Effective October 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works 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 Carelon Medical Benefits Management programs, including cardiology, radiation oncology, radiology, musculoskeletal, sleep, surgical, and additional outpatient services.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on CMS guidance, including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in the Medical Policies and Clinical Guidelines of Anthem listed in the table below. These Clinical Guidelines can be found at Availity.com.

Detailed prior authorization (PA) requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted care providers should call Provider Services at the phone number on the back of the member’s ID card for PA requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting PA requests on September 24, 2024, for dates of service October 1, 2024, and after. For procedures scheduled to begin on or after
October 1, 2024, care providers must contact Carelon Medical Benefits Management to obtain PA for the non‑emergency modalities below. Refer to the clinical guidelines on the microsite resource pages for complete code lists.

To determine if PA is needed for a member on or after October 1, 2024, call Provider Services using the phone number on the back of the member’s ID card. Care providers using the interactive care reviewer (ICR) tool on Availity.com for PA requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management (Note: ICR cannot accept PA requests for services administered by Carelon Medical Benefits Management).

How to place a review request

Care providers may place a PA request online to Carelon Medical Benefits Management by way of providerportal.com. ProviderPortal_SM is available 24/7, processing requests in real-time using clinical criteria.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, surgical, and programs, visit:

• Cardiovascular Solution | Carelon Insights
• Musculoskeletal (MSK) Solution | Carelon Insights (AIM)
• Sleep Solution | Sleep Healthcare | Carelon Insights
• Surgical Procedures Solution | Carelon Insights
• Radiation Oncology Solution | Carelon Insights

Our website helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQ.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

As a reminder, effective October 1, 2024, Carelon Medical Benefits Management will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem members. Carelon Medical Benefits Management works 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 continued migration will expand clinical appropriateness review for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, radiation oncology, radiology, sleep, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — additional outpatient utilization management (UM) that will include some transportation (including ambulance) and fertility procedures as set forth below. Transportation may include emergency post-service reviews.

The Clinical UM Guidelines and Medical Policies (also known as coverage guidelines in Virginia) by Anthem for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 23, 2024, for dates of service on or after October 1, 2024.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard^®, Medicare Advantage, Medicaid, Medicare Supplemental, or Federal Employee Program^® (FEP^®). For more information, please contact the phone number on the back of the member ID card.

Pre-service review requirements

For procedures that are scheduled to begin on or after October 1, 2024, all care 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 at anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care. Please note some services below are effective March 1, 2025.

Update to previous notice: The services additional outpatient utilization management and base surgical below are effective March 1, 2025.

To determine if prior authorization is needed for a member on or after October 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on Availity.com 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.)

Care 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 provider portal. The provider portal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providerportal.com to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

• Cardiovascular Solution | Carelon Insights
• Radiology Solution | Carelon Insights
• Sleep Solution | Sleep Healthcare | Carelon Insights
• Surgical Procedures Solution | Carelon Insights
• Radiation Oncology Solution | Carelon Insights
• Additional Outpatient Utilization Management

Our website at anthem.com helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your local network relations representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Improvements in search capabilities in Availity Essentials now result in faster and more accurate results.

To help save you more time upfront while receiving more detailed eligibility & benefits information, we’ve expanded the Current Procedural Terminology^® (CPT) code search capabilities in Availity Essentials’ Eligibility and Benefit tool.

These optimizations enable the use of up to eight specific CPT or Healthcare Common Procedure Coding System (HCPCS) codes per transaction for faster, more accurate, and personalized search results, which include:

• Authorization requirement notifications — so you know up-front if an authorization is needed.
• Additional plan-level benefit limitations details.
• Cost-share information displayed by places of service and procedure codes.

Making these details available on the search results pages can help you save time and effort by giving you access to the right information you need when you need it. Additionally, it reduces the need to contact us, resulting in fewer calls and chats over time.

Watch the recorded training to see how you can start saving time today. Learning sessions show step-by-step how you can use the CPT code search capabilities in Availity Essentials to help increase your productivity. We're dedicated to supporting your success through digital solutions that help reduce your administrative burden and streamline your interactions with us.

If you have any questions, contact your provider relationship management representative.

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines. Along with this upgrade, there will be some changes as to how transcranial magnetic stimulation (TMS) will be approved.

A specific change will be noted for Behavioral Health Care (BHG): Transcranial Magnetic Stimulation B-801-T. An annotation for motor threshold redetermination after initiation of treatment has been added to the Inconclusive or non-supportive evidence section of the evidence summary with new references to support it.

Any requests for CPT^® code 90869 will be referred for peer clinical review to determine medical necessity.

If you have questions, please contact Provider Services by calling the number on the back of the member's ID card.

Effective for dates of service on and after November 17, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Cell-free DNA Testing (Liquid Biopsy) for the Management of Cancer:

• Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)

Prenatal Testing [changed to Screening] using cell-free DNA:

• Expanded criteria to include follow-up screening for abnormal maternal serum screen results in viable singleton/twin pregnancies when diagnostic testing is declined
• Expanded criteria to include screening for pregnancies with multiple anomalies when diagnostic testing is not possible

Somatic Testing of Solid Tumors:

• Tissue-agnostic testing for patients with advanced solid tumors:
  • Clarification about TMB testing by FDA-approved test with reporting threshold ≥ 10 mutations/megabase (mut/Mb)
• Bladder cancer:
  • Expansive changes for microsatellite instability/mismatch repair deficiency (MSI/dMMR)
• Brain cancer:
  • New clinical criteria considered clarifications for what may have otherwise been reviewed using general (umbrella) criteria
• Breast cancer, metastatic:
  • Expanded criteria to include a wider scope of testing for metastatic disease:  AKT1 and PTEN (related to capivasertib/fulvestrant therapy)
• Colorectal cancer, localized and metastatic:
  • Newly diagnosed localized or metastatic CRC — Expanded criteria for MSI/dMMR testing to allow in individuals with de novo metastatic disease
  • Metastatic CRC — Expanded POLE/POLD1 testing
• Endometrial carcinoma:
  • Expanded routine testing for MSI/dMMR; also expanded POLE and p53 testing
  • Panel size limited to ≤ 50 genes
• Non-small cell lung cancer, metastatic:
  • New criteria for metastatic squamous cell carcinoma
  • Allowance for repeat NGS testing in the setting of progressive disease, if a progressing lesion is being used for the repeat testing
• Ovarian (epithelial):
  • Added statement that HRD testing must include evaluation of genomic instability through an FDA approved test
• Pancreatic adenocarcinoma:
  • Added criteria for targeted (50 or fewer genes) somatic testing beyond MSI/dMMR in locally advanced, metastatic, or recurrent pancreatic adenocarcinoma
• Prostate cancer, metastatic:
  • Specified appropriateness of MSI/dMMR testing is in metastatic prostate cancer
  • Moved ATM from required to "may be included" genes in approvable NGS panels
• Thyroid cancer:
  • Testing of indeterminate thyroid nodules (ITN) — Afirma GSC added as a gene expression classifier that may be used
  • Somatic testing of thyroid malignancy — Modified language so that BRAF V600E, ALK, NTRK, and RET testing can be done in anaplastic thyroid cancer at any stage, or in unresectable, locally advanced, recurrent, or metastatic thyroid cancer

Somatic Testing of Hematologic Malignancies:

• Acute Lymphocytic Leukemia:
  • Added statement about NGS testing on bone marrow specimen which specifies time points where testing is appropriate (such as, end of initial induction, end of initial consolidation)
• Acute Myelogenous Leukemia:
  • Added an indication for focused testing using RT-qPCR to measure minimal residual disease (MRD)
• Chronic Myeloid Leukemia:
  • Modified the timing for BCR-ABL1 quantification for monitoring in the first year after completion of tyrosine kinase inhibitor (TKI) therapy
  • Added allowance for BCR-ABL1 quantification for monitoring patients at three-month intervals beyond one year after completion of TKI therapy
• Myeloproliferative Neoplasms:
  • Added allowance for additional focused testing for initial risk stratification if a specific myeloproliferative neoplasm is diagnosed on initial diagnostic workup
• Myelodysplastic Syndrome:
  • Clarified that testing can be pursued for diagnosis or risk stratification and clarified the list of genes that may be associated with MDS

Musculoskeletal

Joint Surgery:

• Reverse Shoulder Arthroplasty:
  • Added a requirement for impaired function for six months for consistency with total shoulder arthroplasty
  • Removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
• Shoulder Arthroscopy and Open Procedures:
  • Removal of loose body — Removed requirement for specific findings on exam
  • Rotator cuff repair and revision — Added an exclusion for subacromial balloon spacer due to lack of supporting evidence
  • Labrum Repair — Removed Bankart lesion broadening MRI findings to allow for any labral tear
  • Chronic shoulder instability or laxity — Broadened exam findings to include any evidence of instability rather than just the apprehension/relocation test
  • Tendinopathy of the long head of the biceps — Removed specific exam findings related to long head of biceps pathology
• Primary Total Hip Arthroplasty:
  • Removed the requirements for conservative management and three-month duration of symptoms when radiographs show severe osteoarthritis
• Primary Partial Hip Arthroplasty:
  • Combined criteria for partial hip arthroplasty and partial hip resurfacing
• Hip Arthroscopy:
  • Removal of loose body — Removed requirement for specific findings on exam
• Knee Arthroplasty:
  • Added exclusion for the use of an implantable shock absorber due to lack of supporting evidence
• Knee Arthroscopy:
  • ACL reconstruction — Removed standalone scenario of physically demanding occupation/pattern of activities
  • Excision of popliteal cyst — Added imaging requirement
  • Repair of subchondral bone defects (subchondroplasty) — Added exclusion for use of engineered calcium phosphate mineral or similar compounds due to lack of supporting evidence
• Osteochondral Grafts:
  • Juvenile Osteochondritis Dissecans — Expanded allowances to include either failed conservative management or unstable lesion
  • Added exclusion for use of particulated juvenile articular cartilage due to lack of evidence supporting its use

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access Carelon Medical Benefits Management’s provider portal 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.

Effective for dates of service on and after November 17, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Cell-free DNA testing (liquid biopsy) for the management of cancer:

• Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)

Prenatal testing (changed to screening) using cell-free DNA:

• Expanded criteria to include follow-up screening for abnormal maternal serum screen results in viable singleton/twin pregnancies when diagnostic testing is declined
• Expanded criteria to include screening for pregnancies with multiple anomalies when diagnostic testing is not possible

Somatic testing of solid tumors:

• Tissue-agnostic testing for patients with advanced solid tumors:
  • Clarification about TMB testing by FDA-approved test with reporting threshold ≥ 10 mutations/megabase (mut/Mb)
• Bladder cancer:
  • Expansive changes for microsatellite instability/mismatch repair deficiency (MSI/dMMR)
• Brain cancer:
  • New clinical criteria considered clarifications for what may have otherwise been reviewed using general (umbrella) criteria
• Breast cancer, metastatic:
  • Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)
• Colorectal cancer (CRC), localized and metastatic:
  • Newly diagnosed localized or metastatic CRC — expanded criteria for MSI/dMMR testing to allow in individuals with de novo metastatic disease
  • Metastatic CRC — expanded POLE/POLD1 testing
• Endometrial carcinoma:
  • Expanded routine testing for MSI/dMMR; also expanded POLE and p53 testing
  • Panel size limited to ≤ 50 genes
• Non-small cell lung cancer, metastatic:
  • New criteria for metastatic squamous cell carcinoma
  • Allowance for repeat next-generation sequencing (NGS) testing in the setting of progressive disease, if a progressing lesion is being used for the repeat testing
• Ovarian (epithelial):
  • Added statement that homologous recombination deficiency (HRD) testing must include evaluation of genomic instability through an FDA approved test
• Pancreatic adenocarcinoma:
  • Added criteria for targeted (50 or fewer genes) somatic testing beyond MSI/dMMR in locally advanced, metastatic, or recurrent pancreatic adenocarcinoma
• Prostate cancer, metastatic:
  • Specified appropriateness of MSI/dMMR testing is in metastatic prostate cancer
  • Moved ataxia-telangiectasia mutated (ATM) from required to "may be included" genes in approvable NGS panels
• Thyroid cancer:
  • Testing of indeterminate thyroid nodules (ITN) — Afirma GSC added as a gene expression classifier that may be used
  • Somatic testing of thyroid malignancy — modified language so that BRAF V600E, ALK, NTRK, and RET testing can be done in anaplastic thyroid cancer at any stage, or in unresectable, locally advanced, recurrent, or metastatic thyroid cancer

Somatic testing of hematologic malignancies:

• Acute lymphocytic leukemia:
  • Added statement about NGS testing on bone marrow specimen which specifies time points where testing is appropriate (such as end of initial induction, end of initial consolidation)
• Acute myelogenous leukemia:
  • Added an indication for focused testing using RT-qPCR to measure minimal residual disease (MRD)
• Chronic myeloid leukemia:
  • Modified the timing for BCR-ABL1 quantification for monitoring in the first year after completion of tyrosine kinase inhibitor (TKI) therapy
  • Added allowance for BCR-ABL1 quantification for monitoring patients at three-month intervals beyond one year after completion of TKI therapy
• Myeloproliferative neoplasms:
  • Added allowance for additional focused testing for initial risk stratification if a specific myeloproliferative neoplasm is diagnosed on initial diagnostic workup
• Myelodysplastic syndrome (MDS):
  • Clarified that testing can be pursued for diagnosis or risk stratification and clarified the list of genes that may be associated with MDS

Musculoskeletal

Joint surgery:

• Reverse shoulder arthroplasty:
  • Added a requirement for impaired function for six months for consistency with total shoulder arthroplasty
  • Removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
• Shoulder arthroscopy and open procedures:
  • Removal of loose body — removed requirement for specific findings on exam
  • Rotator cuff repair and revision — added an exclusion for subacromial balloon spacer due to lack of supporting evidence
  • Labrum repair — removed Bankart lesion broadening MRI findings to allow for any labral tear
  • Chronic shoulder instability or laxity — broadened exam findings to include any evidence of instability rather than just the apprehension/relocation test
  • Tendinopathy of the long head of the biceps — removed specific exam findings related to long head of biceps pathology
• Primary total hip arthroplasty:
  • Removed the requirements for conservative management and three-month duration of symptoms when radiographs show severe osteoarthritis
• Primary partial hip arthroplasty:
  • Combined criteria for partial hip arthroplasty and partial hip resurfacing
• Hip arthroscopy:
  • Removal of loose body — removed requirement for specific findings on exam
• Knee arthroplasty:
  • Added exclusion for the use of an implantable shock absorber due to lack of supporting evidence
• Knee arthroscopy:
  • Anterior cruciate ligament (ACL) reconstruction — removed standalone scenario of physically demanding occupation/pattern of activities
  • Excision of popliteal cyst — added imaging requirement
  • Repair of subchondral bone defects (subchondroplasty) — added exclusion for use of engineered calcium phosphate mineral or similar compounds due to lack of supporting evidence
• Osteochondral grafts:
  • Juvenile osteochondritis dissecans — expanded allowances to include either failed conservative management or unstable lesion
  • Added exclusion for use of particulated juvenile articular cartilage due to lack of evidence supporting its use

Small joint surgery:

• Hallux rigidus surgery:
  • First metatarsophalangeal joint arthrodesis — removed three-month requirement for conservative management (not needed with severe osteoarthritis)
  • First metatarsophalangeal joint arthroplasty — removed three-month requirement for conservative management; added allowance for failed prior hallux rigidus surgery
• Ankle arthritis:
  • Ankle arthrodesis and total ankle arthroplasty — removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
  • Revision total ankle arthroplasty — added requirement for reconstruction after the management of periprosthetic infection to be consistent for staged reconstructions of infected total ankle

Surgical site of care:

• Criteria have been reformatted to align with general categories that are used across all Carelon Medical Benefits Management Site of Care Guidelines.
• Background, Scope, and Rationale sections have been updated and aligned with all Carelon Medical Benefits Management Site of Care Guidelines.
• Clinical comorbidities have been broadened to include any American Society of Anesthesiologists (ASA) Class III or greater condition with specific examples updated as below:
  • The following cardiac comorbidity examples were removed and replaced with “documented history of myocardial infarction or acute coronary syndrome”:
    • “Acute coronary syndrome within the prior three months”
    • Currently taking dual antiplatelet therapy which cannot be temporarily discontinued safely for the proposed surgical procedure
    • Ongoing ischemic symptoms
  • The cerebrovascular example was changed from “Stroke or transient ischemic attack (TIA) within the prior three months” to “Documented history of stroke or transient ischemic attack (TIA).”
• The criteria “mental status change” was removed due to redundancy with existing criteria of “intellectual disability or cognitive impairment.”
• Criteria added for “when performing a procedure outside the Hospital Outpatient Department (HOPD) would reasonably be expected to create clinically significant delays in care.”
• Criteria added for “Absence of a geographically accessible alternative non-HOPD facility capable of performing the requested procedure.”

Advanced imaging site of care:

• Background, Scope, and Rationale sections have been updated and aligned with all Carelon Medical Benefits Management Site of Care Guidelines.
• Criteria was added for “Additional resources required to establish and/or maintain IV access in patients with previous difficulty.”

How to submit prior authorization requests, ask questions, or get more information

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access the Carelon Medical Benefits Management provider portal directly at providerportal.com:
  • Online access is available seven days a week, 24 hours a day to process orders in real-time and is the fastest and most convenient way to request authorization.

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 on the Carelon Medical Benefits Management website.

Effective for dates of service on and after November 17, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Cell-free DNA Testing (Liquid Biopsy) for the Management of Cancer:

• Expanded criteria to include a wider scope of testing for metastatic disease: AKT1 and PTEN (related to capivasertib/fulvestrant therapy)

Prenatal Testing [changed to Screening] using cell-free DNA:

• Expanded criteria to include follow-up screening for abnormal maternal serum screen results in viable singleton/twin pregnancies when diagnostic testing is declined
• Expanded criteria to include screening for pregnancies with multiple anomalies when diagnostic testing is not possible

Somatic Testing of Solid Tumors:

• Tissue-agnostic testing for patients with advanced solid tumors:
  • Clarification about TMB testing by FDA-approved test with reporting threshold ≥ 10 mutations/megabase (mut/Mb)
• Bladder cancer:
  • Expansive changes for microsatellite instability/mismatch repair deficiency (MSI/dMMR)
• Brain cancer:
  • New clinical criteria considered clarifications for what may have otherwise been reviewed using general (umbrella) criteria
• Breast cancer, metastatic:
  • Expanded criteria to include a wider scope of testing for metastatic disease:  AKT1 and PTEN (related to capivasertib/fulvestrant therapy)
• Colorectal cancer, localized and metastatic:
  • Newly diagnosed localized or metastatic CRC — Expanded criteria for MSI/dMMR testing to allow in individuals with de novo metastatic disease
  • Metastatic CRC — Expanded POLE/POLD1 testing
• Endometrial carcinoma:
  • Expanded routine testing for MSI/dMMR; also expanded POLE and p53 testing
  • Panel size limited to ≤ 50 genes
• Non-small cell lung cancer, metastatic:
  • New criteria for metastatic squamous cell carcinoma
  • Allowance for repeat NGS testing in the setting of progressive disease, if a progressing lesion is being used for the repeat testing
• Ovarian (epithelial):
  • Added statement that HRD testing must include evaluation of genomic instability through an FDA approved test
• Pancreatic adenocarcinoma:
  • Added criteria for targeted (50 or fewer genes) somatic testing beyond MSI/dMMR in locally advanced, metastatic, or recurrent pancreatic adenocarcinoma
• Prostate cancer, metastatic:
  • Specified appropriateness of MSI/dMMR testing is in metastatic prostate cancer
  • Moved ATM from required to "may be included" genes in approvable NGS panels
• Thyroid cancer:
  • Testing of indeterminate thyroid nodules (ITN) — Afirma GSC added as a gene expression classifier that may be used
  • Somatic testing of thyroid malignancy — Modified language so that BRAF V600E, ALK, NTRK, and RET testing can be done in anaplastic thyroid cancer at any stage, or in unresectable, locally advanced, recurrent, or metastatic thyroid cancer

Somatic Testing of Hematologic Malignancies:

• Acute Lymphocytic Leukemia:
  • Added statement about NGS testing on bone marrow specimen which specifies time points where testing is appropriate (such as, end of initial induction, end of initial consolidation)
• Acute Myelogenous Leukemia:
  • Added an indication for focused testing using RT-qPCR to measure minimal residual disease (MRD)
• Chronic Myeloid Leukemia:
  • Modified the timing for BCR-ABL1 quantification for monitoring in the first year after completion of tyrosine kinase inhibitor (TKI) therapy
  • Added allowance for BCR-ABL1 quantification for monitoring patients at three-month intervals beyond one year after completion of TKI therapy
• Myeloproliferative Neoplasms:
  • Added allowance for additional focused testing for initial risk stratification if a specific myeloproliferative neoplasm is diagnosed on initial diagnostic workup
• Myelodysplastic Syndrome:
  • Clarified that testing can be pursued for diagnosis or risk stratification and clarified the list of genes that may be associated with MDS

Musculoskeletal

Joint Surgery:

• Reverse Shoulder Arthroplasty:
  • Added a requirement for impaired function for six months for consistency with total shoulder arthroplasty
  • Removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements
• Shoulder Arthroscopy and Open Procedures:
  • Removal of loose body — Removed requirement for specific findings on exam
  • Rotator cuff repair and revision — Added an exclusion for subacromial balloon spacer due to lack of supporting evidence
  • Labrum Repair — Removed Bankart lesion broadening MRI findings to allow for any labral tear
  • Chronic shoulder instability or laxity — Broadened exam findings to include any evidence of instability rather than just the apprehension/relocation test
  • Tendinopathy of the long head of the biceps — Removed specific exam findings related to long head of biceps pathology
• Primary Total Hip Arthroplasty:
  • Removed the requirements for conservative management and three-month duration of symptoms when radiographs show severe osteoarthritis
• Primary Partial Hip Arthroplasty:
  • Combined criteria for partial hip arthroplasty and partial hip resurfacing
• Hip Arthroscopy:
  • Removal of loose body — Removed requirement for specific findings on exam
• Knee Arthroplasty:
  • Added exclusion for the use of an implantable shock absorber due to lack of supporting evidence
• Knee Arthroscopy:
  • ACL reconstruction — Removed standalone scenario of physically demanding occupation/pattern of activities
  • Excision of popliteal cyst — Added imaging requirement
  • Repair of subchondral bone defects (subchondroplasty) — Added exclusion for use of engineered calcium phosphate mineral or similar compounds due to lack of supporting evidence
• Osteochondral Grafts:
  • Juvenile Osteochondritis Dissecans — Expanded allowances to include either failed conservative management or unstable lesion
  • Added exclusion for use of particulated juvenile articular cartilage due to lack of evidence supporting its use

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access Carelon Medical Benefits Management’s provider portal 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.

If you have questions related to guidelines, 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.

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

Revised Medical Policy effective November 1, 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:

• MED.00055 Wearable Cardioverter Defibrillators

Clinical Guideline updates

Revised Clinical Guideline effective November 1, 2024

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-MED-59 Upper Gastrointestinal Endoscopy in Adults

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Quarter 1, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

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.

• LAB.00039 - Combined Pathogen Identification and Drug Resistance Testing; Previously Titled: Pooled Antibiotic Sensitivity Testing

• Revised title
• Revised Position Statement to address “combined pathogen identification and drug resistance” testing

• OR-PR.00008 - Osseointegrated Limb Prostheses
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
  • Revised Medically Necessary criteria for basivertebral nerve ablation (BVNA)
• SURG.00162 - Implantable Shock Absorber for Treatment of Knee Osteoarthritis
  • Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered Investigational & Not Medically Necessary
• CG-DME-53 - Biomechanical Footwear Therapy
  • Biomechanical footwear therapy is considered Not Medically Necessary for all indications
• CG-LAB-32 - Cancer Antigen 125 Testing
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the tumor marker cancer antigen 125 (CA-125) testing
• CG-MED-94 - Vestibular Function Testing
  • Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests
• CG-MED-96 - Prefabricated External Infant Ear Molding Systems
  • Outlines the Medically Necessary, Reconstructive and Cosmetic & Not Medically Necessary criteria for the use of prefabricated external infant ear molding systems to treat external ear malformations and deformations

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect August 8, 2024.

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare members on March 28, 2024. These guidelines take effect August 8, 2024.

Anthem is in the process of shutting down specific authorization fax channels. This is to notify you the below fax numbers will be decommissioned as of August 30, 2024.

Look for additional notifications as other authorization fax lines are retired.

Availity Authorizations is the preferred method for authorization intakes. If you cannot use Availity Authorizations, call our contact center at 833-545-9102, and we will work with you to determine the best submission method.

Available resources

Registering and accessing Availity is easy. If your organization is not registered for Availity, start here.

If you are not already familiar with Availity Authorization, training is available. Register for training today and learn about the simple workflow for submitting digital authorizations.

These fax numbers will be turned off as of August 30, 2024.

Effective August 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 Medicaid 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 PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

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

To request PA, you may use one of the following methods:

• Web: once logged in to Availity at Availity.com
• Fax: 800-964-3627
• Phone: 800-450-8753 

Not all PA requirements are listed here. Detailed PA requirements are available to care providers on https://providers.anthem.com/new-york-provider/home on the Resources tab or for contracted care providers by accessing Availity.com. Care providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

Effective August 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 Medicaid 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 PA 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):

To request PA, you may use one of the following methods:

• Web: Once logged in to Availity Essentials at Availity.com.
• Fax: 800-964-3627
• Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/ny on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

Effective September 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 Medicaid 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 PA 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):

To request PA, you may use one of the following methods:

• Web: Once logged in at Availity.com
• Fax: 800-964-3627
• Phone: 800-450-8753

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providers.anthem.com/ny on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with PA requirements.

Beginning with dates of service on or after November 1, 2024, Anthem will implement a new reimbursement policy titled Intraoperative Neuromonitoring — Professional based on guidelines from the American Academy of Neurology. This reimbursement policy will allow reimbursement for intraoperative neuromonitoring (IONM) when billed by a professional provider with a place of service 19, 21, 22, or 24.

When reporting IONM, providers are required to bill on a CMS-1500 form and use the appropriate place of service. Services must be performed in a hospital setting using the place of service where the member is located even if the monitoring physician is in an office. The following place of service codes are appropriate for use by the monitoring physician:

• Off campus-outpatient hospital (19)
• Inpatient hospital (21)
• On campus-outpatient hospital (22)
• Ambulatory surgical center (24)

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

Past system limitations prevented us from reimbursing Modifier 78 in complete alignment with Centers for Medicare & Medicaid Services (CMS). New system updates will now allow Anthem to closer align with the CMS Medicare Physician Fee Schedule Data Base (MPFSDB).

For claims processed on and after 07/01/2024, you may see a slight adjustment in reimbursement which will reflect this configuration update.

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

Beginning with dates of service on or after November 1, 2024, Anthem will update the Related Coding section of the Professional Anesthesia Service reimbursement policy with the following:

• Updated modifier QZ reimbursement from 100% to 85%.
• Added modifiers QK, QX, or QY language (removed from the policy body section).
• Removed diagnosis codes not eligible for reimbursement when reported with add-on code 99140 code list.
• Added the following statement to modifiers G8, G9, and QS comment column:
  • May be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).

Section V., Qualifying Circumstances for Anesthesia will be updated to indicate that Anthem will consider qualifying circumstances to be always bundled when reported in addition to the anesthesia procedure or service provided.

The policy has been renamed to Anesthesia Services — Professional. For specific policy details, visit the New York reimbursement policy page at tinyurl.com/27nt7awc.

Anthem updated the Modifiers 26 and TC — Professional reimbursement policy in October 2023. The statement below was inadvertently removed from the Nonreimbursable section of the policy, but remained in the policy Definition section:

• There is a separate standalone code that describes the professional component only, technical component only, or global test only of a selected diagnostic test.

 No claims were impacted by the omission of this statement. The Nonreimbursable section of the policy has been updated to include this statement. 

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

Beginning with dates of service on or after November 1, 2024, Anthem will update the Bundled Services and Supplies — Facility reimbursement policy as follows:

• Addition of categories of services considered integral to the primary service, or included in the facility fee that are not allowed for separate reimbursement when billed by a facility provider
• Addition of the following code to the Related Coding section:

• G2211 — visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition

For specific policy details, visit the reimbursement policy page and select the appropriate state.

Beginning with dates of service on or after November 1, 2024, Anthem will update the related coding section of the Outpatient Facility Revenue Code Billing Requirements — Facility reimbursement policy. The policy requires HCPCS or CPT^® codes to be submitted for reimbursement when submitted with certain revenue codes. The policy is updated to include the following revenue codes that require a corresponding HCPCS or CPT code:

• 0270 Medical/Surgical Supplies and Devices — General
• 0271 Medical/Surgical Supplies and Devices — Nonsterile
• 0272 Medical/Surgical Supplies and Devices — Sterile
• 0273 Medical/Surgical Supplies and Devices — Take-home supplies
• 0274 Medical/Surgical Supplies and Devices — Prosthetic/orthotic devices
• 0275 Medical/Surgical Supplies and Devices — Pacemaker
• 0276 Medical/Surgical Supplies and Devices — Intraocular lens
• 0277 Medical/Surgical Supplies and Devices — Take-home oxygen
• 0279 Medical/Surgical Supplies and Devices — Other supplies/devices
• 0280 Oncology — General
• 0920    Other diagnostic services — General
• 0940    Other therapeutic services — General 

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

Beginning with dates of service on or after 11/01/2024, Anthem will update the Nurse Practitioner and Physician Assistant Services reimbursement policy as indicated below.

The following services will be removed as physicians’ services:

• Preventive Services
• Radiology Services

The following services will be included as physicians’ services:

• Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
• Laboratory Services and Screening Services

For specific policy details, visit the reimbursement policy page at Anthem.com/provider.

Beginning with dates of service on or after 11/01/2024, Anthem will update the Nurse Practitioner and Physician Assistant Services reimbursement policy as indicated below.

The following services will be removed as physicians’ services:

• Preventive Services
• Radiology Services

The following services will be included as physicians’ services:

• Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
• Laboratory Services and Screening Services

For additional information, please review the Nurse Practitioner and Physician Assistant Services reimbursement policy at https://providers.anthem.com/new-york-provider/claims/reimbursement-policies.

Specialty pharmacy updates for Anthem are listed below

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Update: In the May 2023 edition of Provider News, we announced prior authorization for Adstiladrin would be effective August 2023. Review of Adstiladrin is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

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

Quantity limit updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of a national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after November 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria at anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

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

Quantity limit updates

Effective for dates of service on or after November 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process. 

Access our Clinical Criteria at anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these quantity limit updates.

The formulary changes listed below were reviewed and approved at our first quarter 2024 Pharmacy and Therapeutics Committee meeting.

Effective August 1, 2024, the changes outlined below apply to all Anthem members.

Don’t forget to read the footnotes at the bottom of the tables.

What is the impact of this change?

* This change will be implemented once the medication is on the market.
** This change will be implemented ASAP. 

What actions do I need to take?

Please work with your patients to transition to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you must obtain prior authorization to continue coverage beyond the applicable effective dates.

What if I need assistance?

We recognize the unique aspects of patients’ cases. If for medical reasons your patient cannot be converted to a formulary alternative, call Provider Services at 800-450-8753 and follow the voice prompts for pharmacy prior authorization. You can find the preferred drug list on our provider website at https://providers.anthem.com/ny.

If you need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800-450-8753.

The Medical Specialty Drug Review team for Anthem will manage the pre-service clinical review of non-oncology specialty pharmacy drugs. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc., a separate company.

The following Clinical Criteria documents were endorsed at the May 17, 2024, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective November 1, 2024

The following Clinical Criteria are new:

• CC-0262 Tevimbra (tislelizumab-jsgr)

Revised Clinical Criteria effective November 1, 2024

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

• CC-0002 Colony Stimulating Factor Agents
• CC-0063 Ustekinumab Agents (Stelara, Selarsdi, Wezlana)
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0092 Adcetris (brentuximab vedotin)
• CC-0098 Doxorubicin Liposome (Doxil)
• CC-0105 Vectibix (panitumumab)
• CC-0107 Bevacizumab for Non-ophthalmologic Indications
• CC-0111 Nplate (romiplostim)
• CC-0124 Keytruda (pembrolizumab)
• CC-0130 Imfinzi (durvalumab)
• CC-0162 Tepezza (teprotumumab-trbw)
• CC-0188 Imcivree (setmelanotide)
• CC-0199 Empaveli (pegcetacoplan)
• CC-0221 Spevigo (spesolimab-sbzo)