The following new and revised medical policies were endorsed at the September 13, 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 September 20, 2018

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

 

CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications

CG-SURG-79 - Implantable Infusion Pumps

 

Revised clinical guidelines effective September 20, 2018

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

 

CG-DRUG-16 - White Blood Cell Growth Factors 

CG-DRUG-64 - FDA-Approved Biosimilar Products

CG-MED-38 - Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer

CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift

CG-SURG-09 - Temporomandibular Disorders

 

Revised clinical guidelines effective October 17, 2018

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

 

CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema

CG-MED-46 - Electroencephalography and Video Electroencephalographic Monitoring

 

Revised clinical guidelines effective October 17, 2018 

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

 

CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use

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

CG-DRUG-03 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

CG-DRUG-08 - Enzyme Replacement Therapy for Gaucher Disease

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

CG-DRUG-55 - Elosulfase alfa (Vimizim®)

CG-DRUG-58 - Laronidase (Aldurazyme®)

CG-DRUG-61 - Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

CG-DRUG-74 - Canakinumab (Ilaris®)

CG-MED-63 - Treatment of Hyperhidrosis

CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)

CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue

CG-REHAB-04 - Physical Therapy

CG-REHAB-05 - Occupational Therapy

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

CG-SURG-28 - Transcatheter Uterine Artery Embolization

CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

Clinical guideline adopted effective November 1, 2018

(This guideline is now an AIM clinical guideline.)

 

CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Archived clinical guidelines effective November 5, 2018 

(These clinical guidelines are now MCG Behavioral Health Clinical Guidelines. This is a correction to the archive date from previous communications.)

 

CG-BEH-03 - Psychiatric Disorder Treatment

CG-BEH-04 - Substance-Related and Addictive Disorder Treatment

CG-BEH-05 - Eating and Feeding Disorder Treatment

CG-BEH-07 - Psychological Testing

CG-MED-23 - Home Health

 

New and adopted clinical guideline effective January 1, 2019

(This guideline is now an AIM clinical guideline.)

 

CG-REHAB-06 - Speech-Language Pathology Services

 



Featured In:
December 2018 Anthem New Hampshire Provider Newsletter