Medical policy and clinical guideline updates are available on anthem.com

The following new and revised medical policies and clinical guidelines were endorsed at the August 12, 2021 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies and clinical guidelines, are available at anthem.com/provider > select state > scroll down and select ‘See Policies and Guidelines.'

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines. 

 

Medical policy updates

 

Revised medical policies effective August 19, 2021

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

• 00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
• 00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
• 00119 - Endobronchial Valve Devices
• 00121 - Transcatheter Heart Valve Procedures

 

Coding update effective October 1, 2021

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

• 00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• 00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• 00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
• 00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• 00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• 00016 - Umbilical Cord Blood Progenitor Cell Transplant
• 00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
• 00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
• 00027 - Hematopoietic Stem Transplant for Pediatric Solid Tumors
• 00028 - Hematopoietic Stem Cell Transplant for Hodgkin's Disease and Non-Hodgkin’s Lymphoma
• 00029 - Hematopoietic Stem Cell Transplant for Genetic Diseases and Acquired Anemias
• 00030 - Hematopoietic Stem Cell Transplant for Germ Cell Tumors
• 00031 - Hematopoietic Stem Cell Transplant for Autoimmune Disease and Miscellaneous Solid Tumors
• 00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
• 00035 - Other Stem Cell Therapy

 

Reviewed medical policies effective October 6, 2021

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

• 00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• 00025 - Self-Operated Spinal Unloading Devices
• 00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• 00020 - Gene Expression Profile Tests for Multiple Myeloma
• 00023 - Gene Expression Profiling of Melanomas
• 00033 - Genetic Testing for Inherited Peripheral Neuropathies
• 00034 - SensiGene® Fetal RhD Genotyping Test
• 00047 - Methylenetetrahydrofolate Reductase Mutation Testing
• 00011 - Analysis of Proteomic Patterns
• 00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Patients with Chronic Liver Disease
• 00028 - Serum Biomarkers for Multiple Sclerosis
• 00029 - Rupture of Membranes Testing in Pregnancy
• 00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• 00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• 00055 - Wearable Cardioverter Defibrillators
• 00082 - Quantitative Sensory Testing
• 00089 - Quantitative Muscle Testing Devices
• 00095 - Anterior Segment Optical Coherence Tomography
• 00096 - Low-Frequency Ultrasound Therapy for Wound Management
• 00099 - Electromagnetic Navigational Bronchoscopy
• 00103 - Automated Evacuation of Meibomian Gland
• 00134 - Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
• 00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging
• 00061 - PET/MRI
• 00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• 00008 - Mechanized Spinal Distraction Therapy
• 00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• 00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• 00088 - Coblation® Therapies for Musculoskeletal Conditions
• 00092 - Implanted Devices for Spinal Stenosis
• 00101 - Suprachoroidal Injection of a Pharmocoligc Agent
• 00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• 00107 - Prostate Saturation Biopsy
• 00114 - Facet Joint Allograft Implants for Facet Disease
• 00128 - Implantable Left Atrial Hemodynamic Monitor
• 00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• 00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
• 00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
• 00153 - Cardiac Contractility Modulation Therapy
• 00156 - Implanted Artificial Iris Devices
• 00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
• 00004 - Cell Transplantation (Adrenal-Brain, Fetal Mesencephalic, and Fetal Xenograft)

 

Archived medical policies effective October 6, 2021

The following medical policies have been archived.

• 00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• 00085 - Antineoplaston Therapy
• 00037 - Whole Body Computed Tomography Scanning

 

New medical policies effective January 1, 2022

The following policies are new and may result in services previously covered now being considered either not medically necessary and/or investigational.

• 00043 - Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
• 00058 - TruGraf Blood Gene Expression Test for Transplant Monitoring
• 00040 - Biomarker Tests for Risk of Preeclampsia
• 00042 - Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
• OR-PR.00007 - Microprocessor Controlled Knee-Ankle-Foot Orthosis

 

Revised medical policy effective January 1, 2022

The following policy listed below was revised and might result in services previously covered, but now being considered either not medically necessary and/or investigational.

• 00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

 

Clinical guideline updates

 

Revised clinical guideline effective August 19, 2021

The following adopted guidelines were revised to expand medical necessity indications or criteria.

• CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids

 

Reviewed clinical guidelines effective October 6, 2021

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

• CG-BEH-02 - Adaptive Behavioral Treatment
• CG-DME-10 - Durable Medical Equipment
• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-MED-69 - Inhaled Nitric Oxide
• CG-MED-83 - Site of Care: Specialty Pharmaceuticals
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 - Private Duty Nursing in the Home Setting
• CG-SURG-28 - Transcatheter Uterine Artery Embolization
• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-52 - Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
• CG-SURG-55 - Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
• CG-SURG-79 - Implantable Infusion Pumps
• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised clinical guidelines effective January 1, 2022

The following adopted guidelines were revised and might result in services previously covered, but now being considered not medically necessary.

• CG-DME-44 - Electric Tumor Treatment Field (TTF)
• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

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