The following new and revised medical policies were endorsed at the November 7, 2019 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and 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 www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies.   

 

Revised medical policies effective November 12, 2019

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

  • ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
  • BEH.00002 - Transcranial Magnetic Stimulation
  • MED.00124 - Tisagenlecleucel (Kymriah®)
  • SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

 

Archived medical policy effective December 14, 2019

(The following policy has been archived and has been replaced by AIM guidelines.)

  • RAD.00054 - MRI of the Bone Marrow

 

Revised medical policies effective December 18, 2019

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

  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • SURG.00127 - Sacroiliac Joint Fusion
  • TRANS.00033 - Heart Transplantation

 

Revised medical policies effective December 18, 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.00001 - Medical Policy Formation
  • DME.00025 - Self-Operated Spinal Unloading Devices
  • GENE.00016 - Gene Expression Profiling for Colorectal Cancer
  • GENE.00034 - SensiGene™ Fetal RHD genotyping
  • GENE.00036 - Genetic Testing for Hereditary Pancreatitis
  • GENE.00037 - Genetic Testing for Macular Degeneration
  • GENE.00039 - Genetic Testing for Frontotemporal Dementia
  • GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
  • LAB.00024 - Immune Cell Function Assay
  • LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
  • LAB.00034 - Serological Testing for Helicobacter Pylori
  • LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
  • MED.00002 - Selected Sleep Testing Services
  • MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
  • MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
  • MED.00065 - Hepatic Activation Therapy
  • MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
  • MED.00091 – Rhinophototherapy
  • MED.00092 - Automated Nerve Conduction Testing
  • MED.00097 - Neural Therapy
  • MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy
  • MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • MED.00116 - Near-Infrared Brain Screening for Hematoma Detection
  • MED.00121 - Implantable Interstitial Glucose Sensors
  • MED.00122 - Wilderness Programs including Adventure Therapy
  • MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
  • MED.00128 - Insulin Potentiation Therapy
  • RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
  • RAD.00036 - MRI of the Breast
  • RAD.00053 - Cervical and Thoracic Discography
  • RAD.00065 - Radiostereometric Analysis
  • REHAB.00003 - Hippotherapy
  • SURG.00019 - Transmyocardial Revascularization
  • SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
  • SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
  • SURG.00073 - Epiduroscopy
  • SURG.00079 - Nasal Valve Suspension
  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
  • SURG.00100 - Cryoblation for Plantar Fasciitis and Plantar Fibroma
  • SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00111 - Axial Lumbar Interbody Fusion
  • SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
  • SURG.00121 - Transcatheter Heart Valve Procedures
  • SURG.00123 - Transmyocardial/perventricular Device Closure of a Ventricular Septal Defect
  • SURG.00130 - Annulus Closure After Discectomy
  • SURG.00138 - Laser Treatment of Onychomycosis
  • SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
  • SURG.00146 - Extracorporeal Carbon Dioxide Removal
  • THER-RAD.00008 - Neutron Beam Radiotherapy
  • THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
  • TRANS.00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)
  • TRANS.00008 - Liver Transplantation
  • TRANS.00009 - Lung and Lobar Transplantation
  • TRANS.00010 - Autologous and Allogenic Pancreatic Islet Cell Transplant
  • 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.00026 - Heart-Lung Transplantation
  • TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised medical policies effective January 1, 2020

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

  • GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
  • GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00026 - Cell-Free Expression Profiling of Melanomas
  • LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
  • MED.00125 - Biofeedback and Neurofeedback
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
  • RAD.00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
  • SURG.00150 - Leadless Pacemaker
  • SURG.00153 - Cardiac Contractility Modulation Therapy

 

Revised medical policy effective February 5, 2020

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

  • MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium

 

Archived medical policies effective February 5, 2020

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing (Recategorized to CG-GENE-20)
  • GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers (Recategorized to CG-GENE-19)
  • MED.00109 - Corneal Collagen Cross-Linking (Recategorized as CG-SURG-105)
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications (Recategorized as CG-MED-87)
  • SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (Recategorized as CG-SURG-106)

 

Archived medical policies effective February 5, 2020

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • GENE.00001 - Genetic Testing for Cancer Susceptibility (Recategorized to CG-GENE-14. For panels see GENE.00052)
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent (Recategorized to CG-GENE-13. For panels see GENE.00052)
  • GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility (Recategorized to CG-GENE-15. For panels see GENE.00052)
  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome (Recategorized to CG-GENE-16. For panels see GENE.00052)
  • GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility (Recategorized to CG-GENE-17. For panels see GENE.00052)
  • GENE.00035 - Genetic Testing for TP53 Mutations (Recategorized to CG-GENE-18. For panels see GENE.00052)
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases (Recategorized to CG-GENE-13. For panels see GENE.00052)

 

Archived medical policies effective February 5, 2020

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

  • MED.00123 - Axicabtagene ciloleucel (Yescarta®) [transitioned as ING-CC-0051]
  • MED.00124 - Tisagenlecleucel (Kymriah®) [transitioned as ING-CC-0150]

 

New medical policy effective February 5, 2020

(The policy below is new and had no significant changes to the policy position or criteria.)

  • GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling (Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043)

 

Revised medical policies effective May 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.00025 - Proteogenomic Testing for the Evaluation of Malignancies
  • GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents



Featured In:
February 2020 Anthem New Hampshire Provider News