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. The Medical Policies and Clinical Guidelines for Anthem 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 Policy effective January 1, 2025

The following policy is new:

• DME.00052 Brain Computer Interface Rehabilitation Devices

New Medical Policies effective January 11, 2025

The following policies are new:

• LAB.00051 Per- and Polyfluoroalkyl Substances (PFAS) Testing
• MED.00150 Hepzato Kit™ (melphalan hepatic delivery system)

Revised Medical Policies effective January 1, 2025

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:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions
• MED.00148 Gene Therapy for Metachromatic Leukodystrophy

Revised Medical Policies effective January 11, 2025

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:

• MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring Systems
• SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices

Clinical Guideline updates

Adopted Clinical Guideline effective January 1, 2025

The following guideline will be applied and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-MED-97 Biofeedback and Neurofeedback