The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. 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 members of your practice and office staff.

To view a guideline, visit the Medical Policies & Clinical UM Guidelines website.

Medical Policies

The Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 1, 2025.

Clinical UM Guidelines

The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members. These guidelines take effect May 1, 2025.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. 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 members of your practice and office staff.

To view a guideline, visit the Medical Policies & Clinical UM Guidelines website.

Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 25, 2025.

Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect May 25, 2025.

Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Chromosomal microarray analysis:

• Added neonatal death to the list of indications considered medically necessary.
• Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.

Whole Exome Sequencing (WES) and Whole Genome Sequencing:

• Clarified and restructured the criteria for improved readability.
• Added Medically Necessary criteria for Prenatal and PostNatal testing
• Added Not Medically Necessary statement for early neonatal death
• Added note that WES may include comparator testing.

Pharmacogenomic testing:

• Deleted typo (“one” before “genotyping”) in first sentence
• Added “considered medically necessary for genotyping” to title of Table 1
• Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
• Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
• Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
• Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics

Predictive and prognostic polygenic testing:

• Updated Description/Scope and Rationale and added References

Musculoskeletal

Interventional pain management:

• Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
• Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
• Exclusions:
• Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
• Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.
• Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
• Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:
• Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
• Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.
• Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:
• Specified nonsurgical low back pain as an exclusion.

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

• Access the Carelon Medical Benefits Management provider portal directly at www.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.

For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com.

These updates list new and/or revised Medical Policies and Clinical Guidelines for Anthem. Implementation of a new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

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

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

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

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program FEP^®), visit https://fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policies effective August 1, 2025

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

Revised Medical Policies effective August 1, 2025

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
• SURG.00155 Cryosurgery of Peripheral Nerves
• TRANS.00033 Heart Transplantation

Revised Medical Policies effective August 16, 2025

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications
• MED.00148 Gene Therapy for Metachromatic Leukodystrophy

 Clinical Guideline updates

Revised Clinical Guidelines effective August 1, 2025

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

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

Revised Clinical Guideline effective August 16, 2025

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

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

Effective June 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization 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 precertification/prior authorization rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by phone by calling Provider Services with additional information which may include medical records.

Precertification/prior authorization requirements will be added for the following code(s):

• J9248 — Injection, melphalan (Hepzato), 1mg

To request precertification/prior authorization, you may use one of the following methods:

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

Not all precertification/prior authorization requirements are listed here. Detailed precertification/prior authorization requirements are available to providers on https://providers.anthem.com/new-york-provider/claims/prior-authorization-requirements or for contracted providers by accessing https://Availity.com. Providers may also call Provider Services at 800-450-8753 for assistance with precertification/prior authorization requirements.

Integrating fluoride varnish in routine exams

Offering fluoride varnish during routine exams ensures young patients receive crucial oral healthcare, even if they do not have regular dental appointments. This procedure is safe and simple and minimizes ingestion risk compared to traditional gels. It can be seamlessly integrated into your practice, providing an opportunity to engage with parents about best oral hygiene practices and enhance overall oral health awareness.

The prevalence of tooth decay

Tooth decay is the most common chronic disease among children in the United States. To combat this issue, we recommend integrating fluoride varnish applications during well‑child visits for children aged 1 to 4 years.

The importance of preventive dental care

Preventive dental care is crucial, and fluoride varnish is a highly effective method to prevent cavities. It strengthens tooth enamel and inhibits harmful bacteria growth, which is particularly important for young children who may not visit a dentist regularly. This practice not only helps prevent early childhood cavities but also promotes remineralization of the enamel, potentially reversing early signs of decay.

Effective June 1, 2025, the following Medicare Part B medication from the current Clinical Criteria Guidelines will be included in our medical step therapy preapproval review process. Step therapy review will apply upon preapproval initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving the medication listed below.

Visit our Clinical Criteria page to search for specific criteria.

Effective for dates of service on and after August 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our preapproval review process.

Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over preapproval rules and must be considered first when determining coverage. Claims that do not comply with these new requirements may not be approved.

The Anthem pre‑service clinical review of non‑oncology specialty pharmacy drugs will be managed by our Medical Specialty Drug Review team. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc.

To access the Clinical Criteria information, visit Clinical Criteria In Pharmacy.

New Clinical Criteria effective August 1, 2025:

• CC-0275 Ziihera (zanidatamab‑hrii)
• CC‑0276 Tryngolza (olezarsen)
• CC‑0277 Vyalev (foscarbidopa/foslevodopa)

Revised Clinical Criteria effective August 1, 2025

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

• CC‑0058 Octreotide Agents
• CC‑0063 Ustekinumab Agents (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Wezlana)
• CC‑0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
• CC‑0094 Pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi)
• CC‑0130 Imfinzi (durvalumab)
• CC‑0185 Oxlumo (lumasiran)
• CC‑0256 Rivfloza (nedosiran)