The following new and revised medical policies were endorsed at the July 26, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > 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 August 2, 2018

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

 

CG-SURG-24 - Functional Endoscopic Sinus Surgery (FESS)

CG-SURG-73 - Balloon Sinus Ostial Dilation

 

Revised clinical guidelines effective August 29, 2018

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

 

CG-DRUG-09 - Immune Globulin (Ig) Therapy

CG-DRUG-65 - Tumor Necrosis Factor Antagonists

CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

CG-DRUG-73 - Denosumab (Prolia®, Xgeva®)

CG-DRUG-81 - Tocilizumab (Actemra®)

CG-GENE-03 - BRAF Mutation Analysis

 

Revised clinical guidelines effective August 29, 2018   

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

 

CG-DME-07 - Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

CG-DRUG-05 - Recombinant Erythropoietin Products

CG-DRUG-11 - Infertility Drugs

CG-DRUG-24 - Repository Corticotropin Injection (H.P. Acthar® Gel)

CG-DRUG-47 - Level of Care: Specialty Pharmaceuticals

CG-DRUG-56 - Galsulfase (Naglazyme®)

CG-DRUG-69 - Ustekinumab (Stelara®)

CG-DRUG-72 - Pertuzumab (Perjeta®)

CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions

CG-GENE-02 - Analysis of KRAS Status 

CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules

CG-MED-26 - Neonatal Levels of Care

CG-REHAB-08 - Private Duty Nursing in the Home Setting

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-33 - Lumbar Fusion and Lumbar Total Disc Arthroplasty

CG-SURG-38 - Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy

CG-SURG-42 - Cervical Fusion 

CG-SURG-43 - Knee Arthroscopy

CG-SURG-44 - Coronary Angiography in the Outpatient Setting

CG-SURG-47 - Surgical Interventions for Scoliosis and Spinal Deformity

CG-SURG-48 - Elective Percutaneous Coronary Interventions (PCI)

CG-SURG-53 - Elective Total Hip Arthroplasty

CG-SURG-54 - Elective Total Knee Arthroplasty

CG-SURG-60 - Cervical Total Disc Arthroplasty

CG-SURG-65 - Recombinant Human Bone Morphogenetic Protein

CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

CG-SURG-67 - Treatment of Osteochondral Defects

CG-SURG-68 - Surgical Treatment of Femoroacetabular Impingement Syndrome 

CG-SURG-69 - Meniscal Allograft Transplantation of the Knee

CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

 

New and adopted clinical guidelines effective September 20, 2018

(The following guidelines were previously medical policies and have been adopted as clinical guidelines. No significant changes were made.)

 

CG-DME-45 - Ultrasound Bone Growth Stimulation

CG-DRUG-103 - Botulinum Toxin

CG-DRUG-104 - Omalizumab (Xolair®)

CG-DRUG-105 - Abatacept (Orencia®)

CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)

CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema

CG-DRUG-108 - Enteral Carbidopa and Levodopa Intestinal Gel Suspension

CG-DRUG-109 - Asfotase Alfa (Strensiq™)

CG-DRUG-110 - Naltrexone Implantable Pellets

CG-DRUG-111 - Sebelipase alfa (KANUMA™)

CG-DRUG-112 - Abaloparatide (Tymlos™) Injection)

CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical) 

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-REHAB-11 - Cognitive Rehabilitation

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-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

 

Archived clinical guidelines effective October 1, 2018

(The following guidelines were archived.)

 

CG-SURG-83 - Bariatric Surgery and other Treatments for Clinically Severe Obesity

CG-SURG-85 - Hip Resurfacing

CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

 

Revised clinical guideline effective January 1, 2019

(The following guideline below might result in services that were previously covered now being considered not medically necessary.)

 

CG-DRUG-65 - Tumor Necrosis Factor Antagonists

 

Archived clinical guidelines effective January 1, 2019. These guidelines are now AIM guidelines.

 

CG-SURG-33 - Lumbar Fusion and Lumbar Total Disc Arthroplasty

CG-SURG-38 - Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy

CG-SURG-42 - Cervical Fusion 

CG-SURG-43 - Knee Arthroscopy

CG-SURG-44 - Coronary Angiography in the Outpatient Setting

CG-SURG-47 - Surgical Interventions for Scoliosis and Spinal Deformity

CG-SURG-48 - Elective Percutaneous Coronary Interventions (PCI)

CG-SURG-53 - Elective Total Hip Arthroplasty

CG-SURG-54 - Elective Total Knee Arthroplasty

CG-SURG-60 - Cervical Total Disc Arthroplasty

CG-SURG-65 - Recombinant Human Bone Morphogenetic Protein

CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

CG-SURG-67 - Treatment of Osteochondral Defects

CG-SURG-68 - Surgical Treatment of Femoroacetabular Impingement Syndrome

CG-SURG-69 - Meniscal Allograft Transplantation of the Knee

 

New and adopted clinical guidelines effective January 1, 2019

(The following guidelines were previously unadopted and have now been adopted. No significant changes were made.)

 

CG-DME-09 - Continuous Local Delivery of Analgesia to Operative Sites using and Elastromeric Infusion Pump during the Post-operative Period

CG-DME-13 - Lower Limb Prosthesis

CG-DME-21 - External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings

CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)

CG- REHAB-02 - Outpatient Cardiac Rehabilitation

CG-DRUG-33 - Palonosetron

CG-DRUG-40 - Bortezomib (Velcade®)

CG-DRUG-44 - Pegloticase (Krystexxa®)

CG-DRUG-52 - Temsirolimus (Torisel®)

CG-DRUG-60 - Gonadotropin Releasing Hormone Analogs for Oncologic Indications



Featured In:
October 2018 Anthem New Hampshire Provider Newsletter