 Provider News NevadaNovember 1, 2019 November 2019 Anthem Provider News and Important Updates - NevadaAs the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.
Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.
Reminder about ICD-10 coding
As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions. The Centers for Medicare and Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
- Include any secondary diagnosis codes that are actively being managed.
- Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports your area: Socorro.Carrasco@anthem.com.Anthem contracted providers are required to update their demographic information when changes occur to their practice / organization, including:
- Change of address/location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Change in phone/fax numbers
- Closing a practice location
- Change in status for Accepting New Patients
- Plus more
As a reminder, our Find a Doctor online tool is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans.
Action Needed:
To help ensure we have the most current and accurate information, please take a moment to access the Find a Doctor tool and review how you and your practice are being displayed.
- Select Search as a Guest, then Search by All Plans and Networks
- Enter the appropriate search criteria to find your Provider information
Report discrepancies:
Please make any necessary corrections using the Provider Maintenance Form. The Provider Maintenance Form (PMF) is available online at anthem.com. Select Providers │under Provider Resources heading, select Provider Maintenance Form (Note: select Nevada, if you haven’t done so already). The PMF can also be found on the Availity Portal│ Payer Spaces │ Anthem Blue Cross and Blue Shield icon │Resources │ Provider Maintenance Form.
Please join us for one of our upcoming provider seminar in Las Vegas, NV. The session includes important updates and information about our networks. Lunch will be provided!
Important Note: Registration is through a WebEx account, but this will be an In-Person meeting. The WebEx option will not be available, but this registration tool allows for online registration and to ability add the appointment to your calendar.
Online registration that’s quick and easy!
The online registration includes automated acknowledgement of your registration, an appointment to add to your calendar, and reminder notifications. Don’t forget to accept the calendar appointment to add it to your calendar.
For additional information for dates and times, see the attached Provider Seminar Invitation.
Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.
- Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
- Management of OSA using APAP and CPAP Devices
- Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM 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. More exciting new changes are coming to the public provider site at anthem.com. This next wave of updates includes a new, enhanced Medical Policies page. The page will have an improved and straightforward process for viewing policies that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Medical Policies landing page. Below is a preview of the streamlined page:
Anthem’s launch of its new pharmacy benefits manager (PBM) solution, IngenioRx, which will serve members of all Anthem affiliated health plans is nearly complete. We began transitioning members on May 1, 2019, and have continued throughout 2019, with all members completely transitioned to IngenioRx by January 1, 2020.
As a reminder, most day-to-day pharmacy experiences will not be affected:
- Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery, or specialty pharmacy.
- Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
- If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
- If you do not use ePrescribing, send home delivery and specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
- Members will continue to use the same drug list.
Frequently Asked Questions
Q. When can I expect my patients to transition to IngenioRx?
A. Most Anthem members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020.
Q. Do providers need to take any action?
A. Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they’ve transitioned.
Q. Will my patients be notified of this change?
A. Anthem will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail.
Q. How will a provider know if an Anthem member has moved to IngenioRx?
A. Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx.
Q. How will specialty drugs be transitioned?
A. Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take.
Q. How do I submit prescriptions to IngenioRx?
A. If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system.
If you do not use ePrescribing, you can submit prescriptions using the following information:
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone Number: 1-833-203-1742
Fax number: 1-800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 1-833-262-1726
Prescriber fax: 1-833-263-2871
Q. What phone number should I call with questions?A. For questions, contact the Provider Service phone number on the back of your patient’s ID card.Category: Medicare
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact Provider Services at 1-844-396-2330.
Category: Medicaid
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Medicaid and Medicare Advantage 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. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following codes:
- 0026U -- Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
- 0533T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
- 0534T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
- 0535T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
- 0536T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
- 0546T -- Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
- 33270 -- Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
- 33271 -- Insertion of subcutaneous implantable defibrillator electrode
- 77299 -- Unlisted procedure, therapeutic radiology clinical treatment planning
- 81205 -- BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
- 81219 -- CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9
- 81250 -- G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
- 81302 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
- 81303 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
- 81304 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants
- 81331 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81332 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81400 -- Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
- 81401 -- Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81407 -- Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
- 81408 -- Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
- 97033 -- Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- C9042 -- Injection, bendamustine hcl (belrapzo), 1 mg
- C9043 -- Injection, levoleucovorin, 1 mg
- C9141 -- Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
- D9130 -- Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
- D9920 -- or management, by report
- J9999 -- Not otherwise classified, antineoplastic drugs
- S3850 -- Genetic testing for sickle cell anemia
To request PA, you may use one of the following methods:
Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-844-396-2330 for assistance with PA requirements. To reach Medicare Advantage Provider Services, call the number on the back of members’ ID cards.
Category: Medicaid
Effective August 1, 2019, Anthem Blue Cross and Blue Shield Healthcare Solutions will follow the limitations for behavioral therapy sessions from the Medicaid Services Manual. Prior authorization is required once the session’s limitations have been met. Therapy limits apply to the following to codes: 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90845, 90846, 90847, 90849, 90853 and H0004. This is update is in alignment with Web Announcement 1663 issued by the Nevada Department of Health and Human Services on August 13, 2018.
Therapy codes have the following limitations:
|
Billing provider type
|
Number of therapy sessions allowed per recipient per calendar year from all providers without prior authorization
|
|
PT 14 (Behavioral Health Outpatient Treatment)
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26 (recipient under 18)
|
|
PT 14 (Behavioral Health Outpatient Treatment)
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18 (recipient 18 and older)
|
|
PT 26 (Psychologist)
|
26
|
|
PT 20 (Physician, M.D., Osteopath, D.O.)
|
No limits
|
|
PT 82 (Behavioral Health Rehabilitative Treatment)
|
Not covered
|
Please refer to Web Announcement 1663 at https://www.medicaid.nv.gov/providers/newsannounce/default.aspx for more information.
If you have any questions, contact Provider Services by phone at 1-844-396-2330 or by email at nv1-providerservices@anthem.
Category: Medicaid
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www11.anthem.com/search.html.
Notes/updates:
- CG-DME-44 -- Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
- CG-MED-72 -- Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.
- CG-SURG-09 -- Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
- CG-SURG-30 -- Tonsillectomy for Children with or without Adenoidectomy was revised to:
- Spell out number of episodes of throat infections in MN criteria (A1, A2, A3).
- Clarify criterion addressing parapharyngeal abscess (B4) to say two or more.
- Add “asthma” as potential condition improved by tonsillectomy in MN criteria (C1b).
- The following AIM Specialty Health® updates took effect on March 31, 2019:
- Advanced Imaging
- Imaging of the Brain
- Imaging of the Extremities
- Imaging of the Spine
Medical Policies
On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
4/24/2019
|
MED.00127
|
Chelation Therapy
|
New
|
|
4/24/2019
|
GENE.00050
|
Gene Expression Profiling for Coronary Artery Disease
|
New
|
|
4/24/2019
|
MED.00128
|
Insulin Potentiation Therapy
|
New
|
|
4/24/2019
|
SURG.00152
|
Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
|
New
|
|
3/28/2019
|
DRUG.00088
|
Atezolizumab (Tecentriq®)
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Revised
|
|
3/28/2019
|
DRUG.00053
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Carfilzomib (Kyprolis®)
|
Revised
|
|
4/24/2019
|
GENE.00045
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Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
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Revised
|
|
4/24/2019
|
GENE.00010
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Genotype Testing for Genetic Polymorphisms to Determine
Drug-Metabolizer Status
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Revised
|
|
4/24/2019
|
SURG.00139
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Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
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Revised
|
|
4/24/2019
|
GENE.00012
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Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
|
Revised
|
|
4/24/2019
|
SURG.00121
|
Transcatheter Heart Valve Procedures
|
Revised
|
Clinical UM Guidelines
On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations Committee for members on May 7, 2019.
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Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
3/28/2019
|
CG-ANC-07
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Inpatient Interfacility Transfers
|
Revised
|
|
3/28/2019
|
CG-DRUG-50
|
Paclitaxel, protein-bound (Abraxane®)
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Revised
|
|
3/28/2019
|
CG-DRUG-96
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Ado-trastuzumab emtansine (Kadcyla®)
|
Revised
|
|
3/28/2019
|
CG-GENE-04
|
Molecular Marker Evaluation of Thyroid Nodules
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Revised
|
|
4/24/2019
|
CG-DME-44
|
Electric Tumor Treatment Field (TTF)
|
Revised
|
|
4/24/2019
|
CG-DRUG-68
|
Bevacizumab (Avastin®) for
Non-Ophthalmologic Indications
|
Revised
|
|
4/24/2019
|
CG-GENE-01
|
Janus Kinase 2, CALR, and MPL Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
|
Revised
|
|
4/24/2019
|
CG-GENE-05
|
Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)
|
Revised
|
|
4/24/2019
|
CG-MED-82
|
Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
|
New
|
|
4/24/2019
|
CG-MED-83
|
Level of Care: Specialty Pharmaceuticals
|
New
|
|
4/24/2019
|
CG-SURG-30
|
Tonsillectomy for Children with or without Adenoidectomy
|
Revised
|
|
5/9/2019
|
CG-DRUG-113
|
Inotuzumab ozogamicin (Besponsa®)
|
New
|
|
5/9/2019
|
CG-GENE-06
|
Preimplantation Genetic Diagnosis Testing
|
New
|
|
5/9/2019
|
CG-GENE-07
|
BCR-ABL Mutation Analysis
|
New
|
|
5/9/2019
|
CG-GENE-08
|
Genetic Testing for PTEN Hamartoma Tumor Syndrome
|
New
|
|
5/9/2019
|
CG-GENE-09
|
Genetic Testing for CHARGE Syndrome
|
New
|
|
5/9/2019
|
CG-MED-81
|
High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
|
New
|
|
5/9/2019
|
CG-SURG-98
|
Prostate Multiparametric Magnetic Resonance Imaging
|
New
|
|
5/9/2019
|
CG-SURG-99
|
Panniculectomy and Abdominoplasty
|
New
|
|
6/24/2019
|
CG-SURG-97
|
Cardioverter Defibrillators
|
New
|
Category: Medicaid
The effective date for Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) to use InterQual® 2019 criteria has been updated from May 1, 2019, to October 31, 2019. On this effective date, Anthem providers should begin using InterQual 2019 criteria and can access the criteria by logging into the provider portal.
For more information, contact Provider Services at 1-844-396-2330.
Category: Medicaid
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.
For questions or additional information, please use this email.
Category: Medicaid
On March 29, 2019, April 12, 2019, and May 1, 2019, the Pharmacy and Therapeutic (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Healthcare Solutions. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on our provider website (https://mediproviders.anthem.com/nv), and the effective dates will be reflected in the Clinical Criteria Q2 web posting. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
Category: Medicaid
Anthem Blue Cross and Blue Shield Healthcare Solutions will implement the following clinical guideline effective December 1, 2019, to support the review for unnecessary outpatient pneumatic compression devices (PCDs) postoperative orthopedic procedures.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs
PCDs are used in clinics or can be purchased or rented for home use for prevention and treatment of a number of conditions. PCD therapy involves the use of an inflatable garment and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. This document only addresses the home use of PCDs postoperative outpatient orthopedic procedures for the prevention of deep vein thrombosis (DVT) of the lower limbs.
Note: This document addresses devices for the prevention of DVT only. Pneumatic devices used in the treatment or prevention of lymphedema, venous insufficiency and therapy for musculoskeletal injuries are not addressed in this document, nor are devices for prevention of DVT postmajor surgical procedures.
Not medically necessary
The home use of PCDs for prevention of thromboembolism of the lower limbs following outpatient orthopedic surgery is considered not medically necessary for all indications.
ANV-NU-0083-19 September 2019Category: Medicaid
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact Provider Services at 1-844-396-2330.
Category: Medicaid
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www11.anthem.com/search.html.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *DME.00037 — Added devices that combine cooling and vibration to the Investigational (INV) & not medically necessary (NMN) statement
- *LAB.00027 — Added Mediator Release Test to INV&NMN statement.
- *LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7
- *OR-PR.00003:
- Clarified medically necessary (MN) position statement criteria 2 to 4
- Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered INV&NMN for all indications
- *SURG.00011:
- Added new MN and INV&NMN statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
- Added new products to INV&NMN statement.
- *SURG.00045:
- Added erectile dysfunction, Peyronie’s disease and wound repair to the INV&NMN statement
- Revised title
- *SURG.00121 — Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications
- The following AIM Specialty Health® updates were approved on June 6, 2019:
- Advanced Imaging:
- Imaging of the Heart
- Oncologic Imaging
- Vascular Imaging
- Proton Beam Therapy
- Rehabilitative Therapies — Physical Therapy, Occupational Therapy and Speech Therapy (New)
Medical Policies
On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
6/13/2019
|
MED.00129
|
Gene Therapy for Spinal Muscular Atrophy
|
New
|
|
6/13/2019
|
GENE.00029
|
Genetic Testing for Breast and/or Ovarian Cancer Syndrome
|
Revised
|
|
6/13/2019
|
*SURG.00011
|
Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
|
6/13/2019
|
SURG.00023
|
Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
|
Revised
|
|
6/13/2019
|
SURG.00028
|
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
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Revised
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|
6/27/2019
|
GENE.00025
|
Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
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Revised
|
|
6/27/2019
|
DRUG.00046
|
Ipilimumab (Yervoy®)
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Revised
|
|
6/27/2019
|
DRUG.00053
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Carfilzomib (Kyprolis®)
|
Revised
|
|
6/27/2019
|
DRUG.00062
|
Obinutuzumab (Gazyva®)
|
Revised
|
|
6/27/2019
|
DRUG.00067
|
Ramucirumab (Cyramza®)
|
Revised
|
|
6/27/2019
|
DRUG.00071
|
Pembrolizumab (Keytruda®)
|
Revised
|
|
6/27/2019
|
DRUG.00075
|
Nivolumab (Opdivo®)
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Revised
|
|
6/27/2019
|
DRUG.00107
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Avelumab (Bavencio®)
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Revised
|
|
6/27/2019
|
GENE.00044
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Analysis of PIK3CA Status in Tumor Cells
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Revised
|
|
6/27/2019
|
*SURG.00121
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Transcatheter Heart Valve Procedures
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Revised
|
|
6/27/2019
|
GENE.00001
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Genetic Testing for Cancer Susceptibility
|
Revised
|
|
6/27/2019
|
GENE.00043
|
Genetic Testing of an Individual’s Genome for Inherited Diseases
|
Revised
|
|
6/27/2019
|
LAB.00011
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Analysis of Proteomic Patterns
|
Revised
|
|
6/27/2019
|
LAB.00015
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Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
|
Revised
|
|
7/10/2019
|
GENE.00051
|
Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
|
New
|
|
7/10/2019
|
SURG.00153
|
Cardiac Contractility Modulation Therapy
|
New
|
|
7/10/2019
|
*DME.00037
|
Cooling Devices and Combined Cooling/Heating Devices
|
Revised
|
|
7/10/2019
|
DME.00038
|
Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
|
Revised
|
|
7/10/2019
|
GENE.00011
|
Gene Expression Profiling for Managing Breast Cancer Treatment
|
Revised
|
|
7/10/2019
|
*LAB.00027
|
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
Revised
|
|
7/10/2019
|
*LAB.00033
|
Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
|
Revised
|
|
7/10/2019
|
MED.00109
|
Corneal Collagen Cross-Linking
|
Revised
|
|
7/10/2019
|
*OR-PR.00003
|
Microprocessor Controlled Lower Limb Prosthesis
|
Revised
|
|
7/10/2019
|
SURG.00005
|
Partial Left Ventriculectomy
|
Revised
|
|
7/10/2019
|
*SURG.00045
|
Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions
|
Revised
|
|
7/10/2019
|
SURG.00120
|
Internal Rib Fixation Systems
|
Revised
|
|
9/4/2019
|
GENE.00010
|
Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
Revised
|
Clinical UM Guidelines
On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Nevada Medicaid members on July 5, 2019.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
6/24/2019
|
CG-SURG-97
|
Cardioverter Defibrillators
|
New
|
|
6/27/2019
|
CG-DRUG-48
|
Azacitidine (Vidaza®)
|
Revised
|
|
6/27/2019
|
CG-DRUG-62
|
Fulvestrant (FASLODEX®)
|
Revised
|
|
6/27/2019
|
CG-DRUG-106
|
Brentuximab Vedotin (Adcetris)
|
Revised
|
|
6/27/2019
|
CG-DRUG-98
|
Bendamustine Hydrochloride
|
Revised
|
|
6/27/2019
|
CG-LAB-09
|
Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
|
Revised
|
|
6/27/2019
|
CG-LAB-14
|
Respiratory Viral Panel Testing in the Outpatient Setting
|
Revised
|
|
7/10/2019
|
CG-SURG-100
|
Laser Trabeculoplasty and Laser Peripheral Iridotomy
|
New
|
|
7/10/2019
|
CG-ADMIN-01
|
Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
|
Revised
|
|
7/10/2019
|
CG-ANC-06
|
Ambulance Services: Ground; Non-Emergent
|
Revised
|
|
7/10/2019
|
CG-DME-03
|
Neuromuscular Stimulation in the Treatment of Muscle Atrophy
|
Revised
|
|
7/10/2019
|
CG-DME-07
|
Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
|
Revised
|
|
7/10/2019
|
CG-DME-08
|
Infant Home Apnea Monitors
|
Revised
|
|
7/10/2019
|
CG-DME-39
|
Dynamic Low-Load Prolonged-Duration Stretch Devices
|
Revised
|
|
7/10/2019
|
CG-DME-42
|
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
|
Revised
|
|
7/10/2019
|
CG-DME-45
|
Ultrasound Bone Growth Stimulation
|
Revised
|
|
7/10/2019
|
CG-MED-41
|
Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
|
Revised
|
|
7/10/2019
|
CG-MED-49
|
Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
|
Revised
|
|
7/10/2019
|
CG-MED-57
|
Cardiac Stress Testing with Electrocardiogram
|
Revised
|
|
7/10/2019
|
CG-MED-59
|
Upper Gastrointestinal Endoscopy in Adults
|
Revised
|
|
7/10/2019
|
CG-SURG-11
|
Surgical Treatment for Dupuytren's Contracture
|
Revised
|
|
7/10/2019
|
CG-SURG-17
|
Trigger Point Injections
|
Revised
|
|
7/10/2019
|
CG-SURG-35
|
Intracytoplasmic Sperm Injection (ICSI)
|
Revised
|
|
7/10/2019
|
CG-SURG-49
|
Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
|
Revised
|
|
7/10/2019
|
CG-SURG-81
|
Cochlear Implants and Auditory Brainstem Implants
|
Revised
|
|
7/10/2019
|
CG-SURG-85
|
Hip Resurfacing
|
Revised
|
|
7/10/2019
|
CG-SURG-93
|
Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
|
Revised
|
|
9/4/2019
|
CG-GENE-11
|
Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
New
|
|
9/4/2019
|
CG-GENE-10
|
Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
|
New
|
|
9/4/2019
|
CG-SURG-101
|
Ablative Techniques as a Treatment for Barrett’s Esophagus
|
New
|
|
9/4/2019
|
CG-SURG-102
|
Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
|
New
|
Category: Medicare
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Medicaid and Medicare Advantage 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. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following codes:
- 0026U -- Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
- 0533T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
- 0534T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
- 0535T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
- 0536T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
- 0546T -- Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
- 33270 -- Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
- 33271 -- Insertion of subcutaneous implantable defibrillator electrode
- 77299 -- Unlisted procedure, therapeutic radiology clinical treatment planning
- 81205 -- BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
- 81219 -- CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9
- 81250 -- G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
- 81302 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
- 81303 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
- 81304 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants
- 81331 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81332 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81400 -- Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
- 81401 -- Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81407 -- Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
- 81408 -- Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
- 97033 -- Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- C9042 -- Injection, bendamustine hcl (belrapzo), 1 mg
- C9043 -- Injection, levoleucovorin, 1 mg
- C9141 -- Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
- D9130 -- Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
- D9920 -- or management, by report
- J9999 -- Not otherwise classified, antineoplastic drugs
- S3850 -- Genetic testing for sickle cell anemia
To request PA, you may use one of the following methods:
Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-844-396-2330 for assistance with PA requirements. To reach Medicare Advantage Provider Services, call the number on the back of members’ ID cards.
Category: Medicare
CMS defines an expedited/urgent request as ‘an expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.’ Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request.
Category: Medicare
The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.
More information about this mandate will be published in the December 2019 newsletter.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
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