July 2024 Provider Newsletter

Beginning with claims processing on or after August 1, 2024, Anthem will use coding policies to support the use of anatomical modifiers. These policies were developed to promote national correct coding methods and to control improper coding that leads to incorrect payment. This update is part of continuing efforts to process claims accurately without having to request additional documentation from care providers.

What are the policies for using anatomical modifiers in procedure coding?

CPT^® and HCPCS Level II guidelines supporting the use of anatomic-specific modifiers were used to develop these policies, which validate the area or part of the body on which a procedure is performed. Procedure codes that do not specify right or left require the appropriate anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

Action needed

CPT and HCPCS Level II guidelines support the following set of anatomical modifiers to facilitate correct coding for claims processing. Care providers are encouraged to follow these guidelines and append the modifiers relevant to the procedure code on the service line.

The anatomical modifiers, which must be reported, are:

Modifier	Description
E1–E4	Eyelids
FA, F1–F9	Fingers
TA, T1–T9	Toes
LC	Left circumflex, coronary artery
LD	Left anterior descending, coronary artery
LM	Left main coronary artery
RC	Right coronary artery
RI	Ramus intermedius
LT	Left side
RT	Right side
50	Bilateral

We are committed to a future of shared success. If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CD-059555-24-CPN58952

AdministrativeCommercialJuly 1, 2024

Recovery room — facility editing update

Effective for all claims received on and after August 1, 2024, Anthem is updating its outpatient facility editing system to deny revenue code 0710 (recovery room services) when billed without revenue code 037X (anesthesia services), on the same claim. Per industry-standard coding resources, including the UB04 editor and the National Uniform Billing Committee (NUBC), “an anesthesia charge (revenue code category 037X) should be billed with a revenue code from category 071X, recovery room charge.”

If you believe you have received a denial in error, follow the Anthem claim dispute process.

Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-061118-24-SRS60998

AdministrativeCommercialJuly 1, 2024

Anesthesia modifiers — professional editing update

Effective for all claims received on and after August 1, 2024, Anthem is updating its professional claims editing system to deny anesthesia services billed without the required anesthesia modifiers. According to industry-standard coding resources including the American Society of Anesthesiologists and AMA CPT^® coding manuals, and the Anthem current commercial professional anesthesia services reimbursement policy, anesthesia modifiers are necessary to identify whether a procedure was personally performed, medically directed, or medically supervised.

The required modifiers to be reported by provider type are as follows:

Provider type	Required modifier(s)
Anesthesiologist	AA, AD, QK, or QY
CRNA or anesthesiologist assistant — medically directed	QX
CRNA — not medically directed	QZ

If you believe you have received a claim denial in error, follow the Anthem claim dispute process.

MULTI-BCBS-CM-061114-24

AdministrativeCommercialJuly 1, 2024

Timely receipt of other carrier EOB or rejection helps avoid timely filing denials

When working with another carrier, submit documentation from the other carrier when you send the claim to Anthem to help avoid the claim from denying for timely filing. You can submit the documentation and the claim through Availity Essentials using the Claims and Payments application.

If we are the secondary payer, we will need to receive an Explanation of Benefits (EOB) along with the claim submission to determine our payment amount. To avoid a timely filing denial, the documentation must demonstrate that submission to the other insurer was within Anthem’s timely filing limit and must reflect that it was received within the timely filing limit starting from the date of the remittance advice or Explanation of Payments.

If you submit to the other carrier first and receive a rejection, submit the denial letter from the other insurance carrier along with the claim. To avoid a timely filing denial, the denial letter must be dated and printed on letterhead, and the claim and documentation must be submitted to Anthem within the timely filing limit starting from the date of the denial letter.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can delay your receiving payment and can also cause you to miss the timely filing guideline.

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

Resource

Coordination of benefits — how to avoid timely filing denials

NYBCBS-CM-061116-24

ATTACHMENTS (available on web): Coordination of benefits — how to avoid timely filing denials (pdf - 0.07mb)

AdministrativeCommercialJuly 1, 2024

Drugs and biologic

Effective October 1, 2024, Anthem is enhancing its claims editing system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate Federal Drug Administration (FDA) approved indicators for on- and off-label use.

These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with the FDA indicator for on-/off-label use.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record that is relevant to the drug provided.

If you have questions about this notification, contact your contract manager or provider relationship management account representative.

MULTI-BCBS-CM-061244-24

AdministrativeCommercialMedicare AdvantageMedicaidJune 18, 2024

Phoenix Sepsis Criteria for coding and billing pediatric sepsis

To ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis for our pediatric members, we review clinical information (including treatment and medical management) and laboratory and diagnostic procedure findings in the medical records submitted for review. To conduct the review accurately and consistently, our review process for pediatric sepsis applies coding and documentation guidelines.

Beginning with admission dates of July 1, 2024, and later for members aged 29 days through 17 years of age, we will also apply the updated and most recent publication of the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force criteria known as the Phoenix Sepsis Criteria, published in the Journal of the American Medical Association (JAMA) in January 2024.

Clinicians and facilities should apply the Phoenix Sepsis Criteria when determining at discharge if the pediatric patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the Phoenix Sepsis Criteria.

Together, we can work towards improved outcomes.

jamanetwork.com/journals/jama/article-abstract/2814297

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CDCRCM-056040-24-CPN55116

AdministrativeCommercialJuly 1, 2024

CAA: Maintain your online provider directory information

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/provider. Then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your care provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

Updating care provider demographic information for all assigned payers in one location.
Attesting to and managing current care provider demographic information.
Monitoring submitted demographic updates in real-time with a digital dashboard.
Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

Log on to Availity.com to learn about and attend one of our training opportunities.
On Availity.com, you can view the Availity PDM quick start guide.
Roster Automation Standard Template and Roster Automation Rules of Engagement training:
- Listen to our recorded webinar on Availity.com.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your care providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

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

MULTI-BCBS-CM-060917-24-SRS60902

Digital SolutionsCommercialJune 20, 2024

Digital-only authorization case status notification coming to you

In our previous communications, we shared information about using the Authorizations and Referrals application on Availity Essentials to receive digital notifications for your authorization cases and related decision letters, and we introduced the Preference Center for Authorization and Referrals where you can select your preferred method of communication. We are excited to announce that we launched the Preference Center for Authorization and Referrals in April and will start using your preferences there in July.

Here is a quick recap on how to receive digital notifications and set your preferred communication method for the status of your authorization cases.

Use the Authorizations and Referrals application for digital notifications:

Retrieve cases submitted digitally and non-digitally by your organization through Auth/Referral Inquiry; use the Pin to Dashboard feature to keep these cases on the Auth/Referral Dashboard, saving you from repeating the search in the future.
Find the most recent statuses of cases submitted by your organization on the Auth/Referral Dashboard — Select View Details in the Actions menu for case details, including decision letters. For pinned cases, select the case card to get the latest status and case details.

Access the Preference Center and set your preferences:

After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile.
Select your organization and then set your communication preference (your default is Digital Access (Default) or if you prefer to receive paper surface mail, you can select Digital + Mail) for Authorization and Referrals:
- Adjust the preference for the tax IDs and NPIs of your organization to fit your business needs.
- You can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs.

Manage preferences (Availity administrators)

Availity Administrators can learn more about managing preferences related to Authorization Decision letters. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters.

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

MULTI-BCBS-CM-060250-24-CPN60234

Digital SolutionsMedicare AdvantageMedicaidJuly 1, 2024

Admission, discharge, and transfer information is now available for Medicare Advantage and Medicaid members

If you and your organization are focused on promoting evidence-based medicine and clinical quality performance, our Alerts Hub clinical notification tool, accessed through Availity Essentials, can help drive your success.

Our clinical notification application, Alerts Hub, offers admission, discharge, and transfer (ADT) notifications for Medicare Advantage and Medicaid members. For those members, Alerts Hub offers a simple way to view a list of patients who have been admitted to the hospital or visited the emergency room.

Discover what users across the country already know.

Alerts Hub offers timely, actionable information to help your organization reach out to patients who can benefit from transitions in care planning or other interventions following inpatient or emergency care.

Viewing and responding to ADT notifications with outreach to patients can help drive your organizations’ clinical quality and cost of care performance in value-based care arrangements —More importantly, it helps drive better outcomes for your patients.

Get started today.

We are committed to finding solutions that help our care provider partners offer quality services to our members. To access Alerts Hub, log on to Availity Essentials, select Payer Spaces, then select Alerts Hub. New users will need to register and set preferences. Registered users will receive daily notification emails with a summary of relevant alerts and a reminder to view details in Alerts Hub. Be sure to check your junk or spam folders if you aren’t receiving messages in your inbox.

Need more help? The Availity Custom Learning Center offers a range of training materials that can help you get up to speed quickly so that you can take advantage of all Alerts Hub has to offer.

Contact us.

Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CDCR-060640-24-CPN59897

Education & TrainingCommercialJune 13, 2024

Faster notification of EDI corrected claims errors

For those providers and their corresponding vendors (either billing services or clearinghouses) who submit corrected claims through EDI, we’re enhancing the 277CA to notify you of submission errors discovered during our claims processing. Although you’ll continue to receive physical mail notifications related to claims processing issues, the 277CA notifications can expedite the turnaround time by highlighting submission issues upfront.

Now, the 277CA will also communicate the following messages:

Tax ID and NPI are not registered.
Billed place of treatment doesn’t correspond with the place of service.
Rendering provider isn’t valid for the service date.
Billing NPI doesn’t align with the claim’s tax ID.

Despite the addition of this new feature, there will be no reductions in the services we already provide. Our hope is that this change will augment the speed and communication of our service.

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

MULTI-BCBS-CM-060850-24-CPN59863

Education & TrainingMedicaidJune 21, 2024

Human papillomavirus vaccinations facts

Fact 1: The HPV vaccine prevents certain cancers.

Human papillomavirus (HPV) is known to cause cancers of the throat, cervix, vulva, vagina, penis, and anus. Studies show that the HPV vaccine provides close to 100% protection against infections and pre-cancers caused by certain types of HPV.

Fact 2: The HPV vaccination works best when given between ages 9 and 12.

Vaccines are used to help prevent diseases, so children are vaccinated before being exposed to an infection. Most people in the United States are exposed to HPV in their teens and early twenties, therefore, it is best to administer the vaccine between ages 9 and 12. The body also produces the most antibodies to HPV when the vaccine is given in this age range. Teens and young adults aged 13 through 26 who have not been vaccinated, or who have not completed the series, should get the vaccine as soon as possible. The American Cancer Society does not recommend HPV vaccination for anyone older than 26 years of age.

Fact 3: The HPV vaccine is for boys and girls.

The HPV vaccine is strongly recommended for boys and girls, as both can get HPV. In fact, HPV is so common that at least eight out of 10 people in the United States will come in contact with it at some point in their lives. Most HPV infections resolve without any health problems. However, there is no way to know when it will not, and an infection could lead to cancer.

Fact 4: The HPV vaccine is safe.

The HPV vaccine has been used since 2006 and went through extensive safety testing before becoming available. Scientists and health organizations around the world closely monitor HPV vaccine safety. In the United States, vaccine safety is watched by several national systems working together to make sure that any harmful side effects are found early.

More than 100 studies in millions of people worldwide have all shown that the HPV vaccine is safe. Like any vaccination, there may be common mild side effects, such as a headache or fever, that resolve quickly. Pain, redness, or swelling can be present at the injection site. A small number of people may have a more serious side effect, such as an allergic reaction or fainting when the vaccine is given.

Fact 5: The HPV vaccine does not contain harmful ingredients.

The ingredients in the HPV vaccine, like all vaccines, help make sure that it is effective and safe. These ingredients occur naturally in the environment, the human body, and foods. For example, the HPV vaccine contains aluminum like the hepatitis B and Tdap vaccines. Aluminum boosts the body’s immune response to the vaccine. People are exposed to aluminum every day through food, cooking utensils, water, and even breast milk.

Fact 6: The HPV vaccine can protect fertility.

There is no data to suggest that getting the HPV vaccine will affect a patient’s future fertility. Moreover, the HPV vaccine can help protect women from future fertility problems linked to cervical cancer and pre-cancer.

Fact 7: The HPV vaccine lasts a long time.

When a child gets the HPV vaccine, the body will make proteins called antibodies that fight the virus. Antibodies give strong and long-lasting protection.

Fact 8: Most children in the United States can get the HPV vaccine for little or no cost.

Most insurance plans will cover the HPV vaccine cost if it is given according to national guidelines, between ages 9 and 26.

For children and teens who do not have insurance, the federal Vaccines for Children (VFC) program covers vaccine costs, including the HPV vaccine. The VFC program provides free vaccines to children and teens until 18 years of age, who are Medicaid-eligible, American Indian, Alaska Native, underinsured, or uninsured.

The VFC program also allows children and teens to get VFC vaccines through federally qualified health centers or rural health centers.

References:

HPV vaccine facts. Cancer.org
HPV vaccination: what everyone should know. HPV Vaccination: What Everyone Should Know
Vaccines by age. Vaccines for Your Children by Age

NYBCBS-CD-053140-24

Education & TrainingCommercialMedicare AdvantageMedicaidJuly 1, 2024

July is Disability Awareness Month

We hope you are finding our monthly observance articles helpful and informative. We will continue to feature these monthly articles to keep you informed about our resources that are here to support you in caring for all of our members.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers.

In recognition of July as Disability Awareness Month, and to commemorate the signing of the Americans with Disabilities Act (ADA) in 1990 that promotes equal rights and accessibility for people with disabilities, we are introducing three eLearning resources and tools on My Diverse Patients. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address disparities. Availability of multiple free continuing medical education (CME) courses with CMEs are offered through the American Academy of Family Physicians (AAFP).

For the month of July, our featured eLearning Resources & Tools are:

Health Equity Framework for People with Disabilities:
- This policy brief provides the rationale for the need for an all-of-government approach to achieve health equity in the United States and its territories for the largest unrecognized minority group in this country — the over 61 million people with disabilities — and sets forth a framework to achieve health equity for all people with disabilities. Disability is a natural part of the human condition, which occurs across all ages, genders, races, ethnicities, languages, and social groups.
Health Equity for People with Disabilities:
- The CDC’s Division of Human Development and Disability (DHDD) works to promote health and reduce health inequities for people with disabilities of all ages so they can participate fully in all aspects of their communities throughout their lives and have the opportunity to achieve all they set out to do.
Connections Between Health Equity and Disability:
- When it comes to healthcare, significant disparities abound between people with disabilities and able-bodied people. From physical barriers and discrimination to financial hurdles and a lack of available resources, access to healthcare is alarmingly inequitable for people with disabilities around the world.

We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare.

MULTI-ALL-CDCRCM-060726-24-CPN60345

Education & TrainingCommercialMarch 12, 2024

Important reminder: The correct original claim number must be included if submitting a corrected claim

When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim.

For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:

In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.

For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:

In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.

We’ve also developed a training video that can help you reduce duplicate claims along with a training guide called Making the Claims Process Work for You to help you properly submit a corrected claim. Access the video and download the guide here. Provider information is required to view this training; however, you will only be prompted to enter this information the first time viewing this training.

If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report.

MULTI-BCBS-CM-049145-23-CPN48099, MULTI-BCBS-CM-061597-24-CPN61590

Education & TrainingMedicaidJune 4, 2024

Childhood immunization status (CIS)

Healthcare Effectiveness Data Information Set^®(HEDIS) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

Childhood immunization status (CIS)

Measure description: the percentage of children who had the recommended vaccines by their second birthday (see numerator); different vaccines can be given on the same day (the same vaccine must be given on different DOS)

Measure population (denominator): children who turn two years of age during the measurement year

Exclusions:

Children who had any of the following on or before their second birthday:
- Immunodeficiency, severe combined immunodeficiency
- HIV
- Lymphoreticular cancer, multiple myeloma, leukemia
- Intussusception
Received hospice services anytime during the measurement year
Deceased during the measurement year

Measure compliance (numerator): children who had any of the following (from each row) on or before their second birthday:

Vaccine	Doses	Combo vaccine or antigen*	History of illness	Anaphylaxis due to vaccine	Encephalitis due to vaccine
DTap (Diphtheria, tetanus, acellular pertussis)	4	X		X	X
IPV (Polio)	3	X		X
MMR (Measles, mumps, rubella)	1	X	X	X
HiB (Hemophilus influenza B)	3	X		X
HepB (Hepatitis B)	3	X	X	X
VZV Chicken pox (Varicella zoster)	1	X	X	X
PCV (Pneumococcal conjugate)	4	X		X
HepA (Hepatitis A)	1	X	X	X
RV (Rotavirus)	2-3	X		X
Flu (Influenza)	2	X		X

Note:

Combination vaccines must have evidence of all antigens.
The below count towards compliance for the vaccine. Document with event date:
- For DTaP: Encephalitis due to the vaccine
- For ALL vaccines:
  - Anaphylaxis due to the vaccine
  - Evidence of the antigen or combination vaccine
- For Hep B, MMR, VZV, and Hep A, count any of the following:
  - Documented history of illness
Must be done by second birthday (when scheduling, check the calendar and schedule prior to second birthday)
For rotavirus, if documentation does not indicate whether the two-dose schedule or three-dose schedule was used, assume a three-dose schedule.

Acceptable documentation:

A certificate of immunization prepared by an authorized healthcare provider or agency including the specific dates and types of immunizations administered
A note indicating the name of the specific antigen and immunization date
A note in the medical record indicating the member received the immunization at delivery or in the hospital (use the date of birth as the date administered)

For combination vaccinations that require more than one antigen (DTaP, MMR), evidence of all antigens must be documented. LAIV only counts if administered on the second birthday.

Not acceptable:

A note that says the member is up to date with all immunizations but does not list the dates and names of all immunizations
Influenza: Do not count a vaccination administered prior to six months (180 days after birth).
DTaP, IPV, HiB, Pneumococcal conjugate, Rotavirus: Do not count a vaccination administered prior to 42 days after birth.

Measure codes:

DTaP:
- CPT^®: 90697, 90698, 90700, 90723
IPV:
- CPT: 90697, 90698, 90713, 90723
MMR:
- CPT: 90707, 90710
HIB:
- CPT: 90644, 90647, 90648, 90697, 90698, 90748
Hep B:
- CPT: 90697, 90723, 90740, 90744, 90747, 90748
- HCPCS: G0010
VZV:
- CPT: 90710, 90716
PCV:
- CPT: 90670
- HCPCS: G0009
Hep A:
- CPT: 90633
Rotavirus:
- CPT: 90681 (two dose), 90680 (three dose)
Influenza:
- CPT: 90655, 90657, 90661, 90673, 90674, 90756, 90685-90689
- HCPCS: G0008
Influenza LAIV:
- CPT: 90660, 90672

Helpful HEDIS tips:

MMR, VZV, and Hep A need to be given on or between the child’s first and second birthdays.
For DTaP, IPV, HIB, PCV, and RV, do not count a vaccination administered prior to 42 days after birth.
For flu, one of the two vaccines can be a live attenuated influenza vaccine (LAIV) if given on the second birthday.
For flu, do not count a vaccination administered prior to six months (180 days) after birth.
Review the child’s immunization status at every visit and provide necessary vaccines.
Provide parents with recommended immunization schedules and stress the importance of keeping their children immunized in a timely manner. Ensure the next immunization appointment is scheduled prior to leaving the provider’s office.
The immunization will not be valid for HEDIS purposes if given even one day after the second birthday.
Practitioners spending time addressing parental concerns and providing strong recommendations has shown to increase parental compliance with recommended immunizations.
Reminders by mail, email, and text have been shown to be effective in increasing immunization rates.
Make sure to request previous immunization records for new or recently transferred patients.
If the child shouldn’t be immunized because he or she has already had the disease, be sure to document this information, including the date.

Resources:

NCQA: Ncqa.org

HEDIS^®is a registered trademark of the National Committee for Quality Assurance (NCQA).

NYBCBS-CD-059226-24

Education & TrainingMedicaidJune 4, 2024

Immunizations for Adolescents (IMA)

Healthcare Effectiveness Data Information Set^®(HEDIS) is a widely used set of performance measures developed and maintained by NCQA.
These are used to drive improvement efforts surrounding best practices.

Measure description: This HEDIS measure represents the percentage of children who turned 13 years of age during the measurement year and had the following vaccinations on or by their thirteenth birthday:

One dose of meningococcal vaccine
One tetanus, diphtheria toxoids and one acellular pertussis vaccine (Tdap): and
Completed the human papillomavirus (HPV) series.

Meningococcal Serogroups A, C, W, Y:

At least one meningococcal serogroups A, C, W, Y vaccine, with a date of service on or between the member’s eleventh and 13th birthdays
Anaphylaxis due to the meningococcal vaccine any time on or before the member’s 13th birthday meets criteria.
Do not count meningococcal recombinant (serogroup B) (MenB) vaccines. Immunizations documented under a generic header or meningococcal and generic documentation that meningococcal vaccine, meningococcal conjugate vaccine or meningococcal polysaccharide vaccine were administered meet criteria.

Tdap:

At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, with a date of service on or between the member’s tenth and 13th birthdays.
Anaphylaxis due to tetanus, diphtheria, or pertussis vaccine any time on or before the member’s thirteenth birthday meets criteria. Encephalitis due to the tetanus, diphtheria, or pertussis vaccine any time on or before the member’s thirteenth birthday. Immunizations documented using a generic header of Tdap/Td can be counted as evidence of Tdap.

HPV:

At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart. For example, if the service date for the first vaccine was March 1, then the service date for the second vaccine must be on or after July 25.
Or at least three HPV vaccines, with different dates of service on or between the member’s ninth and 13th birthdays.
Anaphylaxis due to the HPV vaccine any time on or before the member’s 13th birthday meets criteria.

Numerator codes for Immunizations for Adolescents (IMA):

Category	Code	Vaccine
CPT^®	90715	Tdap
CPT	90619, 90733, 90734	Meningococcal
CPT	90649-90651	HPV
ICD-10-CM	T80.52XA, T80.52XD, T80.52XS	Anaphylactic reaction due to vaccination

Documentation required

Acceptable:

A note indicating the name of the specific antigen and the date of the immunization
A certificate of immunization prepared by an authorized health care provider or agency, including the specific dates and types of immunizations administered

Nonacceptable:

A note that says the member is up to date with all immunizations but does not list the dates and names of immunizations
Meningococcal recombinant (serogroup B) (MenB) vaccines

Strategies for improvement:

Educate staff to reach out to patients to schedule well-care visits and vaccines between the ages of nine and 12.
Use appointment reminders for well-care visits and vaccines.
Consider offering drop-in hours, after-hours, or weekend appointments for member convenience.
Create alerts within your electronic health record (EHR) to indicate when the vaccines are due.
Implement standing orders for adolescent vaccines so that patients may complete vaccines through a nurse visit.
Educate families on the importance of these vaccines (use of motivational interviewing).
Address vaccine hesitancy in parents by answering their questions and using fact-based educational materials.
Document and submit claims in a timely manner and with the correct codes.
Document all vaccines given with the date of service.
Missing HPV vaccines are the primary reason for noncompliance. Provide enhanced and consistent provider/clinic recommendation of HPV vaccine.
Ensure administration of the HPV vaccine when Tdap and meningococcal are given and during subsequent well-care and sick visits.
Schedule the second HPV appointment when giving the first HPV vaccine.
HPV rates are now reported for both females and males.
Bill exclusionary diagnosis codes and dates given when applicable.
Complete CDC's You Call the Shots interactive web-based immunization training course by visiting https://cdc.gov/vaccines/ed/YouCalltheShots (receive continuing education credit upon completion).

Resources:

NCQA: ncqa.org
You call the shots: https://cdc.gov/vaccines/ed/YouCalltheShots

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

NYBCBS-CD-059188-24

Policy UpdatesMedicaidMay 29, 2024

Clinical Criteria updates

Effective June 29, 2024

Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 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.

Effective date	Clinical Criteria number	Clinical Criteria title	New or revised
June 29, 2024	*CC-0258	iDoseTR (travoprost Implant)	New
June 29, 2024	*CC-0259	Amtagvi (lifleucel)	New
June 29, 2024	*CC-0260	Nexobrid (anacaulase-bcdb)	New
June 29, 2024	*CC-0199	Empaveli (pegcetacoplan)	Revised
June 29, 2024	*CC-0041	Complement Inhibitors	Revised
June 29, 2024	CC-0128	Tecentriq (atezolizumab)	Revised
June 29, 2024	CC-0116	Bendamustine agents	Revised
June 29, 2024	CC-0161	Sarclisa (isatuximab-irfc)	Revised
June 29, 2024	CC-0158	Enhertu (fam-trastuzumab deruxtecan-nxki)	Revised
June 29, 2024	CC-0157	Padcev (enfortumab vedotin)	Revised
June 29, 2024	CC-0230	Adstiladrin (nadofaragene firadenovec-vncg)	Revised
June 29, 2024	*CC-0125	Opdivo (nivolumab)	Revised
June 29, 2024	*CC-0119	Yervoy (ipilimumab)	Revised
June 29, 2024	*CC-0099	Abraxane (paclitaxel, protein bound)	Revised
June 29, 2024	*CC-0093	Docetaxel (Taxotere)	Revised
June 29, 2024	*CC-0094	Pemetrexed (Alimta, Pemfexy, Pemrydi)	Revised
June 29, 2024	CC-0130	Imfinzi (durvalumab)	Revised
June 29, 2024	*CC-0088	Elzonris (tagraxofusp-erzs)	Revised
June 29, 2024	*CC-0118	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)	Revised
June 29, 2024	*CC-0112	Xofigo (Radium Ra 223 Dichloride)	Revised
June 29, 2024	*CC-0123	Cyramza (ramucirumab)	Revised
June 29, 2024	*CC-0131	Besponsa (inotuzumab ozogamicin)	Revised
June 29, 2024	CC-0121	Gazyva (obinutuzumab)	Revised
June 29, 2024	CC-0122	Arzerra (ofatumumab)	Revised
June 29, 2024	CC-0232	Lunsumio (mosunetuzumab-axgb)	Revised
June 29, 2024	CC-0109	Zaltrap (ziv-aflibercept)	Revised
June 29, 2024	CC-0135	Melanoma Vaccines	Revised
June 29, 2024	*CC-0096	Asparagine Specific Enzymes	Revised
June 29, 2024	CC-0120	Kyprolis (carfilzomib)	Revised
June 29, 2024	*CC-0117	Empliciti (elotuzumab)	Revised
June 29, 2024	*CC-0126	Blincyto (blinatumomab)	Revised
June 29, 2024	CC-0113	Sylvant (siltuximab)	Revised
June 29, 2024	CC-0132	Mylotarg (gemtuzumab ozogamicin)	Revised
June 29, 2024	CC-0097	Vidaza (azacitidine)	Revised
June 29, 2024	CC-0129	Bavencio (avelumab)	Revised
June 29, 2024	*CC-0090	Ixempra (ixabepilone)	Revised
June 29, 2024	CC-0110	Perjeta (pertuzumab)	Revised
June 29, 2024	*CC-0115	Kadcyla (ado-trastuzumab)	Revised
June 29, 2024	*CC-0108	Halaven (eribulin)	Revised
June 29, 2024	CC-0089	Mozobil (plerixafor)	Revised
June 29, 2024	CC-0124	Keytruda (pembrolizumab)	Revised
June 29, 2024	*CC-0002	Colony Stimulating Factor Agents	Revised
June 29, 2024	*CC-0212	Tezspire (tezepelumab-ekko)	Revised
June 29, 2024	*CC-0033	Xolair (omalizumab)	Revised
June 29, 2024	*CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
June 29, 2024	*CC-0029	Dupixent (dupilumab)	Revised
June 29, 2024	*CC-0208	Adbry (tralokinumab)	Revised
June 29, 2024	*CC-0062	Tumor Necrosis Factor Antagonists	Revised
June 29, 2024	*CC-0067	Prostacyclin Infusion and Inhalation Therapy	Revised
June 29, 2024	*CC-0066	Monoclonal Antibodies to Interleukin-6	Revised
June 29, 2024	*CC-0064	Interleukin-1 Inhibitors	Revised
June 29, 2024	*CC-0057	Krystexxa (pegloticase)	Revised
June 29, 2024	*CC-0068	Growth Hormones	Revised
June 29, 2024	*CC-0047	Trogarzo	Revised
June 29, 2024	*CC-0078	Orencia (abatacept)	Revised
June 29, 2024	*CC-0020	Natalizumab Agents (Tysabri, Tyruko)	Revised
June 29, 2024	*CC-0174	Kesimpta (ofatumumab)	Revised
June 29, 2024	*CC-0011	Ocrevus (ocrelizumab)	Revised

NYBCBS-CD-059009-24-CPN57972

Policy UpdatesMedicare AdvantageJune 4, 2024

Clinical Criteria updates

Effective July 6, 2024

Summary

On November 17, 2023, and March 21, 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. For questions or 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.

Effective date	Clinical Criteria number	Clinical Criteria title	New or revised
July 6, 2024	*CC-0261	Winrevair (sotatercept-csrk)	New
July 6, 2024	*CC-0125	Opdivo (nivolumab)	Revised
July 6, 2024	*CC-0003	Immunoglobulins	Revised
July 6, 2024	CC-0033	Xolair (omalizumab)	Revised
July 6, 2024	*CC-0062	Tumor Necrosis Factor Antagonists	Revised
July 6, 2024	CC-0121	Gazyva (obinutuzumab)	Revised
July 6, 2024	CC-0201	Rybrevant (amivantamab-ymjw)	Revised
July 6, 2024	*CC-0251	Ycanth (cantharidin)	Revised

Medicare services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC., or Anthem Blue Cross and Blue Shield Retiree Solutions, trade name of Anthem Insurance Companies, Inc.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CR-059942-24-CPN59599

Policy UpdatesMedicare AdvantageJune 3, 2024

Clinical Criteria updates — November 2023

Summary: On February 24, 2023, September 11, 2023, and November 17, 2023, 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. For questions or 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.

Effective Date	Clinical Criteria Number	Clinical Criteria Title	New or Revised
July 7, 2024	*CC-0252	Adzynma (ADAMTS13, recombinant-krhn)	New
July 7, 2024	*CC-0253	Aphexda (motixafortide)	New
July 7, 2024	*CC-0254	Zilbysq (zilucoplan)	New
July 7, 2024	CC-0130	Imfinzi (durvalumab)	Revised
July 7, 2024	CC-0223	Imjudo (tremelimumab-actl)	Revised
July 7, 2024	*CC-0059	Selected Injectable NK-1 Antiemetic Agents	Revised
July 7, 2024	CC-0074	Akynzeo (fosnetupitant and palonosetron) for injection	Revised
July 7, 2024	*CC-0065	Agents for Hemophilia A and von Willebrand Disease	Revised
July 7, 2024	CC-0124	Keytruda (pembrolizumab)	Revised
July 7, 2024	CC-0150	Kymriah (tisagenlecleucel)	Revised
July 7, 2024	CC-0187	Breyanzi (lisocabtagene maraleucel)	Revised
July 7, 2024	CC-0133	Aliqopa (copanlisib)	Revised
July 7, 2024	CC-0205	Fyarro (sirolimus albumin bound)	Revised
July 7, 2024	CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
July 7, 2024	*CC-0226	Elahere (mirvetuximab)	Revised
July 7, 2024	CC-0125	Opdivo (nivolumab)	Revised
July 7, 2024	CC-0058	Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents	Revised
July 7, 2024	*CC-0009	Lemtrada (alemtuzumab) for the Treatment of Multiple Sclerosis	Revised
July 7, 2024	*CC-0014	Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis	Revised
July 7, 2024	*CC-0011	Ocrevus (ocrelizumab)	Revised
July 7, 2024	*CC-0174	Kesimpta (ofatumumab)	Revised
July 7, 2024	*CC-0020	Natalizumab Agents (Tysabri, Tyruko)	Revised
July 7, 2024	*CC-0032	Botulinum Toxin	Revised
July 7, 2024	*CC-0068	Growth Hormone	Revised
July 7, 2024	*CC-0173	Enspryng (satralizumab-mwge)	Revised
July 7, 2024	*CC-0170	Uplizna (inebilizumab-cdon)	Revised
July 7, 2024	*CC-0199	Empaveli (pegcetacoplan)	Revised
July 7, 2024	*CC-0041	Complement Inhibitors	Revised
July 7, 2024	*CC-0071	Entyvio (vedolizumab)	Revised
July 7, 2024	*CC-0064	Interleukin-1 Inhibitors	Revised
July 7, 2024	*CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
July 7, 2024	*CC-0066	Monoclonal Antibodies to Interleukin-6	Revised
July 7, 2024	*CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
July 7, 2024	*CC-0078	Orencia (abatacept)	Revised
July 7, 2024	*CC-0063	Ustekinumab Agents	Revised
July 7, 2024	*CC-0062	Tumor Necrosis Factor Antagonists	Revised
July 7, 2024	CC-0003	Immunoglobulins	Revised
July 7, 2024	*CC-0002	Colony Stimulating Factor Agents	Revised
July 7, 2024	CC-0247	Beyfortus (nirsevimab)	Revised
July 7, 2024	CC-0072	Vascular Endothelial Growth Factor (VEGF) Inhibitors	Revised
July 7, 2024	CC-0010	Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors	Revised
July 7, 2024	CC-0209	Leqvio (inclisiran)	Revised
July 7, 2024	*CC-0182	Iron Agents	Revised
July 7, 2024	*CC-0086	Spravato (esketamine) Nasal Spray	Revised

MULTI-BCBS-CR-050483-24-CPN49884

Policy UpdatesMedicaidJune 4, 2024

Carelon Medical Benefits Management, Inc. updates

This article was updated as of August 23, 2024.

Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

Site of Care Guidelines:
- Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care

Please share this notice with other members of your practice and office staff.

NYBCBS-CD-055214-24-CPN54524, MULTI-ALL-CDCR-066460-24

Policy UpdatesMedicare AdvantageMay 29, 2024

Carelon Medical Benefits Management, Inc. updates

This article was updated as of August 23, 2024.

Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

Site of Care Guidelines:
- Site of Care for Advanced Imaging
- Rehabilitative Site of Care
- Surgical Site of Care

Please share this notice with other members of your practice and office staff.

MULTI-BCBS-CR-055356-24-CPN54514, MULTI-ALL-CDCR-066460-24

Medical Policy & Clinical GuidelinesMedicare AdvantageJune 21, 2024

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective for dates of service on and after October 20, 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.

Radiology:

Brain Imaging:
- Added indications for MRI and amyloid beta PET imaging in Alzheimer disease to address patients considering or receiving lecanemab
Spine Imaging:
- Changed Perioperative and Periprocedural Imaging to Postoperative and Postprocedural Imaging; pre-procedure requests should be reviewed based on more specific indication
Extremity Imaging:
- Separated criteria for osteomyelitis and septic arthritis into separate indications; US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication
Vascular Imaging:
- CTA/MRA Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
- Lower Extremity PAD: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with ACR Appropriateness Criteria
- Suboptimal imaging option downgrades/removals in Brain, Head and Neck, and Abdomen/Pelvis

Cardiovascular:

Imaging of the Heart:
- Resting Transthoracic Echocardiography (TTE)
- Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
- Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant
Cardiac Resynchronization Therapy:
- Added exclusion for Wireless CRT
Diagnostic Coronary Angiography:
- Criteria reaffirmed — no changes
Endovascular Revascularization:
- Added indication for endovascular venous arterialization of the tibial or peroneal veins
- Added exclusions for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
- Also added exclusion for atherectomy (clarification)
Implantable Cardioverter Defibrillators:
- Transvenous ICD placement
- Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies
Percutaneous Coronary Intervention:
- Added exclusion for percutaneous transluminal coronary lithotripsy
Permanent Implantable Pacemakers:
- Device replacement
- Added criteria for permanent implantable pacemaker device replacement
- Single chamber leadless pacemakers
- Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
- Added exclusion for right atrial single chamber leadless pacemakers
- Dual chamber leadless pacemakers
- Added exclusion for dual chamber leadless pacemakers

Genetic Testing:

Chromosomal Microarray Analysis:
- Clarified recommendations for Genetic Counseling
- Clarified requirements for postnatal evaluation of individuals with:
- Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
- Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
- Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound
Pharmacogenomic Testing:
- Added APOE testing
Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing:
- Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications), and moved these tests to exclusions as they are considered not medically necessary
- Retitled guideline to Predictive and Prognostic Polygenic Testing to address this change in scope.
Somatic Testing of Solid Tumors:
- Breast Cancer
- Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer
Whole Exome and Whole Genome Sequencing:
- Expanded WES criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications.
- Clarified well-delineated genetic syndrome in criterion for multiple anomalies
- Clarified Genetic Counseling details for WES

MSK:

Sacroiliac Joint Fusion:
- New medical necessity criteria for open SI joint fusion
- As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum
- As an adjunct to the medical treatment of sacroiliac joint infection/sepsis (for example, osteomyelitis, pyogenic sacroiliitis)
- For severe traumatic injuries associated with pelvic ring disruption (for example, pelvic ring fractures, acetabular fracture, spinopelvic dissociation)
- During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium as part of medically necessary lumbar spine fusion procedures
- Open SI joint fusion is not medically necessary for poorly defined low back pain and sacral insufficiency fractures.
Spine Surgery:
- Lumbar Discectomy, Foraminotomy, and Laminotomy
- Added exclusion for annular closure device
- Lumbar Laminectomy
- Expanded timeframe for imaging lumbar disc herniation (9 months) and lumbar spinal stenosis (12 months)

Radiation Oncology:

Removed criteria for hyperthermia
Clarified inclusion criteria of the RTOG 1112 protocol.

Sleep Disorder Management:

Expanded definitions and terminology
Expanded documentation of hypoventilation
Expanded criteria for home and in-lab sleep studies
Added contraindication to APAP titration for use of supplemental oxygen
Removed home sleep apnea testing (HSAT) as an option in medical necessity of MSLT/MWT for suspected narcolepsy
Management of OSA using Implanted Hypoglossal Nerve Stimulators — Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by FDA
Miscellaneous Devices section added: electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of high-quality evidence

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 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.

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.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBC-CR-059468-24-CPN58860

Medical Policy & Clinical GuidelinesCommercialMedicaidJune 28, 2024

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Radiology:

Brain Imaging:
- Added indications for MRI and amyloid beta PET imaging in Alzheimer disease to address patients considering or receiving lecanemab
Spine Imaging:
- Changed Perioperative and Periprocedural Imaging to Postoperative and Postprocedural Imaging; pre-procedure requests should be reviewed based on more specific indication
Extremity Imaging:
- Separated criteria for osteomyelitis and septic arthritis into separate indications; US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication
Vascular Imaging:
- CTA/MRA Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
- Lower Extremity PAD: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with ACR Appropriateness Criteria
- Suboptimal imaging option downgrades/removals in Brain, Head and Neck, and Abdomen/Pelvis

Cardiovascular:

Imaging of the Heart:
- Resting Transthoracic Echocardiography (TTE)
- Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
- Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant
Cardiac Resynchronization Therapy:
- Added exclusion for Wireless CRT
Diagnostic Coronary Angiography:
- Criteria reaffirmed — no changes
Endovascular Revascularization:
- Added indication for endovascular venous arterialization of the tibial or peroneal veins
- Added exclusions for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
- Also added exclusion for atherectomy (clarification)
Implantable Cardioverter Defibrillators:
- Transvenous ICD placement
- Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies
Percutaneous Coronary Intervention:
- Added exclusion for percutaneous transluminal coronary lithotripsy
Permanent Implantable Pacemakers:
- Device replacement
- Added criteria for permanent implantable pacemaker device replacement
- Single chamber leadless pacemakers
- Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
- Added exclusion for right atrial single chamber leadless pacemakers
- Dual chamber leadless pacemakers
- Added exclusion for dual chamber leadless pacemakers

Genetic Testing:

Chromosomal Microarray Analysis:
- Clarified recommendations for Genetic Counseling
- Clarified requirements for postnatal evaluation of individuals with:
- Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
- Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
- Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound
Pharmacogenomic Testing:
- Added APOE testing
Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing:
- Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications), and moved these tests to exclusions as they are considered not medically necessary
- Retitled guideline to Predictive and Prognostic Polygenic Testing to address this change in scope.
Somatic Testing of Solid Tumors:
- Breast Cancer
- Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer
Whole Exome and Whole Genome Sequencing:
- Expanded WES criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications.
- Clarified well-delineated genetic syndrome in criterion for multiple anomalies
- Clarified Genetic Counseling details for WES

MSK:

Sacroiliac Joint Fusion:
- New medical necessity criteria for open SI joint fusion
- As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum
- As an adjunct to the medical treatment of sacroiliac joint infection/sepsis (for example, osteomyelitis, pyogenic sacroiliitis)
- For severe traumatic injuries associated with pelvic ring disruption (for example, pelvic ring fractures, acetabular fracture, spinopelvic dissociation)
- During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium as part of medically necessary lumbar spine fusion procedures
- Open SI joint fusion is not medically necessary for poorly defined low back pain and sacral insufficiency fractures.
Spine Surgery:
- Lumbar Discectomy, Foraminotomy, and Laminotomy
- Added exclusion for annular closure device
- Lumbar Laminectomy
- Expanded timeframe for imaging lumbar disc herniation (9 months) and lumbar spinal stenosis (12 months)

Radiation Oncology:

Removed criteria for hyperthermia
Clarified inclusion criteria of the RTOG 1112 protocol.

Sleep Disorder Management:

Expanded definitions and terminology
Expanded documentation of hypoventilation
Expanded criteria for home and in-lab sleep studies
Added contraindication to APAP titration for use of supplemental oxygen
Removed home sleep apnea testing (HSAT) as an option in medical necessity of MSLT/MWT for suspected narcolepsy
Management of OSA using Implanted Hypoglossal Nerve Stimulators — Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by FDA
Miscellaneous Devices section added: electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of high-quality evidence

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.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CDCM-059469-24-CPN58860

Medical Policy & Clinical GuidelinesCommercialJuly 1, 2024

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. Anthem’s Medical Policies and Clinical Guidelines 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 October 1, 2024

The following policy is new:

RAD.00069 Absolute Quantitation of Myocardial Blood Flow Measurement

Revised Medical Policies effective October 19, 2024

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.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

NYBCBS-CM-060993-24

Medical Policy & Clinical GuidelinesMedicare AdvantageMay 30, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Effective July 1, 2024

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Q4 2023. 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 > Providers > Provider Resources > Policies, Guidelines & Manuals.

Notes/updates:

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

MED.00146 - Gene Therapy for Sickle Cell Disease

Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease

RAD.00068 - Myocardial Strain Imaging

Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications

SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation

Reformatted Position Statement and added headers
Reformatted Medically Necessary statements to move target treatment areas into criteria
Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
Reformatted Medically Necessary statements for epilepsy
Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
Revised and reformatted Investigational & Not Medically Necessary statements

SURG.00097 - Scoliosis Surgery

Revision to Position Statement formatting
Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement

SURG.00142 - Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
Revised title
Added genicular artery embolization to the scope of document
Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary

CG-DME-42 - Continuous Glucose Monitoring Devices

Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
Revised title
Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
Revised existing Medically Necessary and Not Medically Necessary statements

CG-DME-52 - Continuous Passive Motion Devices in the Home Setting

Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications

CG-MED-94 - Vestibular Function Testing

Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing

CG-SURG-09 - Temporomandibular Disorders

Revised formatting of Medically Necessary statement
Revised surgical procedures criteria
Added MIRO Therapy to Not Medically Necessary statement

CG-SURG-70 - Gastric Electrical Stimulation

Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect July 1, 2024.

Publish date	Medical Policy number	Medical Policy title	New or revised
1/3/2024	LAB.00026	Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer Previously titled: Systems Pathology Testing for Prostate Cancer	Revised
1/3/2024	LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	Revised
1/3/2024	LAB.00050	Metagenomic Sequencing for Infectious Disease in the Outpatient Setting	Conversion new
1/3/2024	MED.00057	MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications	Revised
1/18/2024	*MED.00146	Gene Therapy for Sickle Cell Disease	New
1/3/2024	*RAD.00068	Myocardial Strain Imaging	New
1/3/2024	SURG.00010	Treatments for Urinary Incontinence	Revised
12/28/2023	*SURG.00026	Deep Brain, Cortical, and Cerebellar Stimulation	Revised
12/28/2023	*SURG.00097	Scoliosis Surgery	Revised
1/3/2024	*SURG.00142	Genicular Procedures for Treatment of Knee Pain Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain	Revised
1/3/2024	TRANS.00027	Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors	Revised

Clinical UM Guidelines

On November 9, 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 January 4, 2024. These guidelines take effect July 1, 2024.

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
1/3/2024	*CG-DME-42	Continuous Glucose Monitoring Devices Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps	Revised
1/3/2024	CG-DME-44	Electric Tumor Treatment Field (TTF)	Revised
1/3/2024	CG-DME-50	Automated Insulin Delivery Systems	Conversion new
1/3/2024	CG-DME-51	External Insulin Pumps	Conversion new
1/3/2024	*CG-DME-52	Continuous Passive Motion Devices in the Home Setting	New
1/3/2024	CG-LAB-25	Outpatient Glycated Hemoglobin and Protein Testing	Revised
1/3/2024	CG-MED-92	Foot Care Services	Revised
1/3/2024	*CG-MED-94	Vestibular Function Testing	New
1/3/2024	*CG-SURG-09	Temporomandibular Disorders	Revised
12/28/2023	*CG-SURG-70	Gastric Electrical Stimulation	Revised
1/3/2024	CG-SURG-94	Keratoprosthesis	Revised
12/28/2023	CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention	Revised

MULTI-BCBS-CR-056176-24-CPN54635

Medical Policy & Clinical GuidelinesMedicaidJune 12, 2024

MCG Care Guidelines 28th edition

Effective September 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

Behavioral Health Care (BHG):
- The goal length of stay (GLOS) has been changed in two guidelines in the 28th edition of Behavioral Health Care.
Inpatient & Surgical Care (ISC):
- The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines, in the 28th edition of Inpatient & Surgical Care.
General Recovery Care (GRG):
- The benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
Recovery Facility Care (RFC):
- A total of one guideline has been removed from the 28th edition of Recovery Facility Care.
Chronic Care (CCG):
- A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

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

NYBCBS-CD-056531-24-CPN55821

Prior AuthorizationCommercialJune 19, 2024

Carelon Medical Benefits Management, Inc. genetic testing code updates

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

CPT^® code	Description
81457	Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability
81458	Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability
81459	Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements
81462	Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements
81463	Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability
81464	Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements
0420U	Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma
0422U	Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate
0423U	Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition
0424U	Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer
0425U	Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings)
0426U	Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis
0428U	Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden
0434U	Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes
0438U	Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions

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

Access the ProviderPortal_SM for Carelon Medical Benefits Management 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 Availity.com.

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

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-059592-24-CPN59056

Prior AuthorizationMedicaidJune 20, 2024

Prior authorization requirement changes effective August 1, 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.

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

Code	Description
C9790	Histotripsy (i.e., nonthermal ablation via acoustic energy delivery) of malignant renal tissue, including image guidance

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 care providers on providers.anthem.com/ny 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.

UM AROW A2023M0967

NYBCBS-CD-050782-24-CPN50146

Prior AuthorizationCommercialJuly 1, 2024

Precertification list change notification

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

To obtain precertification, providers can access Availity Essentials or call the 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.

Add to precertification

Criteria	Criteria description	Code	Effective date
SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	64722	October 1, 2024

Commercial services provided by Anthem Blue Cross, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBC-CM-057776-24

Prior AuthorizationCommercialJuly 1, 2024

Precertification list change notification July 1, 2024

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

To obtain precertification, providers can access Availity (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.

Add to precertification
Criteria	Criteria description	Code	Effective date
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33276	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33277	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33278	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33279	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33280	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33281	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33287	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	33288	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	93150	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	93151	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	93152	10/1/2024
CG-MED-79	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	93153	10/1/2024
CG-OR-PR-08	Microprocessor Controlled Lower Limb Prosthesis	L5615	10/1/2024
CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	0813T	10/1/2024
DME.00011	Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices	A4540	10/1/2024
DME.00011	Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices	E0732	10/1/2024
DME.00042	Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea	E0530	10/1/2024
DME.00043	Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring	E0492	10/1/2024
DME.00043	Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring	E0493	10/1/2024
DME.00046	Intermittent Abdominal Pressure Ventilation Devices	A4468	10/1/2024
DME.00049	External Upper Limb Stimulation for the Treatment of Tremors	A4542	10/1/2024
DME.00049	External Upper Limb Stimulation for the Treatment of Tremors	E0734	10/1/2024
GENE.00010	Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status	0423U	10/1/2024
GENE.00010	Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status	0434U	10/1/2024
GENE.00010	Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status	0438U	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81457	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81458	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81459	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81462	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81463	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	81464	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	0422U	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	0424U	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	0425U	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	0426U	10/1/2024
GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	0428U	10/1/2024
GENE.00056	Gene Expression Profiling for Bladder Cancer	0420U	10/1/2024
LAB.00003	In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays	0435U	10/1/2024
LAB.00016	Fecal Analysis in the Diagnosis of Intestinal Disorders	0430U	10/1/2024
LAB.00019	Proprietary Algorithms for Liver Fibrosis Previously titled: Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease	81517	10/1/2024
LAB.00050	Metagenomic Sequencing for Infectious Disease in the Outpatient Setting	0112U	10/1/2024
LAB.00050	Metagenomic Sequencing for Infectious Disease in the Outpatient Setting	0152U	10/1/2024
LAB.00050	Metagenomic Sequencing for Infectious Disease in the Outpatient Setting	0323U	10/1/2024
MED.00130	Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring	E0746	10/1/2024
RAD.00068	Myocardial Strain Imaging	C9762	10/1/2024
RAD.00068	Myocardial Strain Imaging	C9763	10/1/2024
SURG.00007	Vagus Nerve Stimulation	E0735	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4279	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4287	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4288	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4289	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4290	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4291	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4292	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4293	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4294	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4295	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4296	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4297	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4298	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4299	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4300	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4301	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4302	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4303	10/1/2024
SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Q4304	10/1/2024
SURG.00026	Deep Brain, Cortical, and Cerebellar Stimulation	61889	10/1/2024
SURG.00026	Deep Brain, Cortical, and Cerebellar Stimulation	61891	10/1/2024
SURG.00026	Deep Brain, Cortical, and Cerebellar Stimulation	C1778	10/1/2024
SURG.00045	Extracorporeal Shock Wave Therapy	0864T	10/1/2024
SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	58580	10/1/2024
SURG.00097	Scoliosis Surgery	22836	10/1/2024
SURG.00097	Scoliosis Surgery	22837	10/1/2024
SURG.00097	Scoliosis Surgery	22838	10/1/2024
SURG.00097	Scoliosis Surgery	0790T	10/1/2024
SURG.00142	Genicular Procedures for Treatment of Knee Pain Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain	37242	10/1/2024
SURG.00150	Leadless Pacemaker	0823T	10/1/2024
SURG.00150	Leadless Pacemaker	0824T	10/1/2024
SURG.00150	Leadless Pacemaker	0825T	10/1/2024
SURG.00150	Leadless Pacemaker	0826T	10/1/2024
SURG.00152	Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing	0861T	10/1/2024
SURG.00152	Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing	0862T	10/1/2024
SURG.00152	Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing	0863T	10/1/2024
SURG.00157	Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis	31242	10/1/2024
SURG.00157	Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis	31243	10/1/2024
SURG.00158	Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain	64596	10/1/2024
SURG.00158	Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain	64597	10/1/2024

UM AROW# A2024M1436

NYBCBS-CM-058791-24-CPN57724

Prior AuthorizationCommercialMay 7, 2024

Anthem Precertification List Change Notification for July 1, 2024

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

To obtain precertification, providers can access Availity at 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.

Add to precertification
Criteria	Criteria description	Code	Effective date
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0786T	October 1, 2024
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0787T	October 1, 2024
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0816T	October 1, 2024
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0817T	October 1, 2024
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0818T	October 1, 2024
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention	0819T	October 1, 2024

NYBCBS-CM-057228-24-SRS56901

Reimbursement PoliciesCommercialJuly 1, 2024

Reimbursement policy update: Incident to Services — Professional

Beginning with dates of service on or after October 1, 2024, Anthem will update the Incident to Service — Professional policy. The intent of the policy is to identify the reimbursement guidelines for incident to services.

This reimbursement policy identifies the following two different types of incidents:

Incident to Billing: When Incident to billing services are rendered and billed in accordance with this policy, the incident to services are eligible for reimbursement based on a 15% reduction of the maximum allowance of the applicable supervising provider’s fee schedule.
Incident to Services or Supplies: Incident to services or supplies that are essential to the performance of professional service are considered bundled in the primary service and are not allowed for separate reimbursement.

The Related Coding section of the policy includes Modifier SA which must be appended when the supervising physician is billing on behalf of non-physician practitioner (NPP) for non-surgical services.

The policy has been renamed to Incident to Services and Billing — Professional to define incident to services from incident to billing guidelines.

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

MULTI-BCBS-CM-061323-24-CPN61066

Reimbursement PoliciesCommercialJuly 1, 2024

Reimbursement policy update: Frequency Editing — Professional

Beginning with dates of service on or after October 1, 2024, Anthem will update the Related Coding section of the Frequency Editing — Professional reimbursement policy.

This policy identifies reimbursement for a procedure or service that is billed for a single member, on a single date of service by the same provider and/or provider group, up to the maximum number of units allowed. In addition to using claims processing logic to determine when the use of multiple units is appropriate, we use the nomenclature for a particular CPT^®or HCPCS level II code, the CMS’s medically unlikely edits (MUEs) designation, industry standards, or the ability to clinically perform or report a specific service more than one time on a single date of service or within a specific date span per member, per provider in making these determinations.

In the Related Coding section of the policy, the following updates will be made:

CPT maximum frequency code list:

Remove 36415 and 36416 (refer to laboratory and venipuncture C-10001)
Remove 96158-96159, 96164-96165 (refer to health and behavioral assessment/intervention C-11003)
Delete 76942, 77002, 77003, 77012, 77021, 77338, 77600, 77605, 80320-80377, 81479, 86160, 87483, 87491, 87591, 88305, 87529, 90378, 92250, 92273, 92274, 92326, 93325, 95925, 95926, 95938, 95927, 95928, 95929, 95939, 96900, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 93792, and 93793

HCPCS maximum frequency code list:

Remove S9529 (refer to laboratory and venipuncture C-10001)
Remove G0480, G0481, G0482, and G0483 (refer to drug screen testing — professional C-12004)
Remove C9257, G0480, G0481, G0482, and G0483
Add A4238, A4239, A6520-A6529, A6552-A6589, A6593-A6610, and Q0509

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

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

MULTI-BCBS-CM-061232-24

Reimbursement PoliciesCommercialJuly 1, 2024

New reimbursement policy: Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility

Beginning with dates of service on or after October 1, 2024, Anthem will implement a new reimbursement policy titled Diagnostic Radiopharmaceuticals and Contrast Materials —Professional and Facility.

Under this policy, when radiopharmaceuticals and contrast materials are billed by the facility, such services are not reimbursed as they are considered included in the facility fee. In addition, the following statement was removed from the Place of Service — Professional reimbursement policy and added to this policy:

The health plan does not allow separate reimbursement for diagnostic radiopharmaceutical and contrast materials by professional providers when reported in a facility place of service.

The Related Coding section contains specific codes with guidelines for both professional and facility providers.

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

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

MULTI-BCBS-CM-061235-24

Federal Employee Program (FEP)CommercialJuly 1, 2024

Antidepressant Medication Management (AMM)

The National Committee Quality Assurance (NCQA) develops and collects HEDIS^® measurements to set performance and drive improvement in quality-of-care outcomes.

The Federal Employee Program^® (FEP) for Anthem is continuously working to improve clinical quality of care and performance outcomes. To comply with the NCQA standards and improve HEDIS AMM performance rate, FEP takes this opportunity to remind providers to document every service rendered in an accurate, timely manner and use the appropriate ICD-10-CM, CPT^®, and HCPCS codes when billing services rendered for patients who are receiving antidepressant medications. Below is a description of the AMM measure, why it is important, exclusions, and helpful tips (such as medical records documentation and best practices).

HEDIS AMM measure description

This HEDIS measure evaluates the percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported:

Effective acute phase treatment: the percentage of members who remained on antidepressant medication for at least 85 days (12 weeks)
Effective continuation phase treatment: the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

Members with any diagnosis of major depression who are seen in any of the care settings are included in the AMM measure.

Place of services
Outpatient visit Telehealth visit ED visit Acute or nonacute inpatient stay	Intensive outpatient encounter or partial hospitalization Community mental health center E-Visit or virtual check-in (online assessment)

Why is the HEDIS AMM measure important?

Major depression is a serious mental illness with a significant burden of symptoms and the most common psychiatric disorder in individuals who die from suicide.¹ Integrating the right antidepressant medication with appropriate behavioral therapy leads to positive benefits and outcomes for members. Compliance with antidepressant medication is an essential component in treatment guidelines for major depression.²

Exclusions

Enrollees who did not have an encounter with a diagnosis of major depression during the 121-day period from 60 days prior to the index prescription start date (IPSD) through the IPSD and the 60 days after the IPSD

Common behavioral health codes used with any diagnosis of major depression that trigger patients into the HEDIS AMM measure are:

Description	Behavioral health codes (ICD-10-CM, CPT, HCPCS, POS)
Major depression	ICD-10-CM: F32.0–F32.4, F32.9, F33.0–F33.3, F33.41, F33.42, F33.9. F34.1
BH outpatient visit	CPT: 98960–98962, 99078, 99202–99205, 99211–99215, 99242–99245, 99341–99345, 99347–99350, 99381–99387, 99391–99397, 99401–99404, 99411, 99412, 99483, 99492–99494, 99510 HCPCS: G0155, G0176, G0177, G0409, G0463, G0512, H0002, H0004, H0031, H0034, H0036, H0037, H0039, H0040, H2000, H2010, H2011, H2013 - H2020, T1015
Place of service (POS)	POS: 02, 10, 52, 53
Telehealth visit	POS: 10 CPT: 98966–98968, 99441–99443
ED visit	CPT: 99281–99285
E-visit or virtual check-in (online assessment)	CPT: 98970–98972, 98980, 98981, 99421–99423, 99457, 99458 HCPCS: G0071, G2010, G2012, G2250, G2251, G2252

Helpful tips

Medical record documentation:

Diagnosis of major depression
Date of services
Date of dispensing
Evidence of antidepressant medication prescription

Best practices:

Educate members that most antidepressants take four to six weeks to work.
Encourage members to continue any prescribed medication even if they feel better. Inform them of the danger of discontinuing suddenly. If they take the medication for less than six months, they are at a higher risk of recurrence.
Assess members within 30 days from when the prescription is first filled for any side effects and their response to treatment.
When patients are making a follow-up visit, educate and encourage patients to bring their discharge instructions and medications list to their first appointment.
Coordinate care between behavioral health and primary care physicians by sharing progress notes and updates.
Educate members on what to do in an emergency, such as when having suicidal thoughts.
Focus on member preferences for treatment, allowing the member to take ownership of their health and treatment plan.

https://pubmed.ncbi.nlm.nih.gov/23411024: Accessed January 21, 2020.
https://ncqa.org/hedis/measures/antidepressant-medication-management

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

MULTI-BCBS-CM-060942-24

PharmacyMedicaidJune 18, 2024

Prior authorization updates for medications billed under the medical benefit

Effective August 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.

Clinical Criteria	HCPCS or CPT^® code(s)	Drug name
CC-0252	C9399	Adzynma (ADAMTS13, recombinant-krhn)
CC-0253	J3490, J3590, J9999	Aphexda (motixafortide)
CC-0107	J3490, J3590	Avzivi (bevacizumab-tnjn)
CC-0042	J3490	Bimzelx (bimekizumab-bkzx)
CC-0032	C9160	Daxxify (daxibotulinumtoxinA-lanm)
CC-0059	J3490	Focinvez (fosaprepitant)
CC-0255	C9399, J3490, J3590	Loqtorzi (toripalimab-tpzi)
CC-0050	J3590	Omvoh (mirikizumab-mrkz)
CC-0256	J3490	Rivfloza (nedosiran)
CC-0002	J3490, J3590	Ryzneuta (efbemalenograstim alfa-vuxw)
CC-0066	J3490, J3590	Tofidence (tocilizumab-bavi)
CC-0257	C9399, J3490	Wainua (eplontersen)
CC-0254	J3490	Zilbrysq (zilucoplan)
CC-0062	J3590	Zymfentra (infliximab-dyyb)

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your 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.

NYBCBS-CD-056682-24-CPN56332

PharmacyMedicare AdvantageJune 20, 2024

Anthem expands specialty pharmacy precertification list

Effective for dates of service on and after October 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. They must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

HCPCS codes	Medicare Part B drugs
J3490, J3590	Amtagvi (lifleucel)
J3490, J3590	iDoseTR (travoprost implant)

MULTI-BCBS-CR-058746-24-CPN58434

PharmacyCommercialJuly 1, 2024

Correction: Specialty pharmacy updates — July 2024

This article was updated on October 9, 2024, to remove Ilumya as non-preferred from the step therapy requirements section below. Ilumya is not being added to the step therapy program at this time.

Specialty pharmacy updates for Anthem are listed below.

Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. 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 PA 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

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

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

Clinical Criteria	Drug	HCPCS or CPT® Code(s)
CC-0003*	Alyglo (immune globulin intravenous, human-stwk)	J1599
CC-0062	Simlandi (adalimumab-ryvk)	J3590
CC-0261	Winrevair (sotatercept-csrk)	C9399, J3590

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria	Status	Drug	HCPCS or CPT Code(s)
CC-0003	Non-preferred	Alyglo (immune globulin intravenous, human-stwk)	J1599
CC-0062	Non-preferred	Cimzia (certolizumab pegol)	J0717
CC-0042	Non-preferred	Cosentyx intravenous (secukinumab)	C9399, J3490, J3590, C9166
CC-0050	Non-preferred	Omvoh (mirkizumab-mrkz)	C9168, J3590

Quantity limit updates

Effective for dates of service on or after October 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.

Clinical Criteria	Drug	HCPCS or CPT Code(s)
CC-0062	Simlandi (adalimumab-ryvk)	J3590
CC-0261	Winrevair (sotatercept-csrk)	C9399, J3590

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-060687-24-CPN60563, MULTI-BCBS-CM-069897-24

Quality ManagementMedicare AdvantageJuly 1, 2024

Understanding your role in the Health Outcomes Survey

The Centers for Medicare & Medicaid Services (CMS) Health Outcomes Survey (HOS) gathers patient-reported health outcomes from members enrolled in Medicare Advantage plans to support quality improvement activities and improve the overall health of members.

Increased awareness of all HOS measures can help guide your provider interactions with your patients and positively impact HOS results and can help impact your Star rating.

Refer to attachment to view full details

MULTI-BCBS-CR-055932-24-CPN55629

ATTACHMENTS (available on web): Understanding your role in the Health Outcomes Survey (pdf - 0.88mb)

Quality ManagementMedicaidJuly 1, 2024

Complex Case Management program

Managing illness can be a daunting task for our members. It’s not always easy for patients to understand test results, know how to obtain essential resources for treatment, or determine who to contact with questions and concerns.

Anthem is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals available to support members, families, providers, and caregivers. The complex case management process leverages the experience and expertise of the Care Coordination team to educate and empower our members by increasing self-management skills. The complex case management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

Members or caregivers can refer themselves or family members by calling the Member Services number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us via phone or visiting our provider website. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

You can contact us by phone at 833-869-5890. Case management business hours are Monday to Friday from 8 a.m. to 5 p.m.

NYBCBS-CD-055970-24

Quality ManagementMedicaidJuly 1, 2024

Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the members’ coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision-makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website.

You can request a free copy of our UM criteria from Provider Services at 800-450-8753. Providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below. To access UM criteria online, visit: anthembluecross.com/provider/policies/clinical-guidelines.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secure voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

Using the Availity Essentials Authorization application. Log in to Availity Essentials and select Patient Registration > Authorizations and Referrals. You can also access information previously mailed or faxed anytime in Availity Essentials.
Faxing to 800-964-3627.
Calling us at 800-450-8753.

Have questions about utilization decisions or the UM process?

Call Provider Services at 800-450-8753, Monday through Friday, from 8:30 a.m. to 5:30 p.m. ET. or use Chat with Payer from Payer Spaces on Availity Essentials.

NYBCBS-CD-056549-24-SRS55970

Quality ManagementMedicaidJuly 1, 2024

Member Rights and Responsibilities statement

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners, and members in our system, Anthem has adopted a Member Rights and Responsibilities statement, which is in the provider manual. For more information, view this section in the Provider Manual.

NYBCBS-CD-056548-24-SRS55970

July 2024 Provider Newsletter

Contents

To view this publication online:

What are the policies for using anatomical modifiers in procedure coding?

Action needed

To view this article online:

To view this article online:

To view this article online:

Resource

To view this article online:

To view this article online:

To view this article online:

Updating your information

PDM features include:

Accessing the PDM application

PDM training

Not registered for Availity yet?

To view this article online:

Use the Authorizations and Referrals application for digital notifications:

Access the Preference Center and set your preferences:

Manage preferences (Availity administrators)

To view this article online:

Discover what users across the country already know.

Get started today.

Contact us.

To view this article online:

To view this article online:

Fact 1: The HPV vaccine prevents certain cancers.

Fact 2: The HPV vaccination works best when given between ages 9 and 12.

Fact 3: The HPV vaccine is for boys and girls.

Fact 4: The HPV vaccine is safe.

Fact 5: The HPV vaccine does not contain harmful ingredients.

Fact 6: The HPV vaccine can protect fertility.

Fact 7: The HPV vaccine lasts a long time.

Fact 8: Most children in the United States can get the HPV vaccine for little or no cost.

To view this article online:

To view this article online:

To view this article online:

Childhood immunization status (CIS)

Measure codes:

Resources:

To view this article online:

Meningococcal Serogroups A, C, W, Y:

Tdap:

HPV:

Numerator codes for Immunizations for Adolescents (IMA):

Documentation required

Strategies for improvement:

Resources:

To view this article online:

To view this article online:

Summary

To view this article online:

To view this article online:

To view this article online:

To view this article online:

Radiology:

Cardiovascular:

Genetic Testing:

MSK:

Radiation Oncology:

Sleep Disorder Management:

To view this article online:

Radiology:

Cardiovascular:

Genetic Testing:

MSK:

Radiation Oncology:

Sleep Disorder Management:

To view this article online:

Medical Policy updates

To view this article online:

Notes/updates:

Medical Policies

Clinical UM Guidelines

To view this article online:

To view this article online:

To view this article online:

To view this article online:

Add to precertification