The following new and revised medical policies were endorsed at the August 22, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at > select state > scroll down and select Review Policies > then select View Medical Policies & 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 > Benefit Plans > Brochures and Forms > Medical Policies.   


Revised medical policies effective August 29, 2019

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

  • DRUG.00082 - Daratumumab (DARZALEX®)
  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications


Transitioned medical policy effective September 1, 2019

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

DRUG.00082 - Daratumumab (DARZALEX®) [Transitioned to ING-CC-0127]


Revised medical policy effective September 25, 2019

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

  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome


Revised medical policies effective September 25, 2019

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

  • ADMIN.000006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
  • BEH.00002 - Transcranial Magnetic Stimulation
  • DME.00011 - Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
  • DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
  • GENE.00010 - Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment
  • GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
  • GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
  • GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
  • GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies
  • GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
  • LAB.00019 - Serum Markers for Liver Fibrosis in the Evalution and Monitoring of Patients with Chronic Liver Disease
  • LAB.00028 - Serum Biomarkers for Multiple Sclerosis
  • LAB.00029 - Rupture of Membranes Testing in Pregnancy
  • LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
  • MED.00055 - Wearable Cardioverter Defibrillators
  • MED.00082 - Quantitative Sensory Testing
  • MED.00085 - Antineoplaston Therapy
  • MED.00089 - Quantitative Muscle Testing Devices
  • MED.00095 - Anterior Segment Optical Coherence Tomography
  • MED.00096 - Low-Frequency Ultrasound Therapy for Wound Management
  • MED.00099 - Electromagnetic Navigational Bronchoscopy
  • MED.00103 - Automated Evacuation of Meibomian Gland
  • OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
  • RAD.00037 - Whole Body Computed Tomography Scanning
  • RAD.00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging
  • RAD.00061 - PET/MRI
  • RAD.00062 - Intravascular Optical Coherence Tomography (OCT)
  • RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
  • SURG.00008 - Mechanized Spinal Distraction Therapy
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
  • SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
  • SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
  • SURG.00092 - Implanted Devices for Spinal Stenosis
  • SURG.00095 - Viscocnalosomy and Canaloplasty
  • SURG.00101 - Suprachoroidal Injection of a Pharmocoligc Agent
  • SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
  • SURG.00114 - Facet Joint Allograft Implants for Facet Disease
  • SURG.00119 - Endobronchial Valve Devices
  • SURG.00127 - Sacroiliac Joint Fusion
  • SURG.00128 - Implantable Left Atrial Hemodynamic Monitor
  • SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • SURG.00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
  • SURG.00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
  • SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
  • TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease


Archived medical policies effective September 25, 2019

(The following policies have been archived.)

  • MED.00041 - Microvolt T-Wave Alternans
  • RAD.00040 - PET Scanning using Gamma Cameras


Revised medical policies effective October 1, 2019

(The following policies were updated with new procedure and/or diagnosis codes.)

  • GENE.00001 - Genetic Testing for Cancer Susceptibility
  • GENE.00009 - Gene-Based Tests for Screening, Detection or Management of Prostate Cancer
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
  • GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
  • LAB.00011 - Analysis of Proteomic Patterns
  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
  • TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
  • TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
  • TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
  • TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodgkin Disease and non-Hodgkin Lymphoma
  • TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
  • TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus


Archived medical policy effective November 12, 2019

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

  • GENE.00044 - Analysis of PIK3CA Status in Tumor Cells [Content transferred to CG-GENE-12]


Archived medical policy effective November 12, 2019

(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)

  • RAD.00004 - Peripheral Bone Mineral Density Measurement [Content transferred to CGMED-39]


New medical policy effective February 1, 2020

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

  • MED.00130 - Surface Electromyography Devices for Seizure Monitoring


Revised medical policies effective February 1, 2020

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

  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
  • GENE.00046 - Prothrombin (Factor II) Genetic Testing
  • MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy
  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
  • TRANS.00035 - Non-Hematopoietic Adult Stem Cell Therapy

Featured In:
November 2019 Anthem New Hampshire Provider News