*Notice of Material Amendment/Change to contract (MAC)

The following Medical Polices, and Clinical Guidelines for Anthem Blue Cross and Blue Shield (Anthem) were reviewed on August 11, 2022.

 

To view Medical Policies and Clinical Guidelines, go to www.anthem.com > select Providers > select your state > under Provider Resources, select Policies, Guidelines & Manuals.

 

To help determine if prior authorization is needed for Anthem members, go to www.anthem.com > select Providers > select your state > under Claims, select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.

 

To view Medical Policies and Clinical Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® [FEP®]), please visit www.fepblue.org > Policies & Guidelines.

 

Below are the new medical policies and/or clinical guidelines that have been approved.

* Denotes prior authorization required

 

Policy/guideline

Information

Effective date

*MED.00140 Gene Therapy for Beta Thalassemia

  • Outlines the MN and INV&NMN criteria for a one-time infusion of betibeglogene autotemcel for individuals with beta thalassemia
  • No specific code for Zynteglo, listed NOC codes C9399, J3490, J3590 for the product, and ICD-10-PCS codes for transfusion of genetically modified stem cells to be reviewed for MN criteria; effective 10/01/2022 there will be specific ICD-10-PCS codes XW133B8, XW143B8 for transfusion of betibeglogene autotemcel

03/01/2023

DME.00049 External Upper Limb Stimulation for the Treatment of Tremors

  • Wrist-worn external upper limb tremor stimulator is considered INV&NMN for all indications, including but not limited to the treatment of essential tremor of the hands
  • Existing HCPCS codes K1018, K1019 will be considered INV&NMN 

03/01/2023

*DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure

  • The use of remote devices for intermittent monitoring of IOP is considered INV&NMN for all indications
  • No specific code for this type of device, considered INV&NMN; listed E1399 NOC

03/01/2023

LAB.00049 Artificial Intelligence-Based Software for Prostate Cancer Detection

  • Use of artificial intelligence-based software for prostate cancer detection is considered INV&NMN for all indications
  • No specific code for this product, considered INV&NMN; listed 88399 NOC

03/01/2023

MED.00141 High-volume Colonic Irrigation

  • High-volume colonic irrigation is considered INV&NMN for all indications
  • Existing CPT Category 3 code 0736T (effective 07/1/2022) considered INV&NMN

03/01/2023

TRANS.00040 Hand Transplantation

  • Hand transplantation is considered INV&NMN
  • No specific code CPT code, listed 26989 NOC; specific ICD-10-PCS proc codes 0XYJ0Z0, 0XYJ0Z1, 0XYK0Z0, 0XYK0Z1; considered INV&NMN

03/01/2023

 

Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.

* Denotes prior authorization required

 

Policy/guideline

Information

Effective date

*CG-DME-31 Powered Wheeled Mobility Devices

  • Added HCPCS code E0986 for push-rim device, will be reviewed for MN criteria (was listed in CG-DME-34)

03/01/2023


MULTI-BCBS-CM-012522-22-CPN11473



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December 2022 Anthem Provider News - Ohio