The following new and revised medical policies were endorsed at the January 24, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > scroll down and select ‘Find Resources for [state]’ > Medical Policies and Clinical UM Guidelines.


If you do not have access to the internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.


Revised Clinical Guidelines effective January 31, 2019

(The following adopted guidelines were revised to expand medical necessity indications or criteria)

  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
  • CG-DRUG-99 - Elotuzumab (Empliciti™)
  • CG-SURG-27 - Sex Reassignment Surgery
  • CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity


Revised Clinical Guidelines effective February 27, 2019

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

  • CG-SURG-77 - Refractive Surgery
  • CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)


Revised Clinical Guidelines effective February 27, 2019

(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)

  • CG-ANC-04 - Ambulance Services; Air and Water
  • CG-BEH-14 - Intensive In-Home Behavioral Health Services
  • CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
  • CG-DME-10 - Durable Medical Equipment
  • CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)
  • CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
  • CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
  • CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use
  • CG-DRUG-28 - Alglucosidase alfa (Lumizyme®)
  • CG-DRUG-29 - Hyaluronan Injections
  • CG-DRUG-43 - Natalizumab (Tysabri®)
  • CG-DRUG-82 - Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension
  • CG-DRUG-83 - Growth Hormone
  • CG-DRUG-84 - Belimumab (Benlysta®)
  • CG-DRUG-85 - Tesamorelin (Egrifta®)
  • CG-DURG-86 - Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
  • CG-DRUG-93 - Sarilumab (Kevzara®)
  • CG-LAB-13 - Skin Nerve Fiber Density Testing
  • CG-MED-23 - Home Health
  • CG-MED-38 - Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
  • CG-MED-39 - Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry
  • CG-OR.PR-05 - Myoelectric Upper Extremity Prosthetic Devices
  • CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-70 - Gastric Electrical Stimulation
  • CG-SURG-71 - Reduction Mammoplasty
  • CG-SURG-72 - Endothelial Keratoplasty
  • CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
  • CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Noncoronary)


Adopted Clinical Guidelines effective March 21, 2019

(The following guidelines were previously medical policies and have been adopted with no significant changes.)

  • CG-SURG-94 - Keratoprosthesis (was SURG.00115)
  • CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention (was SURG.00117)
  • CG-SURG-96 - Intraocular Telescope (was SURG.00136)


Revised Clinical Guidelines effective August 1, 2019

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)
  • CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
  • CG-SURG-27 - Sex Reassignment Surgery


Featured In:
May 2019 Anthem New Hampshire Provider Newsletter