Medical Policy and Clinical Guideline updates

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Anthem. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and Clinical Guidelines (and Medical Policy takes precedence over Clinical Guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the service is rendered must be used. This document supplements any previous Medical Policy and Clinical Guideline updates that may have been issued by Anthem. Please include this update with your provider manual for future reference.

Please note that Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Anthem’s Medical Policies and Clinical Guidelines are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines.

Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program FEP^®), visit fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policies effective August 17, 2024

The following policies are new:

• OR-PR.00008 Osseointegrated Limb Prostheses

• SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis

Revised Medical Policies effective August 1, 2024

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00135 Renal Sympathetic Nerve Ablation

Revised Medical Policy effective August 3, 2024

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• LAB.00039 Combined Pathogen Identification and Drug Resistance Testing

Revised Medical Policy effective August 17, 2024

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

Coding Updates effective August 17, 2024

As a result of coding updates in the claims system, the claim system edits for the policies listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination for certain services:

• MED.00140 Gene Therapy for Beta Thalassemia
• MED.00146 Gene Therapy for Sickle Cell Disease