Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Quarter Two, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria, and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit Provider Medical Policies.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• MED.00148 — Gene Therapy for Metachromatic Leukodystrophy:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for gene therapy for metachromatic leukodystrophy
• RAD.00069 — Absolute Quantitation of Myocardial Blood Flow Measurement:
  • The use of absolute quantitation of myocardial blood flow testing is considered Investigational & Not Medically Necessary for all indications
• SURG.00011 — Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting:
  • Revised ocular indications, including the addition of SurSight to Medically Necessary and Not Medically Necessary section and added new Medically Necessary criterion addressing non-healing or persistent corneal epithelial defects
  • Removed VersaWrap from Investigational & Not Medically Necessary statement
  • Removed Phasix Mesh from Investigational & Not Medically Necessary statement
  • Added Phasix Mesh and Phasix ST Mesh to Medically Necessary and Not Medically Necessary statements
• CG-DME-54 — Mechanical Insufflation-Exsufflation Devices:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for use of mechanical insufflation-exsufflation devices

Medical Policies

On May 9, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take November 3, 2024.

Clinical UM Guidelines

On May 9, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members on June 27, 2024. These guidelines take effect November 3, 2024.