The following Anthem Blue Cross and Blue Shield medical policies and clinical guidelines were reviewed on August 12, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.


Determine if prior authorization is needed for an Anthem member by going to > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.


These medical policies to not apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®). To view medical policies and utilization management guidelines applicable to FEP members, please visit > Policies & Guidelines.


Below are the new medical policies that have been approved.




Effective date

DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

The use of a neuromuscular electrical training device is considered investigational/not medically necessary (INV&NMN) for the treatment of obstructive sleep apnea or snoring

-No specific code for this OSA device considered INV&NMN; listed E1399 NOC 



TruGraf Blood Gene Expression Test for Transplant Monitoring

TruGraf blood gene expression test is considered INV&NMN for monitoring immunosuppression in transplant recipients and for all other indications

-No specific code for TruGraf test considered INV&NMN; listed 81479 NOC 



Serum Biomarker Tests for Risk of Preeclampsia

Serum biomarker tests to diagnosis, screen for, or assess risk of preeclampsia are considered INV&NMN

-Existing CPT PLA code 0243U (effective 04/01/21) for PIGF Preeclampsia Screen will be considered INV&NMN; also listed 81599 NOC code



Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy

Molecular signature testing to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy is considered INV&NMN for all uses, including but not limited to guiding treatment for rheumatoid arthritis

-No specific code for this TNF test (PrismRA test) considered INV&NMN; listed 81479, 81599 NOC codes



Microprocessor Controlled Knee-Ankle-Foot Orthosis

Outlines the MN and NMN criteria for the use of a microprocessor controlled knee-ankle-foot orthosis

-Existing HCPCS KAFO code L2006 will be reviewed for MN criteria



The current clinical guidelines listed below were reviewed and updates were approved.




Effective date


Electric Tumor Treatment Field (TTF)

Added medical necessity (MN) indications for continuation therapy



Policy update


In July 2021, we notified you of the new medical policy effective November 1, 2021 listed below. This policy will be added as a prior authorization requirement on January 1, 2022.


NOTE *Prior authorization required



Effective date


Home Parenteral Nutrition

Outlines the MN and NMN criteria for initial and continuing use of home parenteral nutrition

-Existing codes B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, S9364, S9365, S9366, S9367, S9368 for parenteral nutrition will be reviewed for MN criteria




Featured In:
October 2021 Anthem Provider News - Ohio