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 for Anthem. 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 https://fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policies effective August 1, 2025

• DME.00053 Home Video‑Assisted Robotic Rehabilitation Systems
• MED.00151 Gene Therapy for Aromatic L‑Amino Acid Decarboxylase Deficiency
• MED.00152 Outpatient Intravenous Insulin Therapy
• SURG.00165 Histotripsy

Revised Medical Policies effective August 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
• SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
• SURG.00155 Cryosurgery of Peripheral Nerves
• TRANS.00033 Heart Transplantation

Revised Medical Policies effective August 16, 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.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications
• MED.00148 Gene Therapy for Metachromatic Leukodystrophy

 Clinical Guideline updates

Revised Clinical Guidelines effective August 1, 2025

The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG‑SURG‑88 Mastectomy for Gynecomastia
• CG‑SURG‑123 Autologous Fat Grafting and Injectable Soft Tissue Fillers

Revised Clinical Guideline effective August 16, 2025

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

• CG‑SURG‑119 Treatment of Varicose Veins (Lower Extremities)