Based on feedback from our care provider partners, we understand the majority prefer not to receive paper letters. We want to make our interactions easy through digital channels and ensure you receive authorization case notifications timely. Since notifications about authorization decisions are available today through Availity Essentials, we will soon eliminate sending paper notifications.

You now have 24/7 access to authorization case information in one location through Availity Essentials. The digital authorization case status notifications are available under the Authorizations and Referrals* application once you have logged in to Availity Essentials and selected Patient Registration. By eliminating the redundancy of receiving both a digital and paper letter, you’ll see fewer errors associated with manual processes in handling the paper letters while reducing cost and our carbon footprint.

* Note: Your Availity Essentials administrator must assign you the role of Authorization & Referral Inquiry or request to access this application.

Care providers will be able to choose different options to receive authorization decision notifications via the Provider Preference Center under Availity Payer Spaces. Look for details on the Provider Preference Center options and ways to access authorization case status in an upcoming communication.

This change applies to Commercial products only. We will implement digital-only authorization case status notifications for Medicaid and Medicare products later this year.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Summary: On December 11, 2023, and January 5, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

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

To view a guideline, visit anthem.com/medicareprovider and select Change State and pick appropriate state. Then Providers > Policies, Guidelines & Manuals.

Notes/updates:

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

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities;
• Previously titled: Cosmetic and Reconstructive Services of the Trunk and Groin:
  • Revised title to include “Extremities"
  • Revised Position Statement regarding lipectomy or liposuction for lymphedema and lipedema
• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices:
  • Reformatted bullet points to letters
  • Added lines to Investigational & Not Medically Necessary statement on electrical stimulation wound treatment device, electromagnetic wound treatment devices and pulsed electromagnetic field stimulation
• LAB.00011 - Selected Protein Biomarker Algorithmic Assays:
  • Reformatted bullet points to letters
  • Added IMMray® PanCan-d test to the Investigational & Not Medically Necessary statement
• LAB.00028 - Blood-based Biomarker Tests for Multiple Sclerosis, Previously titled: Serum Biomarker Tests for Multiple Sclerosis:
  • Revised title
  • Expanded scope of document from serum to blood-based biomarker testing for multiple sclerosis (MS)
  • Revised Position Statement to indicate blood-based biomarker tests for multiple sclerosis are considered Investigational & Not Medically Necessary for all uses
• MED.00140 - Lentiviral Gene Therapy for Beta Thalassemia and Sickle Cell Disease; Previously Titled: Gene Therapy for Beta Thalassemia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement on lovotibeglogene autotemcel
• MED.00144 - Gene Therapy for Duchenne Muscular Dystrophy:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the infusion of Delandistrogene moxeparvovec-rokl (ELEVIDYS)
• MED.00147 - Cellular Therapy Products for Allogeneic Stem Cell Transplantation:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the use of ex-vivo expansion of cord blood stem cell products
• SURG.00129 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures:
  • Removed the criteria examples for failed CPAP treatment
  • Added definition for failed CPAP treatment
• SURG.00144 - Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia; Previously titled: Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement for sphenopalatine ganglion nerve blocks
• TRANS.00041 - Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection:
  • Histological analysis using microarray gene expression profiling is considered Investigational & Not Medically Necessary for detection of allograft injury or rejection in kidney transplant recipients
• CG-MED-39 - Bone Mineral Density Testing Measurement:
  • Added phrase “using Dual-X-Ray Absorptiometry” to bullets I and III of Medically Necessary criteria and to bullets I and IV of Not Medically Necessary criteria
  • Added Not Medically Necessary position statement for bone strength and fracture risk assessment using imaging scans other than DXA
• CG-MED-95 - Transanal Irrigation:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for transanal irrigation
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices:
  • Revised formatting of Medically Necessary section
  • Added Repair and Replacement criteria to Clinical Indications section
  • Added new Not Medically Necessary statement regarding enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices
  • Added new Medically Necessary and Not Medically Necessary criteria for device repair and replacement.
• CG-SURG-61 - Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver; Previously titled: Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver:
  • Revised title
  • Added microwave ablation to the Clinical Indications
  • Added cryoablation and microwave ablation to the Medically Necessary indications for NSCLC and malignant tumors that have metastasized to the lung
  • Added Not Medically Necessary statements regarding focal cryoablation of the prostate and microwave ablation for all other indications
  • Revised Medically Necessary indication for cryoablation of the prostate to whole gland cryoablation of the prostate
  • Reordered clinical indications to be based on clinical condition rather than ablative technique

Medical Policies

On August 10, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 5, 2024.

Clinical UM Guidelines

On August 10, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on September 28, 2023. These guidelines take effect April 5, 2024.

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity Essentials (Availity.com) or call Anthem’s Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.

Effective July 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements.

Effective for dates of service on and after July 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.:

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com:
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access the Availity website at Availity.com.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

As communicated in the March 2024, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Oncology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after.

Members included in the new program

All fully insured, self-funded (ASO), HealthLink, and national members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS.

Members of the following products are excluded: Medicaid, Medicare supplement, and Federal Employee Program^® (FEP^®).

Pre-service review requirements

For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the clinical guidelines on the microsite resource pages for complete code lists.

Please note: The procedure list has been updated since the original notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time. Vascular procedures will not require prior authorization for National and Commercial members currently participating in the Carelon Medical Benefits Management Cardiology program.

To determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information.  Providers using the Interactive Care Reviewer (ICR) tool on Availity Essentials to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com/ to register.

For more information

Go to https://providers.carelonmedicalbenefitsmanagement.com/genetictesting, https://providers.carelonmedicalbenefitsmanagement.com/cardiology/, https://providers.carelonmedicalbenefitsmanagement.com/radiology/, https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/, https://providers.carelonmedicalbenefitsmanagement.com/surgicalprocedures/; for resources to help your practice get started with the Radiology, Expanded Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs, or you can call your local Network Relations representative.

With your help, we can continually build towards a future of shared success.

Beginning with dates of service on or after July 1, 2024, Anthem will update the Virtual Visits — Professional and Facility reimbursement policy in response to the conclusion of the federal public health emergency (PHE). The policy will be updated to indicate the following:

• Virtual visits billed by professional providers are eligible for reimbursement for the following services:
  • Audio and visual
  • Audio only
  • Asynchronous
  • Store and forward
  • Remote patient monitoring
• Virtual visits billed by facility providers are eligible for reimbursement for the following services:
  • Audio and visual for behavioral health services only
  • Originating site fee Q3014 only when the member is present

Any service identified as a virtual visit will be reimbursed at the non-office rate.

For specific policy details, visit the reimbursement policy page at anthem.com.

Effective for dates of service on and after July 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Effective May 1, 2024, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 800-450-8753.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.