You have the option to immediately copy a new case just submitted from the ICR dashboard.

Select Click here from the blue bar message located at the top of the dashboard.

Or copy a case that has been submitted within 45 days.

To locate a submitted case to copy select the Request Tracking ID link from your ICR dashboard or choose Search Submitted Requests from the ICR navigation menu. Then select the Copy Case button from the ICR Case Overview screen.

The case type, request type, place and type of service is duplicated onto the new case. You will be given the option to select the following case details to copy:

• Diagnosis Code and Procedure Code
• Inpatient length of stay
• Requesting provider and contact information
• Servicing facility
• Inpatient length of stay
• Servicing provider

You only need to key in the patient details* and include the clinical details to complete the new case.

*Please note: To copy a commercial case the patient needs to be enrolled in the same state and health plan. Federal Employee Program (FEP) requests can be for any state.

Want to learn more about the new ICR copy feature?

Register here to attend our monthly live webinar sessions: Introduction to Interactive Care Reviewer.

Or, view and download the illustrated job aid titled Interactive Care Reviewer Copy Feature.

Find the job aid on the Custom Learning Center: From Availity’s home page select Payer Spaces > Anthem > Custom Learning Center > Resources. To narrow the results, apply the Interactive Care Reviewer filter.

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Who can use this new tool? 

Professional providers whose organizations do not have a credentialing delegation agreement with Anthem may use this new tool. 

Note: Providers who have delegated agreements will continue to use the process in place. 

What does the tool provide? 

• The ability to add new providers to an already existing group
• The ability to apply and request a contract. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts. 
• A dashboard for real time status on the submitted applications
• Streamlined, complete data submission

How the online enrollment application works 

The system automatically accesses CAQH_® to pull in all updated information you’ve already included in your CAQH application. The CAQH information automatically populates the information Anthem needs to complete the enrollment process – including credentialing and loading your new provider to our database. Please ensure that your provider information on CAQH is updated and is in a complete or re-attested status. 

The Availity online application will guide you throughout the enrollment process, providing status updates using a dashboard. As a result, you know where each provider is in the process without having to call or email for a status.  

Please note: For any changes to your practice profile and demographics, continue to use the new online provider maintenance form that allows you to electronically submit to Anthem any changes to your practice profile and demographics. Availity administrators and assistant administrators can access the form by going to Availity.com > Payer Spaces > Resources. 

Accessing the provider enrollment application 

Log on to the Availity Portal and select Payer Spaces > Anthem Blue Cross and Blue Shield Nevada > Applications > Provider Enrollment to begin the enrollment process. 

If your organization is not currently registered with Availity, the person in your organization designated as the Availity administrator should go to Availity.com and select Register.  

For organizations already using Availity, your organization's Availity administrator should go to My Account Dashboard from the Availity homepage to register new users and update or unlock accounts for existing users. Staff who need access to the provider enrollment tool need to be granted the role of provider enrollment. 

Availity administrators and user administrators will automatically be granted access to provider enrollment. 

If you are using Availity today and need access to provider enrollment, please work with your organization’s administrator to update your Availity role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators. 

Need assistance with registering for the Availity Portal?  

Contact Availity Client Services at 1-800-AVAILITY (1-800-282-4548). 

Please note: Going forward, emails to our shared email box to add new providers to an already existing group or requesting a contract will not be worked. All requests to add new providers to an already existing group or requesting a contract must be submitted through the Availity Portal.

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• Availity Learning Center: Your resource for information related to multi-payer tools and transactions.
• Custom Learning Center:Your resource for information related to Anthem tools that are accessed through the Availity portal. 

Availity Learning Center 

Dive into the Availity Learning Center for training materials related to multi-payer functionality. Availity works with many payers to give you the most consistent experience available. For learning opportunities on basic capabilities that you access on behalf of multiple payers, the Availity Learning Center is your go-to source.  

From the secure Availity portal home page select Help & Training > Get Trained to open the Learning Center catalog.  

Once you open the Availity Learning Center,  you can enroll for new administrator and new user onboarding modules, other topic specific courses, and live webinars. 

Custom Learning Center 

Explore Anthem’s Custom Learning Center application on Payer Spaces to increase your understanding of how Anthem’s self-service digital tools function. The Custom Learning Center opens on the Catalog page where you will find videos and courses. Select Resources from the upper left corner of Custom Learning Center to access reference guides. 

Use these self-service learning options to help you get up to speed quickly on Availity transactions and Anthem digital tools. 

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Below are the different ways you can obtain support:

• Watch demos
• Troubleshooting
• FAQs
• Support requests
• Network outages
• Release notes

Log into Availity > Select Help & Training > Availity Support > Select the Organization, Continue and you will reach the Availity Support Community

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The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing.

Availity portal corrected claim submission

You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim, if the Anthem has already accepted the original claim for processing.

Follow these steps:

1. In the Availity portal menu, select claims & payments, and then select professionalclaim or facility claim, depending on which type of claim you want to correct.
2. Enter the claim information, and set the billing frequency and payer control number as follows:
   • Replacement of prior claim or void/cancel of prior claim
   • Billing frequency(or frequency type) field, in the claim information section (for professional and facility claims) or ancillary claim/treatment information section (for dental claims).
   • Set the payer control number (ICN/DCN)(or payer claim control number) field to the claim number assigned to the claim by Anthem .You can obtain this number from the 835 ERA or remittance inquiry on Payer Spaces.
3. Submit the claim.

EDI corrected claim submission

Corrected claims submitted electronically must also have the applicable frequency code.

Frequency code: Indicates the claim is a correction of a previously submitted and adjudicated claim. Providers should use one of the following:

For corrected professional (837P) claims use one the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:

• 7 – Replacement of prior claim\corrected claim
• 8 – Void/cancel prior claim

For corrected institutional (837I) use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:

• 0XX7 – Replacement of prior claim
• 0XX8 – Void/cancel prior claim

Please confirm with your practice management software vendor, as well as your billing service or clearinghouse for full details with information for submitting correct claims.

We encourage you and your staff to utilize the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.

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Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM musculoskeletal program: joint surgery and spine surgery clinical appropriateness guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Joint Surgery – updates by section

• Further defined criteria for home physical therapy
• Removed cognitive behavioral therapy as a conservative care modality for extremity
• Added indication for diagnostic arthroscopy
• Standardized radiographic criteria to align with lateral release criteria
• Adhesive capsulitis – added history of trauma or post-operative contracture as a requirement
• Tendinopathy – removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for SLAP repair or have suggestive MRI findings
• Hip athroscopy – removed complementary alternative medicine as not typically done for the hip
• Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) – removed age as an exclusion for FAIS but further define radiographic exclusions
• Unicompartmental knee arthroplasty/partial knee replacement – added degenerative change of the patellofemoral joint as a contraindication
• Arthroscopically assisted lysis of adhesions – added ligamentous or joint reconstruction criteria
• Added criteria for plica resection

Spine Surgery – updates by section

• Further defined criteria for home physical therapy
• Added standard conservative management requirement for instability to align with spinal stenosis indications
• Added new comprehensive indication for tethered cord syndrome

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’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.
• Access AIM via the Availity web portal at availity.com.
• Call the AIM Contact Center toll-free number: 877-291-0366, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Advanced Imaging clinical appropriateness guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Advanced imaging of the spine – updates by section

Congenital vertebral defects

• New requirement for additional evaluation with radiographs

Scoliosis

• Defined criteria for which presurgical planning is indicated
• Requirement for radiographs and new or progressive symptoms for postsurgical imaging

Spinal dysraphism and tethered cord

• Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed
• New requirement for US prior to advanced imaging for tethered cord in infants age 5 months or less

Multiple sclerosis

• New criteria for imaging in initial diagnosis of MS

Spinal infection

• New criteria for diagnosis and management aligned with IDSA and University of Michigan guidelines

Axial spondyloarthropathy

• Defined inflammatory back pain
• Diagnostic testing strategy outlining radiography requirements

Cervical injury

• Aligned with ACR position on pediatric cervical trauma

Thoracic or lumbar injury

• Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture
• Remove indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits

Syringomyelia

• Removed indication for surveillance imaging

Non-specific low back pain

• Aligned pediatric guidelines with ACR pediatric low back pain guidelines

Advanced imaging of the extremities – updates by section

Osteomyelitis or septic arthritis; myositis

• Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT

Epicondylitis and tenosynovitis – long head of biceps

• Removed due to lack of evidence supporting imaging for this diagnosis

Plantar fasciitis and fibromatosis

• Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT
• Added specific conservative management requirements

Brachial plexus mass

• Added specific requirement for suspicious findings on clinical exam or prior imaging

Morton’s neuroma

• Added requirements for focused steroid injection, orthoses, plan for surgery

Adhesive capsulitis

• Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions)

Rotator cuff tear; labral tear – shoulder; labral tear - hip

• Defined specific exam findings and duration of conservative management
• Recurrent labral tear now requires same criteria as an initial tear (shoulder only)

Triangular fibrocartilage complex tear

• Added requirement for radiographs and conservative management for chronic tear

Ligament tear – knee; meniscal tear

• Added requirement for radiographs for specific scenarios
• Increased duration of conservative management for chronic meniscal tears

Ligament and tendon injuries – foot and ankle

• Defined required duration of conservative management

Chronic anterior knee pain including chondromalacia patella and patellofemoral pain syndrome

• Lengthened duration of conservative management and specified requirement for chronic anterior knee pain

Intra-articular loose body

• Requirement for mechanical symptoms

Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella)

• New requirement for radiographs

Entrapment neuropathy

• Exclude carpal and cubital tunnel

Persistent lower extremity pain

• Defined duration of conservative management (6 weeks)
• Exclude hip joint (addressed in other indications)

Upper extremity pain

• Exclude shoulder joint (addressed in other indications)
• Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is nondiagnostic

Knee arthroplasty, presurgical planning

• Limited to MAKO and robotic assist arthroplasty cases

Perioperative imaging, not otherwise specified

• Require radiographs or ultrasound prior to advanced imaging

Vascular Imaging – updates by section

• Alternative non-vascular modality imaging approaches, where applicable

Hemorrhage, Intracranial

• Clinical scenario specification of subarachnoid hemorrhage indication.
• Addition of pediatric intracerebral hemorrhage indication.

Horner’s syndrome; pulsatile tinnitus; trigeminal neuralgia

• Removal of management scenario to limit continued vascular evaluation

Stroke/TIA; stenosis or occlusion (intracranial/extracranial)

• Acute and subacute time frame specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications
• Sections separated anatomically into anterior/posterior circulation (carotid artery and vertebral or basilar arteries, respectively)

Pulmonary embolism

• Addition of non-diagnostic chest radiograph requirement for all indications
• Addition of pregnancy-adjusted YEARS algorithm

Peripheral arterial disease

• Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’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.
• Access AIM via the Availity web portal at availity.com
• Call the AIM contact center toll-free number: 877-291-0366, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem) are pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to our clinical utilization management (UM) guidelines that are adopted for Nevada. The clinical UM guidelines published on our website represent the clinical UM guidelines currently available to all Plans for adoption throughout our organization. Because local practice patterns, claims systems and benefit designs vary, a local Plan may choose whether or not to implement a particular clinical UM guideline. The link below can be used to confirm whether or not the local Plan has adopted the clinical UM guideline(s) in question. Adoption lists are created and maintained solely by each local Plan. 

The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

New medical policies and effective for service dates on and after September 1, 2021:

• 00056 Gene expression profiling for bladder cancer: This document addresses gene expression profiling to diagnose bladder cancer, predict response to therapy in individuals with bladder cancer, and monitor individuals with a history of bladder cancer.
• Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary.
• 00038 Cell-free DNA testing to aid in the monitoring of kidney transplants for rejection: This document addresses the use of cell-free DNA (cfDNA) as a method of detecting kidney transplant recipients at risk for transplant rejection.
• Cell-free DNA testing is considered investigational and not medically necessary as a non-invasive method of determining the risk of rejection in kidney transplant recipients.
• 00039 Pooled antibiotic sensitivity testing: This document addresses pooled antibiotic sensitivity testing (P-AST) of urine in combination with a multiplex polymerase chain reaction (M-PCR) assay for the identification of susceptible urine pathogens and antibiotic resistance genes.
• Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications.
• 00159 Focal laser ablation for the treatment of prostate cancer: This document addresses the use of focal laser ablation, also known as laser interstitial therapy or laser interstitial photocoagulation, to treat localized prostate cancer.
• Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer.
• 00037 Uterine transplantation: This document addresses uterine transplantation, which has been proposed as a treatment of uterine factor infertility.
• Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus.
• Prior authorization will be required effective September 1, 2021

Revised medical policies and adopted clinical UM guidelines effective September 1, 2021:

• 00008 Cosmetic and reconstructive services of the head and neck: This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of procedures addressing the treatment of abnormalities of the head and neck.
• Removed the word “physical” from the term “physical functional impairment” in facial plastic surgery, otoplasty, rhinophyma, rhinoplasty or rhinoseptoplasty and cranial nerve procedures position statements.
• Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary.

CG-OR-PR-04 Cranial remodeling bands and helmets (cranial orthotics): This document addresses the use of the adjustable band or helmet cranial orthoses as a treatment of craniosynostosis, non-synostotic plagiocephaly (asymmetrically shaped posterior head), scaphocephaly (abnormally shaped narrow head), and brachycephaly (abnormally shaped head; shortened in antero-posterior dimension without asymmetry) in infants.

• Removed condition requirement from reconstructive criteria
• Replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
• Updated formatting in the clinical indications section

• Added transcatheter arterial chemoembolization (TACE) using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications.

• Removed reorganized clinical indications section
• Reorganized and clarified bilateral hearing loss medically necessary criteria
• Clarified medically necessary criteria for transcutaneously-worn bone conduction hearing aids for both bilateral and unilateral hearing loss
• Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
• Moved device-specific threshold information to the discussion section
• Clarified medically necessary criteria for transcutaneously worn and fully- or partially-implantable bone conduction hearing aids for unilateral hearing loss
• Added not medically necessary statement for when medically necessary criteria have not been met
• Clarified not medically necessary statement regarding replacement parts or upgrades
• Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications

Medical policy converted to clinical guideline effective April 7, 2021

Clinical guidelines to be archived and added to other existing clinical guidelines effective April 1, 2021 (except where noted)

Medical policies to be archived

• 00077 In-vivo analysis of gastrointestinal lesions – effective April 7, 2021
• 00022 Lung volume reduction surgery – effective June 25, 2021

Anthem medical policies and clinical UM guidelines are developed by our national medical policy and technology assessment committee. The committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

All coverage written or administered by Anthem excludes from coverage, services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s medical policies.  Review procedures have been refined to facilitate claim investigation.

Anthem’s medical policies and clinical UM guidelines are available online

The complete list of our medical policies and clinical UM guidelines may be accessed on our anthem.com/provider website. Under the Provider Resources heading, select Policies, Guidelines & Manuals. 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 & Clinical UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit fepblue.org > Policies & Guidelines. 

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

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

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

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

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

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

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

If you have questions on this program, contact your local network consultant.

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Effective September 1, 2021, Anthem classifies with an evaluation and management (E&M) code level the intensity/complexity of emergency department (ED) interventions a facility utilizes to furnish all services indicated on the claim. E&M services will be reimbursed based on this classification. Facilities must utilize appropriate HIPAA compliant codes for all services rendered during the ED encounter. If the E&M code level submitted is higher than the E&M code level supported on the claim, we reserve the right to perform one of the following:

• Deny the claim and request resubmission at the appropriate level or request the provider submit documentation supporting the level billed
• Adjust reimbursement to reflect the lower ED E&M classification
• Recover and/or recoup monies previously paid on the claim in excess of the E&M code level supported

Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details at anthem.com/provider.

Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E&M service will be able to follow the dispute resolution process in accordance with the terms of their contract. Claims disputes require a statement providing the reason the intensity/complexity would require a different level of reimbursement and the medical records which should clearly document the facility interventions performed and referenced in that statement.

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To assist providers in administrative requirements for bone mineral density (BMD) studies, the Federal Employee Program (FEP®) medical policy and utilization guidelines can be found on fepblue.org. The medical policy is titled, Medical Policy MPM 6.01.01, Bone Mineral Density Studies.  Below is an outline of this policy.   

Policy Statement:

An initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.

BMD testing may be indicated under the following conditions:

• Women age 65 and older, independent of other risk factors
• Men age 70 and older, independent of other risk factors
• Younger postmenopausal women with an elevated risk factor assessment (see policy guidelines)
• Men age 50 to 70 with an elevated risk factor assessment (see policy guidelines)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3 to 5 years; the interval depends on an updated patient fracture risk assessment.

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-2 years as follows:

• Individuals with a baseline evaluation of osteopenia (BMD T- score -1.0 to -2.5)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years in individuals who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy).

Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.

Dual x-ray absorptiometry of peripheral sites is considered investigational except as noted above.

BMD measurement using ultrasound densitometry is considered not medically necessary.

BMD measurement using quantitative computed tomography is considered investigational.

If you have any questions about Federal Employee benefits or medical policy information, please contact Customer Service at 800-727-4060.

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Effective for dates of service on and after September 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Please note, 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.

To access the Clinical Criteria information, click here.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

Step Therapy updates

Effective for dates of service on and after July 1, 2021, 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. 

Inflectra is changing to preferred status effective July 1, 2021.

To access the Clinical Criteria information, click here.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health^® (AIM).

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FEP Pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

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