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 > 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 > Benefit Plans > Brochures and Forms > Medical Policies.   


Revised medical policy effective September 20, 2018

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


LAB. 00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease


Revised medical policies effective September 20, 2018

(The following policies may have word changes or coding updates, but had no significant changes to the policy position or criteria.)


DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

DRUG.00081 - Eteplirsen (Exondys 51™)

GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

GENE.00016 - Gene Expression Profiling for Colorectal Cancer

GENE.00023 - Gene Expression Profiling for Uveal Melanoma

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

LAB.00029 - Rupture of Membranes (ROM) Testing in Pregnancy

MED.00111 - Intracardiac Ischemia Monitoring

SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke


Archived medical policy effective September 20, 2018

(This policy is now archived and should no longer be used.)


DRUG.00089 - Daclizumab (Zinbryta®)


Revised medical policies effective October 17, 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.00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline

DME.00011 - Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies

GENE.00047 - Methylenetetrahydrofolate Reductase Mutation Testing

LAB.00028 - Serum Biomarkers for Multiple Sclerosis

MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

MED.00082 - Quantitative Sensory Testing

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.00004 - Peripheral Bone Mineral Density Measurement

RAD.00037 - Whole Body Computed Tomography Scanning  

RAD.00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging

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.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

SURG.00092 - Implanted Devices for Spinal Stenosis

SURG.00095 - Viscocnalosomy and Canaloplasty

SURG.00101 - Suprachoroidal Injection of Pharmacologic Agent

SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

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

TRANS.00035 - Mesenchymal Stem Cell Therapy for Orthopedic Indications

TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease


Archived medical policy effective November 5, 2018

(This policy is now an MCG Behavioral Health Clinical Guideline. This is a correction to the archive date from previous communications.)


BEH.00001 - Opioid Antagonists under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification


Revised medical policies effective March 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.)


LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting


New medical policy effective March 1, 2019

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


MED.00125 - Biofeedback and Neurofeedback

Featured In:
December 2018 Anthem New Hampshire Provider Newsletter