The following new and revised medical policies were endorsed at the June 6, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem clinical guidelines, 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.


Transitioned clinical guidelines effective June 10, 2019

(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-38 - Pemetrexed Disodium (Alimta®) [transitioned to ING-CC-0094 Alimta (pemetrexed)]
  • CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase) [transitioned to ING-CC-0096 Asparagine Specific Enzymes]
  • CG-DRUG-63 - Levoleucovorin Products [transitioned to ING-CC-0104 Levoleucovorin Agents]
  • CG-DRUG-66 - Panitumumab (Vectibix®) [transitioned to ING-CC-0105 Vectibix (panitumumab)]
  • CG-DRUG-72 - Pertuzumab (Perjeta®) [transitioned to ING-CC-0110 Perjeta (pertuzumab)]
  • CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®) [transitioned to ING-CC-0115 Kadcyla (ado-trastuzumab)]
  • CG-DRUG-98 - Bendamustine Hydrochloride [transitioned to ING-CC-0116 Bendamustine agents]
  • CG-DRUG-106 - Brentuximab Vedotin (Adcetris®) [transitioned to ING-CC-0092 Adcetris (brentuximab)]


Revised clinical guideline effective July 10, 2019

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults


Revised clinical guidelines effective July 10, 2019

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

  • CG-DME-45 - Ultrasound Bone Growth Stimulation
  • CG-GENE-02 - Analysis of KRAS Status
  • CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
  • CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
  • CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-MED-83 - Level of Care: Specialty Pharmaceuticals
  • CG-REHAB-11 - Cognitive Rehabilitation
  • CG-SURG-05 - Maze Procedure
  • CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • CG-SURG-12 - Penile Prosthesis Implantation
  • CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
  • CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
  • CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
  • CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
  • CG-SURG-85 - Hip Resurfacing
  • CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
  • CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
  • CG-SURG-88 - Mastectomy for Gynecomastia
  • CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation


Transitioned clinical guideline effective August 1, 2019

(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-76 - Plerixafor Injection (Mozobil™) [Transitioned to ING-CC-0089 Mozobil (plerixafor)]


Transitioned clinical guidelines effective September 1, 2019

(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use [transitioned to ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use]
  • CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection [transitioned to ING-CC-0098 Doxorubicin Hydrochloride Liposome]
  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®) [transitioned to ING-CC-0099 Abraxane (paclitaxel protein-bound)]
  • CG-DRUG-51 - Romidepsin (Istodax®) [transitioned to ING-CC-0100 Istodax (romidepsin)]
  • CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration [transitioned to ING-CC-0136 Dose, frequency, and route of administration]
  • CG-DRUG-62 - Fulvestrant (FASLODEX®) [transitioned to ING-CC-0103 Faslodex (fulvestrant)]tCG-DRUG-67 - Cetuximab (Erbitux®) [transitioned to ING-CC-0106 Erbitux (cetuximab)]
  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications [transitioned to ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications (Avastin, Mvasi)]
  • CG-DRUG-70 - Eribulin mesylate (Halaven®) [transitioned to ING-CC-0108 Halaven (eribulin)]
  • CG-DRUG-71 - Ziv-aflibercept (Zaltrap®) [transitioned to ING-CC-0109 Zaltrap (ziv-aflibercept)]
  • CG-DRUG-75 - Romiplostim (Nplate®) [transitioned to ING-CC-0111 Nplate (romiplostim)]
  • CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)[transitioned to ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)]
  • CG-DRUG-80 - Cabazitaxel (Jevtana®) [transitioned to ING-CC-0114 Jevtana (cabazitaxel)]
  • CG-DRUG-99 - Elotuzumab (Empliciti™) [transitioned to ING-CC-0117 Empliciti (elotuzumab)]
  • CG-DRUG-100 - Interferon gamma-1b (Actimmune®) [transitioned to ING-CC-0085 Actimmune (interferon gamma-1B)]
  • CG-DRUG-101 - Ixabepilone (Ixempra®) [transitioned to ING-CC-0090 Ixempra (ixabepilone)]
  • CG-DRUG-102 - Olaratumab (Lartruvo™) [transitioned to ING-CC-0091 Lartruvo (olaratumab)]
  • CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) [transitioned to ING-CC-0131 Besponsa (inotuzumab ozogamicin)]
  • CG-MED-67 - Melanoma Vaccines [transitioned to ING-CC-0135 Melanoma Vaccines]
  • CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [transitioned to ING-CC-0118 Radioimmunotherapy: Zevalin; azedra; Lutathera]


Adopted clinical guidelines effective September 4, 2019 

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

  • CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies (converted from GENE.00021)
  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status (content previously addressed in GENE.00010)
  • CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus (converted from SURG.00106)


Revised clinical guideline effective November 1, 2019

(The guideline listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.)

  • CG-DME-42 - Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices


Transitioned clinical guideline effective November 1, 2019

(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-79 - Siltuximab (Sylvant®) [transitioned to ING-CC-0113 Sylvant (siltuximab)]


Featured In:
August 2019 Anthem New Hampshire Provider News