Medical Policy and Clinical Guideline updates

These updates list new and/or revised Medical Policies and Clinical Guidelines for Anthem. Implementation of a 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 between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law and specific contract provisions/exclusions take precedence over Medical Policy and Clinical Guidelines and shall be considered in determining eligibility for coverage. The member’s contract benefits in effect on the date that the service is rendered shall govern. This document supplements any previous Medical Policy and Clinical Guideline updates with regard to the specified guideline. Please include this update with your provider manual for future reference.

Please note that Medical Policy, which addresses medical efficacy, should be considered before using medical opinion in adjudication. The Medical Policies and Clinical Guidelines for Anthem are available at https://anthem.com/provider. Select your state, then select the link to access the Commercial provider site. Under the Resources heading, select Medical Policies & Clinical UM Guidelines.

Note: These updates may not apply to all administrative services only accounts.

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.

Clinical Guideline updates

Adopted Clinical Guideline effective May 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:

• CGOR-PR-05 Myoelectric Upper Extremity Prosthetic Devices