The following new and revised policies were endorsed at the May 3, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available on our website at 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.


Please note that the Federal Employee Program® Medical Policy Manual may be accessed at Brochures and Forms.


Revised medical policies effective May 10, 2018

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


DRUG.00047 - Brentuximab Vedotin (Adcetris®)

DRUG.00053 - Carfilzomib (Kyprolis®)

DRUG.00076 - Blinatumomab (Blincyto®)

SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation


Revised medical policies effective June 6, 2018

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


DRUG.00046 - Ipilimumab (Yervoy®)

DRUG.00071 - Pembrolizumab (Keytruda®)

DRUG.00075 - Nivolumab (Opdivo®)

GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing


Revised medical policies effective June 6, 2018      

(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.)


DME.00022 - Functional Electrical Stimulation FES; Threshold Electrical Stimulation TES

DRUG.00067 - Ramucirumab (Cyramza®)

DRUG.00088 - Atezolizumab (Tecentriq®)

DRUG.00104 - Nusinersen (SPINRAZA®)

DRUG.00107 - Avelumab (Bavencio®)

DRUG.00109 - Durvalumab (Imfinzi®)

DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)

DRUG.00111 - Monoclonal Antibodies to Interleukin-23

GENE.00001 - Genetic Testing for Cancer Susceptibility

GENE.00002 - Preimplantation Genetic Diagnosis Testing

GENE.00005 - BCR-ABL Mutation Analysis (Qualitative)

GENE.00007 - Cardiac Ion Channel Genetic Testing

GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

GENE.00016 - Gene Expression Profiling for Colorectal Cancer

GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including ARVD/C)

GENE.00023 - Gene Expression Profiling of Melanomas

GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

GENE.00031 - Genetic Testing for PTEN Hamartoma Tumor Syndrome

GENE.00038 - Genetic Testing for Statin-Induced Myopathy

GENE.00040 - Genetic Testing for CHARGE Syndrome

GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

LAB.00011 - Analysis of Proteomic Patterns

LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

LAB.00025 - Topographic Genotyping

MED.00024 - Adoptive Immunotherapy and Cellular Therapy

MED.00053 - Noninvasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting

MED.00077 - In Vivo Analysis of Gastrointestinal Lesions

MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer

MED.00102 - Ultrafiltration in Decompensated Heart Failure

MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin

MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema

MED.00111 - Intracardiac Ischemia Monitoring

MED.00112 - Autonomic Testing

MED.00118 - Continuous Monitoring of Intraocular Pressure

MED.00119 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

MED.00124 - Tisagenlecleucel (KymriahTM)

OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses

OR-PR.00004 - Partial-Hand Myoelectric Prosthesis

RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification

RAD.00022 - Magnetic Resonance Spectroscopy

RAD.00040 - PET Scanning Using Gamma Cameras

RAD.00043 - Computed Tomography Scans for Lung Cancer Screening

RAD.00054 - MRI of the Bone Marrow 

RAD.00059 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions outside the Liver except Central Nervous System (CNS) and Spinal Cord

RAD.00066 - Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy

SURG.00016 - Stereotactic Radiofrequency Pallidotomy

SURG.00022 - Lung Volume Reduction Surgery

SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

SURG.00072 - Lysis of Epidural Adhesions

SURG.00075 - Intervertebral Stabilization Devices

SURG.00107 - Prostate Saturation Biopsy

SURG.00113 - Artificial Retinal Devices

SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices

SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer

SURG.00139 - Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders

SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy

SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue

TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation

TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors


New medical policy effective June 6, 2018

(The policy below is new and may result in services previously covered now being considered either not medically necessary and/or investigational)


DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)


Archived medical policy effective June 22, 2018. This policy is now an Anthem Clinical Guideline.

DRUG.00092 - Buprenorphine Implant (Probuphine®)


Archived medical policies effective June 28, 2018. These polices are now Anthem Clinical Guidelines.

DME.00035 - Electric Tumor Treatment Field (TTF)

DRUG.00036 - Cetuximab (Erbitux®)

DRUG.00041 - Rituximab (Rituxan®) for Non-Oncologic Indications

DRUG.00049 - Belatacept (Nulojix®)

DRUG.00056 - Ado-trastuzumab emtansine (Kadcyla®)

DRUG.00073 - Rilonacept (Arcalyst®)

DRUG.00079 - Bendamustine Hydrochloride

DRUG.00083 - Elotuzumab (Empliciti™)

DRUG.00084 - Interferon gamma-1b (Actimmune®)

DRUG.00085 - Ixabepilone (Ixempra®)

DRUG.00097 - Olaratumab (Lartruvo™)

MED.00026 - Hyperthermia for Cancer Therapy

RAD.00011 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

SURG.00001 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

SURG.00009 - Refractive Surgery

SURG.00065 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

SURG.00068 - Implantable Infusion Pumps


Archived medical policy effective November 1, 2018. This policy is now an AIM Clinical Guideline.

THER-RAD.00002 - Proton Beam Radiation Therapy


Revised medical policies effective November 1, 2018

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


DRUG.00050 - Eculizumab (Soliris®)

GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing

GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

Featured In:
August 2018 Anthem New Hampshire Provider Newsletter