC-0063 | Ustekinumab Agents | Revised | July 7, 2024 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | July 7, 2024 | CC-0003 | Immunoglobulins | Revised | July 7, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised | July 7, 2024 | CC-0247 | Beyfortus (nirsevimab) | Revised | July 7, 2024 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | July 7, 2024 | CC-0010 | Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors | Revised | July 7, 2024 | CC-0209 | Leqvio (inclisiran) | Revised | July 7, 2024 | *CC-0182 | Iron Agents | Revised | July 7, 2024 | *CC-0086 | Spravato (esketamine) Nasal Spray | Revised |
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-050483-24-CPN49884 Summary: On December 11, 2023, and January 5, 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 need 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 | July 12, 2024 | *CC-0255 | Loqtorzi (toripalimab-tpzi) | New | July 12, 2024 | *CC-0256 | Rivfloza (nedosiran) | New | July 12, 2024 | *CC-0257 | Wainua (eplontersen) | New | July 12, 2024 | *CC-0185 | Oxlumo (lumasiran) | Revised | July 12, 2024 | *CC-0107 | Bevacizumab for Non-ophthalmologic Indications | Revised | July 12, 2024 | *CC-0002 | Colony Stimulating Factor Agents | Revised | July 12, 2024 | CC-0075 | Rituximab Agents for Non-Oncologic Indications | Revised | July 12, 2024 | CC-0213 | Voxzogo (vosoritide) | Revised | July 12, 2024 | CC-0124 | Keytruda (pembrolizumab) | Revised | July 12, 2024 | *CC-0110 | Perjeta (pertuzumab) | Revised |
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-051286-24-CPN50531 This article was updated as of August 23, 2024. Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. 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. - Site of Care Guidelines:
- Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care
Please share this notice with other members of your practice and office staff. 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-055213-24-CPN54524, MULTI-ALL-CDCR-066460-24 This article was updated as of August 23, 2024. Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. 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. - Site of Care Guidelines:
- Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care
Please share this notice with other members of your practice and office staff. 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-055356-24-CPN54514, MULTI-ALL-CDCR-066460-24 This article was updated on August 14, 2024. This article is to communicate the plan adoption of the below 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. Effective on October 20, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review, will apply for Anthem: - 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
- Radiology:
- Imaging of the Spine
- Imaging of the Extremities
- Vascular Imaging
- Imaging of the Brain
- Sleep:
- Sleep Disorder Management
Please share this notice with other members of your practice and office staff. 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-CR-056309-24-CPN54675, NVBCBS-CR-063894-24-SRS63889 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. Since 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 Clinical Guidelines effective for service dates on and after October 1, 2024 Policy or guideline number | Policy title | Explanation of policy | CG-MED-78 | Anesthesia Services for Interventional Pain Management Procedures | Addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures. This document does not address whether or not reimbursement is provided for the anesthesia service and it is not intended to guide the billing and reimbursement of anesthesia services: - Considered investigational and not medically necessary when the criteria are not met.
- Prior authorization required effective October 1, 2024.
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The Medical Policies and Clinical UM Guidelines for Anthem are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes medical directors and representatives for Anthem 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 for Nevada available onlineThe complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s website at anthem.com — Select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & UM Guidelines. Either enter key word or code or select the link for Full List page to search the policy for your inquiry. To view the list of specific Clinical UM Guidelines adopted by Nevada, navigate to the View Medical Policies & UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem in Nevada. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CM-061364-24 Anthem is pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to our Clinical Utilization Management (UM) Guidelines that are adopted for Nevada. The Clinical UM Guidelines published on our website represent the Clinical UM Guidelines currently available to all plans for adoption throughout our organization. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether or not to implement a particular Clinical UM Guideline. The link below can be used to confirm whether or not the local plan has adopted the Clinical UM Guideline(s) in question. Adoption lists are created and maintained solely by each local plan. The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below. New Medical Policies and Clinical UM Guidelines effective for service dates on and after October 1, 2024 Policy or guideline number | Policy title | Explanation of policy | CG-SURG-121 | Fetal Surgery for Prenatally Diagnosed Malformations | Addresses the use of surgical techniques to correct or treat fetal malformations in utero, including: vesico-amniotic shunting as a treatment of urinary tract obstruction, repair of myelomeningocele as a treatment of neural tube defect, fetoscopic endoluminal tracheal occlusion as a treatment of congenital diaphragmatic hernia, and fetal aortic valvuloplasty as a treatment of critical aortic stenosis. This document does not address surgery to correct placental or uterine abnormalities including, but not limited to, amnioreduction or laser coagulation therapy to address interfetal transfusion syndrome: - Considered investigational and not medically necessary when the criteria are not met
- Prior authorization required effective October 1, 2024
| CG-SURG-118 | Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) | Addresses intraocular anterior segment aqueous humor drainage devices (without extraocular reservoir) used in the treatment of glaucoma (open-angle glaucoma; refractory, primary and secondary) to reduce intraocular pressure (IOP): - Considered investigational and not medically necessary when the criteria are not met.
- Prior authorization required effective October 1, 2024.
| CG-SURG-119 | Treatment of Varicose Veins (Lower Extremities) | Addresses various modalities for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV), anterior accessory great saphenous vein (AAGSV), or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins: - Considered investigational and not medically necessary when the criteria are not met
- Prior authorization required effective October 1, 2024
| CG-SURG-120 | Vagus Nerve Stimulation | Addresses the indications for use of an implantable vagus nerve stimulation (VNS) device, the electronic analysis of the implanted neurostimulator pulse generator system, and non-implantable (transcutaneous) VNS devices. These devices are used as a treatment of medically and surgically refractory seizures associated with intractable epilepsy. Implantable devices may deliver stimulation in an open-loop fashion with continuous but intermittent (‘ON’ and ‘OFF’ cycles) stimulation of the vagus nerve (a hand-held magnet allows on-demand stimulation to interrupt seizure activity), or may utilize detection of extra-cerebral indicators, for example, cardiac-based seizure detection (also known as “responsive devices”, “devices with an automatic stimulation mode”, or “closed loop devices”) that specifically use tachycardia as a surrogate marker for seizure prediction: - Considered investigational and not medically necessary when the criteria are not met
- Prior authorization required effective October 1, 2024.
| OR-PR.00008 | Osseointegrated Limb Prostheses | Addresses the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss. A prosthetic device can play an important role in rehabilitation when an upper or lower extremity is lost. The standard type of device used after limb loss is a socket-type prosthesis. The use of a bone-anchored prosthetic device such as the Osseointegrated Prostheses for the Rehabilitation of Amputees system (OPRA™, Integrum, Mölndal, Sweden) has been proposed as an alternative: - Considered investigational and not medically necessary when the criteria are not met
- Prior authorization required effective October 1, 2024
| SURG.00162 | Implantable Shock Absorber for Treatment of Knee Osteoarthritis | Addresses the use of an implantable shock absorber device (for example, MISHA™ Knee System Moximed, Inc., Fremont, CA) for the treatment of osteoarthritis of the knee: - Considered investigational and not medically necessary when the criteria are not met
- Prior authorization required effective October 1, 2024
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Revised Medical Policies effective October 1, 2024 Policy or guideline number | Policy or guideline title | Explanation of revision | LAB.00039 | Combined Pathogen Identification and Drug Resistance Testing
Previously titled: Pooled Antibiotic Sensitivity Testing | - Revised title
- Revised Position Statement to address “combined pathogen identification and drug resistance” testing
| MED.00140 | Gene Therapy for Beta Thalassemia | - Added medically necessary statement on exagamglogene autotemcel
- Revised not medically necessary statement
| SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | - Revised medically necessary statement to include Cortiva and Surgimend for breast reconstruction
- Revised medically necessary statement to include EPICEL, Integra Omnigraft Dermal Regeneration Template, and ReCell for the treatment of partial and deep thickness burns
- Revised medically necessary statement to include Biovance and Oasis for the treatment of diabetic foot ulcers
- Revised not medically necessary statement to align with revisions to medically necessary statements
- Added new products to the investigational and not medically necessary statement
| SURG.00052 | Percutaneous Vertebral Disc and Vertebral Endplate Procedures | - Revised medically necessary criteria for basivertebral nerve ablation (BVNA)
| SURG.00145 | Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) | - Revised pVAD criteria to include ECMO as concomitant therapy
- Revised Total Artificial Heart criteria for simplification
| TRANS.00028 | Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma | - Updated formatting in Position Statement section
- In the medically necessary Position Statement section for NHL, created criterion B3
- In the investigational and not medically necessary section for NHL, updated bullet “A” by adding “when criteria above are not met, including.”
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Archived Medical Policies effective March 15, 2024 Policy or guideline number | Policy title | Explanation of archive status | MED.00024 | Adoptive Immunotherapy and Cellular Therapy | N/A |
Archived Medical Policies and Clinical Guidelines effective April 1, 2024 Policy or guideline number | Policy title | Explanation of archive status | CG-GENE-04 | Molecular Marker Evaluation of Thyroid Nodules | N/A | CG-GENE-10 | Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies | N/A | CG-GENE-11 | Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status | N/A | CG-GENE-13 | Genetic Testing for Inherited Diseases | N/A | CG-GENE-14 | Gene Mutation Testing for Cancer Susceptibility and Management | N/A | CG-GENE-15 | Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis | N/A | CG-GENE-16 | BRCA Genetic Testing | N/A | CG-GENE-18 | Genetic Testing for TP53 Mutations | N/A | CG-GENE-19 | Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing | N/A | CG-GENE-21 | Cell-Free Fetal DNA-Based Prenatal Testing | N/A | CG-GENE-22 | Gene Expression Profiling for Managing Breast Cancer Treatment | N/A | CG-SURG-49 | Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities | N/A | CG-SURG-63 | Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure | N/A | CG-SURG-97 | Cardioverter Defibrillators | N/A | GENE.00009 | Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer | N/A | GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | N/A | GENE.00016 | Gene Expression Profiling for Colorectal Cancer | N/A | GENE.00018 | Gene Expression Profiling for Cancers of Unknown Primary Site | N/A | GENE.00020 | Gene Expression Profile Tests for Multiple Myeloma | N/A | GENE.00023 | Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma | N/A | GENE.00025 | Proteogenomic Testing for the Evaluation of Malignancies | N/A | GENE.00041 | Genetic Testing to Confirm the Identity of Laboratory Specimens | N/A | GENE.00050 | Gene Expression Profiling for Coronary Artery Disease | N/A | GENE.00051 | Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer | N/A | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | N/A | GENE.00054 | Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer | N/A | GENE.00055 | Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity | N/A | GENE.00056 | Gene Expression Profiling for Bladder Cancer | N/A | GENE.00057 | Gene Expression Profiling for Idiopathic Pulmonary Fibrosis | N/A | GENE.00058 | TruGraf Blood Gene Expression Test for Transplant Monitoring | N/A | GENE.00059 | Hybrid Personalized Molecular Residual Disease Testing for Cancer | N/A | LAB.00038 | Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection | N/A | SURG.00150 | Leadless Pacemaker | N/A | TRANS.00025 | Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection | N/A | TRANS.00041 | Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection | N/A |
Archived Medical Policies and Clinical Guidelines effective April 10, 2024 Policy or guideline number | Policy title | Explanation of archive status | CG-MED-72 | Hyperthermia for Cancer Therapy | N/A | LAB.00043 | Immune Biomarker Tests for Cancer | N/A | SURG.00070 | Photocoagulation of Macular Drusen | N/A | SURG.00007 | Vagus Nerve Stimulation | Content converted to CG-SURG-120. | SURG.00036 | Fetal Surgery for Prenatally Diagnosed Malformations | Content converted to CG-SURG-121. | SURG.00037 | Treatment of Varicose Veins (Lower Extremities) | Content converted to CG-SURG-119. | SURG.00103 | Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) | Content converted to CG-SURG-118. |
Archived Medical Policies and Clinical Guidelines effective June 1, 2024 Policy or guideline number | Policy title | Explanation of archive status | SURG.00105 | Bicompartmental Knee Arthroplasty | N/A |
Archived Medical Policies and Clinical Guidelines effective September 1, 2024 Policy or guideline number | Policy title | Explanation of archive status | CG-MED-38 | Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer | N/A | CG-MED-55 | Site of Care: Advanced Radiologic Imaging | N/A | CG-REHAB-10 | Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services | N/A | CG-SURG-52 | Site of Care: Hospital-based Ambulatory Surgical Procedures and Endoscopic Services | N/A | CG-SURG-86 | Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection | N/A |
Anthem’s Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments. All coverage written or administered by Anthem excludes from coverage, services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s medical policies. Review procedures have been refined to facilitate claim investigation. Anthem’s Medical Policies and Clinical UM Guidelines are available online.
For Nevada:The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s website at anthem.com and select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & Clinical UM Guidelines. Either enter key word or code, or select the link for Full List page to search the policy for your inquiry. To view the list of specific clinical UM guidelines adopted by Nevada, navigate to the View Medical Policies & UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CM-060773-24 The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Q4 2023. 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 > Providers > Provider Resources > Policies, Guidelines & Manuals. Notes/updates:Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive. - MED.00146 - Gene Therapy for Sickle Cell Disease
- Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease
- RAD.00068 - Myocardial Strain Imaging
- Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- Reformatted Position Statement and added headers
- Reformatted Medically Necessary statements to move target treatment areas into criteria
- Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
- Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
- Reformatted Medically Necessary statements for epilepsy
- Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
- Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
- Revised and reformatted Investigational & Not Medically Necessary statements
- SURG.00097 - Scoliosis Surgery
- Revision to Position Statement formatting
- Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement
- SURG.00142 - Genicular Procedures for Treatment of Knee Pain
- Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- Revised title
- Added genicular artery embolization to the scope of document
- Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary
- CG-DME-42 - Continuous Glucose Monitoring Devices
- Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
- Revised title
- Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
- Revised existing Medically Necessary and Not Medically Necessary statements
- CG-DME-52 - Continuous Passive Motion Devices in the Home Setting
- Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications
- CG-MED-94 - Vestibular Function Testing
- Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing
- CG-SURG-09 - Temporomandibular Disorders
- Revised formatting of Medically Necessary statement
- Revised surgical procedures criteria
- Added MIRO Therapy to Not Medically Necessary statement
- CG-SURG-70 - Gastric Electrical Stimulation
- Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator
Medical PoliciesOn November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect July 1, 2024. Publish date | Medical Policy number | Medical Policy title | New or revised | 1/3/2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer
Previously titled: Systems Pathology Testing for Prostate Cancer | Revised | 1/3/2024 | LAB.00046 | Testing for Biochemical Markers for Alzheimer’s Disease | Revised | 1/3/2024 | LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | Conversion new | 1/3/2024 | MED.00057 | MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications | Revised | 1/18/2024 | *MED.00146 | Gene Therapy for Sickle Cell Disease | New | 1/3/2024 | *RAD.00068 | Myocardial Strain Imaging | New | 1/3/2024 | SURG.00010 | Treatments for Urinary Incontinence | Revised | 12/28/2023 | *SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | Revised | 12/28/2023 | *SURG.00097 | Scoliosis Surgery | Revised | 1/3/2024 | *SURG.00142 | Genicular Procedures for Treatment of Knee Pain
Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain | Revised | 1/3/2024 | TRANS.00027 | Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors | Revised |
Clinical UM GuidelinesOn November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on January 4, 2024. These guidelines take effect July 1, 2024. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised | 1/3/2024 | *CG-DME-42 | Continuous Glucose Monitoring Devices
Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps | Revised | 1/3/2024 | CG-DME-44 | Electric Tumor Treatment Field (TTF) | Revised | 1/3/2024 | CG-DME-50 | Automated Insulin Delivery Systems | Conversion new | 1/3/2024 | CG-DME-51 | External Insulin Pumps | Conversion new | 1/3/2024 | *CG-DME-52 | Continuous Passive Motion Devices in the Home Setting | New | 1/3/2024 | CG-LAB-25 | Outpatient Glycated Hemoglobin and Protein Testing | Revised | 1/3/2024 | CG-MED-92 | Foot Care Services | Revised | 1/3/2024 | *CG-MED-94 | Vestibular Function Testing | New | 1/3/2024 | *CG-SURG-09 | Temporomandibular Disorders | Revised | 12/28/2023 | *CG-SURG-70 | Gastric Electrical Stimulation | Revised | 1/3/2024 | CG-SURG-94 | Keratoprosthesis | Revised | 12/28/2023 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | Revised |
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-056176-24-CPN54635 Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. RadiologyBrain imaging: - Added indications for magnetic resonance imaging (MRI) and amyloid beta positron emission tomography (PET) imaging in Alzheimer’s disease to address patients considering or receiving lecanemab
Spine imaging: - Changed perioperative and periprocedural imaging to postoperative and postprocedural imaging:
- Pre-procedure requests should be reviewed based on more specific indication.
Extremity imaging: - Separated criteria for osteomyelitis and septic arthritis into separate indications:
- US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication.
Vascular imaging: - Computed tomography angiography (CTA)/magnetic resonance angiography (MRA) head addition for chronic posterior circulation stroke/transient ischemic attack (TIA) presentations:
- CTA/MRA of the neck is already allowed; an intracranial evaluation is needed for full extent of anatomy.
- Lower extremity peripheral artery disease (PAD):
- Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology (ACR) Appropriateness Criteria®
- Suboptimal imaging option downgrades/removals in brain, head, neck, and abdomen/pelvis
RemindersAs a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by doing the following: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 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 here. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. 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-059153-24 Effective for dates of service on and after September 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc. CPT® code | Description | 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements | 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability | 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma | 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate | 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition | 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer | 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis | 0428U | Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden | 0434U | Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes | 0438U | Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions |
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access the ProviderPortalSM for Carelon Medical Benefits Management directly at providerportal.com.
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access Availity.com.
If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. 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-CM-059592-24-CPN59056 The following services will be added to precertification for the effective dates listed below. Eligibility and benefits can be verified by accessing Availity (Availity.com) or by calling the number on the back of the member’s identification card. Service precertification is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain precertification prior to rendering the designated services listed below may result in denial of reimbursement. Add to precertification | Criteria | Criteria description | Code | Effective date | CG-DME-50 | Automated Insulin Delivery Systems | E0784 | 10/1/2024 | CG-DME-50 | Automated Insulin Delivery Systems | E0787 | 10/1/2024 | CG-DME-50 | Automated Insulin Delivery Systems | S1034 | 10/1/2024 | CG-OR-PR-08 | Microprocessor Controlled Lower Limb Prosthesis | L5615 | 10/1/2024 | CG-SURG-83 | Bariatric Surgery and Other Treatments for Clinically Severe Obesity | 0813T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0786T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0787T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0816T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0817T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0818T | 10/1/2024 | CG-SURG-95 | Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | 0819T | 10/1/2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | A4540 | 10/1/2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | E0732 | 10/1/2024 | DME.00042 | Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea | E0530 | 10/1/2024 | DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0492 | 10/1/2024 | DME.00043 | Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | E0493 | 10/1/2024 | DME.00046 | Intermittent Abdominal Pressure Ventilation Devices | A4468 | 10/1/2024 | DME.00049 | External Upper Limb Stimulation for the Treatment of Tremors | A4542 | 10/1/2024 | DME.00049 | External Upper Limb Stimulation for the Treatment of Tremors | E0734 | 10/1/2024 | GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0423U | 10/1/2024 | GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0434U | 10/1/2024 | GENE.00010 | Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | 0438U | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81457 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81458 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81459 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81462 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81463 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 81464 | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0422U | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0424U | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0425U | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0426U | 10/1/2024 | GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0428U | 10/1/2024 | GENE.00056 | Gene Expression Profiling for Bladder Cancer | 0420U | 10/1/2024 | LAB.00003 | In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | 0435U | 10/1/2024 | LAB.00016 | Fecal Analysis in the Diagnosis of Intestinal Disorders | 0430U | 10/1/2024 | LAB.00019 | Proprietary Algorithms for Liver Fibrosis
Previously titled: Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | 81517 | 10/1/2024 | LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0112U | 10/1/2024 | LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0152U | 10/1/2024 | LAB.00050 | Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | 0323U | 10/1/2024 | MED.00130 | Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring | E0746 | 10/1/2024 | RAD.00068 | Myocardial Strain Imaging | C9762 | 10/1/2024 | RAD.00068 | Myocardial Strain Imaging | C9763 | 10/1/2024 | SURG.00007 | Vagus Nerve Stimulation | E0735 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4279 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4287 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4288 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4289 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4290 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4291 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4292 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4293 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4294 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4295 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4296 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4297 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4298 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4299 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4300 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4301 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4302 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4303 | 10/1/2024 | SURG.00011 | Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Q4304 | 10/1/2024 | SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | 61889 | 10/1/2024 | SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | 61891 | 10/1/2024 | SURG.00026 | Deep Brain, Cortical, and Cerebellar Stimulation | C1778 | 10/1/2024 | SURG.00045 | Extracorporeal Shock Wave Therapy | 0864T | 10/1/2024 | SURG.00077 | Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques | 58580 | 10/1/2024 | SURG.00097 | Scoliosis Surgery | 22836 | 10/1/2024 | SURG.00097 | Scoliosis Surgery | 22837 | 10/1/2024 | SURG.00097 | Scoliosis Surgery | 22838 | 10/1/2024 | SURG.00097 | Scoliosis Surgery | 0790T | 10/1/2024 | SURG.00142 | Genicular Procedures for Treatment of Knee Pain
Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain | 37242 | 10/1/2024 | SURG.00150 | Leadless Pacemaker | 0823T | 10/1/2024 | SURG.00150 | Leadless Pacemaker | 0824T | 10/1/2024 | SURG.00150 | Leadless Pacemaker | 0825T | 10/1/2024 | SURG.00150 | Leadless Pacemaker | 0826T | 10/1/2024 | SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0861T | 10/1/2024 | SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0862T | 10/1/2024 | SURG.00152 | Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | 0863T | 10/1/2024 | SURG.00157 | Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | 31242 | 10/1/2024 | SURG.00157 | Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | 31243 | 10/1/2024 | SURG.00158 | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | 64596 | 10/1/2024 | SURG.00158 | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | 64597 | 10/1/2024 |
UM AROW# A2024M1436 Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CM-058790-24-CPN57724 Effective August 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Description | 81173 | AR (androgen receptor) (such as, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | 81247 | G6PD (glucose-6-phosphate dehydrogenase) (such as, hemolytic anemia, jaundice), gene analysis; common variant(s) (such as, A, A-) | 81249 | G6PD (glucose-6-phosphate dehydrogenase) (such as, hemolytic anemia, jaundice), gene analysis; full gene sequence | 81307 | PALB2 (partner and localizer of BRCA2) (such as, breast and pancreatic cancer) gene analysis; full gene sequence | 81336 | SMN1 (survival of motor neuron 1, telomeric) (such as, spinal muscular atrophy) gene analysis; full gene sequence | 81403 | Molecular pathology procedure, Level 4 (such as, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons):
EPCAM (epithelial cell adhesion molecule) (such as, Lynch syndrome), duplication/deletion analysis. | 81405 | Molecular pathology procedure, Level 6 (such as, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, (such as targeted cytogenomic array analysis) [when specified as the following]:
ARSA (arylsulfatase A) (such as, arylsulfatase A deficiency), full gene sequence
BCKDHA (branched chain keto acid dehydrogenase E1, alpha polypeptide) (such as, maple syrup urine disease, type 1A), full gene sequence
DBT (dihydrolipoamide branched chain transacylase E2) (such as, maple syrup urine disease type 2), duplication/deletion analysis
DHCR7 (7-dehydrocholesterol reductase) (such as, Smith-Lemli-Opitz syndrome), full gene sequence
GLA (galactosidase, alpha) (such as, Fabry disease), full gene sequence
NLGN3 (neuroligin 3) (such as, autism spectrum disorders), full gene sequence;
NLGN4X (neuroligin 4, X-linked) (such as, autism spectrum disorders), full gene sequence
OTC (ornithine carbamoyltransferase) (such as, ornithine transcarbamylase deficiency), full gene sequence
TGFBR1 (transforming growth factor, beta receptor 1) (such as, Marfan syndrome), full gene sequence
TGFBR2 (transforming growth factor, beta receptor 2) (such as, Marfan syndrome), full gene sequence | 81440 | Nuclear encoded mitochondrial genes (such as, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP |
To request PA, you may use one of the following methods: - Web: Once logged in to Availity Essentials at Availity.com.
- Fax: 800-964-3627
- Phone: 844-396-2330
Not all PA requirements are listed here. Detailed PA requirements are available to providers on Home | Anthem Blue Cross and Blue Shield Healthcare Solutions on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-396-2330 for assistance with PA requirements. UM AROW A2024M1371
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-058685-24-CPN57596 Beginning with dates of service on or after October 1, 2024, Anthem will update the Related Coding section of the Frequency Editing — Professional reimbursement policy. This policy identifies reimbursement for a procedure or service that is billed for a single member, on a single date of service by the same provider and/or provider group, up to the maximum number of units allowed. In addition to using claims processing logic to determine when the use of multiple units is appropriate, we use the nomenclature for a particular CPT® or HCPCS level II code, the CMS’s medically unlikely edits (MUEs) designation, industry standards, or the ability to clinically perform or report a specific service more than one time on a single date of service or within a specific date span per member, per provider in making these determinations. In the Related Coding section of the policy, the following updates will be made: CPT maximum frequency code list: - Remove 36415 and 36416 (refer to laboratory and venipuncture C-10001)
- Remove 96158-96159, 96164-96165 (refer to health and behavioral assessment/intervention C-11003)
- Delete 76942, 77002, 77003, 77012, 77021, 77338, 77600, 77605, 80320-80377, 81479, 86160, 87483, 87491, 87591, 88305, 87529, 90378, 92250, 92273, 92274, 92326, 93325, 95925, 95926, 95938, 95927, 95928, 95929, 95939, 96900, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 93792, and 93793
HCPCS maximum frequency code list: - Remove S9529 (refer to laboratory and venipuncture C-10001)
- Remove G0480, G0481, G0482, and G0483 (refer to drug screen testing — professional C-12004)
- Remove C9257, G0480, G0481, G0482, and G0483
- Add A4238, A4239, A6520-A6529, A6552-A6589, A6593-A6610, and Q0509
For specific policy details, visit the reimbursement policy page at anthem.com/provider. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners. 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-CM-061232-24 Beginning with dates of service on or after October 1, 2024, Anthem will update the Incident to Service — Professional policy. The intent of the policy is to identify the reimbursement guidelines for incident to services. This reimbursement policy identifies the following two different types of incidents: - Incident to billing: When incident to billing services are rendered and billed in accordance with this policy, the incident to services are eligible for reimbursement based on the reduction of the maximum allowance of the applicable supervising provider’s fee schedule.
- Incident to services or supplies: Incident to services or supplies that are essential to the performance of professional service are considered bundled in the primary service and are not allowed for separate reimbursement.
The Related Coding section of the policy includes Modifier SA, which must be appended when the supervising physician is billing on behalf of non-physician practitioner (NPP) for non-surgical services. The policy has been renamed to Incident to Services and Billing — Professional to define incident to services from incident to billing guidelines. For specific policy details, visit the NV — reimbursement policy page at Anthem.com/provider. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CM-061322-24-CPN61066 Beginning with dates of service on or after October 1, 2024, Anthem will implement a new reimbursement policy titled Diagnostic Radiopharmaceuticals and Contrast Materials —Professional and Facility.
Under this policy, when radiopharmaceuticals and contrast materials are billed by the facility, such services are not reimbursed as they are considered included in the facility fee. In addition, the following statement was removed from the Place of Service — Professional reimbursement policy and added to this policy:
The health plan does not allow separate reimbursement for diagnostic radiopharmaceutical and contrast materials by professional providers when reported in a facility place of service.
The Related Coding section contains specific codes with guidelines for both professional and facility providers.
For specific policy details, visit the reimbursement policy page at anthem.com/provider.
Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners. 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-CM-061235-24 The National Committee Quality Assurance (NCQA) develops and collects HEDIS® measurements to set performance and drive improvement in quality-of-care outcomes. The Federal Employee Program® (FEP) for Anthem is continuously working to improve clinical quality of care and performance outcomes. To comply with the NCQA standards and improve HEDIS AMM performance rate, FEP takes this opportunity to remind providers to document every service rendered in an accurate, timely manner and use the appropriate ICD-10-CM, CPT®, and HCPCS codes when billing services rendered for patients who are receiving antidepressant medications. Below is a description of the AMM measure, why it is important, exclusions, and helpful tips (such as medical records documentation and best practices). HEDIS AMM measure descriptionThis HEDIS measure evaluates the percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: - Effective acute phase treatment: the percentage of members who remained on antidepressant medication for at least 85 days (12 weeks)
- Effective continuation phase treatment: the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)
Members with any diagnosis of major depression who are seen in any of the care settings are included in the AMM measure. Place of services | - Outpatient visit
- Telehealth visit
- ED visit
- Acute or nonacute inpatient stay
| - Intensive outpatient encounter or partial hospitalization
- Community mental health center
- E-Visit or virtual check-in (online assessment)
|
Why is the HEDIS AMM measure important?Major depression is a serious mental illness with a significant burden of symptoms and the most common psychiatric disorder in individuals who die from suicide.1 Integrating the right antidepressant medication with appropriate behavioral therapy leads to positive benefits and outcomes for members. Compliance with antidepressant medication is an essential component in treatment guidelines for major depression.2 ExclusionsEnrollees who did not have an encounter with a diagnosis of major depression during the 121-day period from 60 days prior to the index prescription start date (IPSD) through the IPSD and the 60 days after the IPSD Common behavioral health codes used with any diagnosis of major depression that trigger patients into the HEDIS AMM measure are: Description | Behavioral health codes (ICD-10-CM, CPT, HCPCS, POS) | Major depression | ICD-10-CM: F32.0–F32.4, F32.9, F33.0–F33.3, F33.41, F33.42, F33.9. F34.1 | BH outpatient visit | CPT: 98960–98962, 99078, 99202–99205, 99211–99215, 99242–99245,
99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99492–99494, 99510 HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013 - H2020, T1015 | Place of service (POS) | POS: 02, 10, 52, 53 | Telehealth visit | POS: 10 CPT: 98966–98968, 99441–99443 | ED visit | CPT: 99281–99285 | E-visit or virtual check-in (online assessment) | CPT: 98970–98972, 98980, 98981, 99421–99423, 99457, 99458 HCPCS: G0071, G2010, G2012, G2250, G2251, G2252 |
Helpful tipsMedical record documentation: - Diagnosis of major depression
- Date of services
- Date of dispensing
- Evidence of antidepressant medication prescription
Best practices:- Educate members that most antidepressants take four to six weeks to work.
- Encourage members to continue any prescribed medication even if they feel better. Inform them of the danger of discontinuing suddenly. If they take the medication for less than six months, they are at a higher risk of recurrence.
- Assess members within 30 days from when the prescription is first filled for any side effects and their response to treatment.
- When patients are making a follow-up visit, educate and encourage patients to bring their discharge instructions and medications list to their first appointment.
- Coordinate care between behavioral health and primary care physicians by sharing progress notes and updates.
- Educate members on what to do in an emergency, such as when having suicidal thoughts.
- Focus on member preferences for treatment, allowing the member to take ownership of their health and treatment plan.
- https://pubmed.ncbi.nlm.nih.gov/23411024: Accessed January 21, 2020.
- https://ncqa.org/hedis/measures/antidepressant-medication-management
HEDIS ® is a registered trademark of the National Committee for Quality Assurance (NCQA). 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-CM-060942-24 Effective August 1, 2024, the following medication codes will require prior authorization. Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. Clinical Criteria | HCPCS or CPT® code(s) | Drug name | CC-0252 | C9399 | Adzynma (ADAMTS13, recombinant-krhn) | CC-0253 | J3490, J3590, J9999 | Aphexda (motixafortide) | CC-0107 | J3490, J3590 | Avzivi (bevacizumab-tnjn) | CC-0042 | J3490 | Bimzelx (bimekizumab-bkzx) | CC-0032 | C9160 | Daxxify (daxibotulinumtoxinA-lanm) | CC-0059 | J3490 | Focinvez (fosaprepitant) | CC-0255 | C9399, J3490, J3590 | Loqtorzi (toripalimab-tpzi) | CC-0050 | J3590 | Omvoh (mirikizumab-mrkz) | CC-0256 | J3490 | Rivfloza (nedosiran) | CC-0002 | J3490, J3590 | Ryzneuta (efbemalenograstim alfa-vuxw) | CC-0066 | J3490, J3590 | Tofidence (tocilizumab-bavi) | CC-0257 | C9399, J3490 | Wainua (eplontersen) | CC-0254 | J3490 | Zilbrysq (zilucoplan) | CC-0062 | J3590 | Zymfentra (infliximab-dyyb) |
What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative or call Provider Services at 844-396-2330. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. 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-056679-24-CPN56332 Effective for dates of service on and after October 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process. Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules. They must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims. HCPCS codes | Medicare Part B drugs | J3490, J3590 | Amtagvi (lifleucel) | J3490, J3590 | iDoseTR (travoprost implant) |
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-058746-24-CPN58434 This article was updated on October 9, 2024, to remove Ilumya as non-preferred from the step therapy requirements section below. Ilumya is not being added to the step therapy program at this time. Specialty pharmacy updates for Anthem are listed below. Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. 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 PA 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 Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our PA 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-0003* | Alyglo (immune globulin intravenous, human-stwk) | J1599 | CC-0062 | Simlandi (adalimumab-ryvk) | J3590 | CC-0261 | Winrevair (sotatercept-csrk) | C9399, J3590 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: PA requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT Code(s) | CC-0003 | Non-preferred | Alyglo (immune globulin intravenous, human-stwk) | J1599 | CC-0062 | Non-preferred | Cimzia (certolizumab pegol) | J0717 | CC-0042 | Non-preferred | Cosentyx intravenous (secukinumab) | C9399, J3490, J3590, C9166 | CC-0050 | Non-preferred | Omvoh (mirkizumab-mrkz) | C9168, J3590 |
Quantity limit updates Effective for dates of service on or after October 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-0062 | Simlandi (adalimumab-ryvk) | J3590 | CC-0261 | Winrevair (sotatercept-csrk) | C9399, J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. 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-CM-060687-24-CPN60563, MULTI-BCBS-CM-069897-24 Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at providers.anthem.com/nv. You can request a free copy of our UM criteria from Provider Services at 844-396-2330. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM criteria online, go to anthem.com/provider/policies/clinical-guidelines/search/. We are staffed with clinical professionals who coordinate our member care and are available 24/7 to accept precertification requests. If you have questions or concerns regarding UM decisions, secured voicemail is available for providers during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests by: - Fax:
- Durable medical equipment (DME), physical therapy, occupational therapy, speech therapy, pain management, home care, home infusion requiring nursing services, insulin pumps, hyperbaric treatment, or wound care: 866-920-8362
- All other inpatient and outpatient services: 800-964-3627
- Pharmacy prior authorization, including home infusion injectables, continuous glucose monitoring equipment, and diabetic supplies: 844-490-4876
- Phone: 844-396-2330
- Pharmacy: 844-396-2330
- Availity Essentials: Availity.com
Have questions about utilization decisions or the UM process?Call our clinical team at 844-396-2330, Monday through Friday, from 8 a.m. to 5 p.m. Pacific time. 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-055812-24-SRS55499 In line with our commitment to participating practitioners and members, Anthem has a Member Rights and Responsibilities section located within the provider manual (Section 7). The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Review the provider manual here. 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-055809-24-SRS55499 The Centers for Medicare & Medicaid Services (CMS) Health Outcomes Survey (HOS) gathers patient-reported health outcomes from members enrolled in Medicare Advantage plans to support quality improvement activities and improve the overall health of members. Increased awareness of all HOS measures can help guide your provider interactions with your patients and positively impact HOS results and can help impact your Star rating. Refer to attachment to view full details 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-055932-24-CPN55629 ATTACHMENTS (available on web): Understanding your role in the Health Outcomes Survey (pdf - 0.88mb) The Provider Quality and Health Equity team at Anthem has been hard at work creating and identifying resources to help improve quality rates and the overall experiences of your patients. Be sure to check the Quality Management section of this Provider Newsletter site periodically for resources and new content, including provider toolkits and HEDIS-related materials to help optimize your quality rates. New content, resources, webinars, and training opportunities are also available on the Clinical Quality Webinars Hub. Mydiversepatients.com is a great resource for training and resources to help you learn about and serve your diverse population. We are committed to finding solutions that help our care provider partners offer high quality services to our members. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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-052877-24-CPN50908 |