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.

 

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 August 2, 2018

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

 

DRUG.00067 - Ramucirumab (Cyramza®)

DRUG.00071 - Pembrolizumab (Keytruda®)

GENE.00011 - Gene Expressions Profiling for Managing Breast Cancer Treatment

GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility

MED.00124 - Tisagenlecleucel (Kymriah®)

SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

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

 

Revised medical policies effective August 29, 2018

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

 

ADMIN.00007 - Immunizations

DRUG.00046 - Ipilimumab (Yervoy®) 

DRUG.00050 - Eculizumab (Soliris®)

DRUG.00075 - Nivolumab (Opdivo®)

DRUG.00088 - Atezolizumab (Tecentriq®)

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

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

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

GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests

 

Revised medical policies effective August 29, 2018

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

 

ADMIN.00002 - Preventive Health Guidelines

ADMIN.00004 - Medical Necessity Criteria

ADMIN.00005 - Investigational Criteria

ANC.00006 - Biomagnetic Therapy

DME.00024 - Transtympanic Micropressure for Treatment of Meniere's Disease

DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering

DME.00034 - Standing Frames

DME.00037 - Cooling Devices and Combined Cooling/Heating Devices

DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea

DRUG.00015 - Prevention of Respiratory Syncytial Virus Infections

DRUG.00095 - Ocrelizumab (Ocrevus®)

DRUG.00111 - Monoclonal Antibodies to Interleukin-23

GENE.00021 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

GENE.00041 - Short Tandem Repeat Analysis for Specimen Provenance Testing

GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome

LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

LAB.00031 - Advanced Lipoprotein Testing

LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer Test

LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis

MED.00055 - Wearable Cardioverter Defibrillators

MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders

MED.00098 - Hyperoxemic Reperfusion Therapy

MED.00106 - Sipuleucel-T (Provenge®)

MED.00109 - Corneal Collagen Cross-Linking

MED.00121 - Implantable Interstitial Glucose Sensors

OR-PR.00005 - Upper Extremity Myoelectric Orthoses

RAD.00002 - Positron Emission Tomography

RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)

RAD.00049 - Low-Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring

RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)

SURG.00005 - Partial Left Ventriculectomy

SURG.00010 - Treatments for Urinary Incontinence

SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions 

SURG.00071 - Percutaneous and Endoscopic Spinal Surgery

SURG.00076 - Nerve Graft after Prostatectomy

SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

SURG.00084 - Implantable Middle Ear Hearing Aids

SURG.00105 - Bicompartmental Knee Arthroplasty

SURG.00116 - High-Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus

SURG.00118 - Bronchail Termoplasty

SURG.00120 - Internal Rib Fixation Systems

SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

SURG.00125 - Radiofrequency and Pulsed Radiofrequncy Ablation of Trigger Point Pain

SURG.00126 - Irreversible Electroporation

SURG.00133 - Alcohol Septal Ablation for Treatment of Hypretrophic Cardiomyopathy

SURG.00134 - Interspinous Process Fixation Devices

SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization

SURG.00143 - Perirectal Spacers for Use during Prostate Radiotherapy

SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodgkin’s Disease & Non-Hodgkin’s Lymphoma

 

Archived medical policy effective September 1, 2018

 

GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance

 

Archived medical policies effective September 20, 2018

(These polices are now an Anthem Clinical Guidelines.)

 

DME.00027 - Ultrasonic Bone Growth Stimulation

DRUG.00006 - Botulinum Toxin

DRUG.00024 - Omalizumab (Xolair®)

DRUG.00040 - Abatacept (Orencia)

DRUG.00047 - Brentiximab Vedotin (Adcetris)

DRUG.00058 - Pharmacotherapy for Hereditary Angioedema

DRUG.00064 - Enteral Carbidopa and Levodopa Intestinal Gel Infusion

DRUG.00087 - Asfotase alfa (Strensiq™)

DRUG.00091 - Naltrexone Implants for the Treatment of Alcohol and Opioid Dependence

DRUG.00093 - Sebelipase alfa (Kanuma™)

DRUG.00103 - Abaloparatide (Tymlos) Abaloparatide

MED.00005 - Hyperbaric Oxygen Therapy (Systemic / Topical)

MED.00051 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

MED.00081 - Cognitive Rehabilitation

MED.00107 - Medical and other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

RAD.00019 - Magnetic Source Imaging and Magneto-Encephalography

RAD.00042 - SPECT/CT Fusion Imaging

SURG.00014 - Cochlear Implant and Auditory Brainstem Implants

SURG.00020 - Bone Anchored and Bone Conduction Hearing Aids

SURG.00049 - Mandibular/ Maxillary (Orthognathic) Surgery

SURG.00074 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring

SURG.00085 - Mastectomy for Gynecomastia

SURG.00090 - Radiofrequency and Pulsed Radiofrequency for Neurolysis for Trigeminal Neuralgia

TRANS.00018 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Archived medical policies effective September 20, 2018

(These polices are now AIM Clinical Guidelines.)

 

RAD.00022 - Magnetic Resonance Spectroscopy

RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer

RAD.00043 - Computed Tomography Scans for Lung Cancer Screening

RAD.00045 - Cerebral Perfusion Imaging using Computed Tomography

RAD.00046 - Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging

RAD.00049 - Low-Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring

RAD.00051 - Functional Magnetic Resonance Imaging (MRI)

RAD.00055 - Magnetic Resonance Angiography of the Spinal Canal

 

Archived medical policies effective October 31, 2018

(These policies are now Clinical Guidelines.)

 

SURG.00024 - Bariatric Surgery and other Treatments for Clinically Severe Obesity

SURG.00051 - Hip Resurfacing

SURG.00054 - Endovasuclar/Endoluminal Repair of Aortic Aneurysms, Aneurysms Aortoiliac Disease, Aortic Dissection and Aortic Transection

 

Revised medical policy effective January 1, 2019

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

 

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

 

Revised medical policies effective January 1, 2019

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

 

ANC.00007 - Cosmetic and Reconstructive Services; Skin Related

DRUG.00003 - Chelation Therapy

DRUG.00031 - Subcutaneous Hormone Replacement Implants

GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases

LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests

MED.00123 - Axicabtagene ciloleucel (Yescarta®)

MED.00124 - Tisagenlecleucel (Kymriah®)

 

New medical policy effective January 1, 2019

(The policy below is new and determined to not have significant change.)

 

DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)

GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)



Featured In:
October 2018 Anthem New Hampshire Provider Newsletter