CommercialApril 1, 2024
Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements
Medical Policies and Clinical Guidelines updates — April 2024
The following Medical Polices and Clinical Guidelines for Anthem were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.
To view Medical Policies and Utilization Management Guidelines, go to 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 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 Utilization Management 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 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.00146 Gene Therapy for Sickle Cell Disease | Outlines the MN and INV&NMN criteria for Gene therapy for sickle cell disease. No specific HCPCS codes for Casgevy & Lyfgenia, listed NOC codes C9399, J3490, J3590 and specific ICD-10-PCS XW133J8, XW143J8, XW133H9, XW143H9; considered MN when criteria are met. | 7/1/2024 |
RAD.00068 Myocardial Strain Imaging | Myocardial strain imaging in considered INV&NMN for all indications. Added existing CPT® code 93356 (add-on ro echocardiography) and HCPCS outpatient codes C9762, C9763 associated with strain-encoded cardiac MRI, considered INV&NMN. | 7/1/2024 |
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-GENE-13 Genetic Testing for Inherited Diseases | • Added additional genes to the table, including those identified as medically actionable by ACMG recommendations, drug-related genes for Leqembi (lecanemab-irmb) associated with Late Onset Alzheimer’s, and Rivfloza (Nedosiran) associated with Primary hyperoxaluria type 1 CPT Tier 2 code 81401 when specified as APOE gene testing and HCPCS code S3852 considered MN when criteria are met (was NMN); added CALM genes (NOC code 81479) considered MN when criteria are met; removed 81599 NOC (not applicable); updated CPT descriptors effective 1/1/2024 | 1/3/2024 |
ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities | Revised MN criteria for lipectomy or liposuction for lymphedema and lipedema related to functional impairment or medical complications • Revised Clinical Indications section with minor typographical updates • Reformatted Clinical Indications section No changes to coding | 1/3/2024 |
CG-ANC-04 Ambulance Services: Air and Water | Revised Clinical Indications section regarding timeframe difference for ground and air transport No changes to coding | 1/3/2024
|
CG-DME-31 Powered Wheeled Mobility Devices | • Revised hierarchy and formatting in the Clinical Indications section • Revised MN statement regarding Group 4 devices and MRADLs • Revised MN criteria regarding trial period for motorized wheelchairs for children • Revised NMN statement regarding repair or replacement • Revised NMN statement regarding options/accessories/features for powered wheeled mobility devices • Removed statement addressing home modifications No changes to coding | 11/16/2023 |
CG-DME-44 Electric Tumor Treatment Field (TTF) | • Removed criteria requiring treatment begin within 7 weeks of completion of temozolomide and radiotherapy • Revised criteria to add definition of tumor progression to the Clinical Indications • Reformatted criteria to limit criteria to one requirement per line No changes to coding | 1/3/2024 |
CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management | Listed additional ICD-10-CM diagnosis codes considered MN when criteria are met; added genes to Tier 2 and NOC code 81479 | 1/3/2024 |
CG-GENE-18 Genetic Testing for TP53 Mutations | Added personal or family history of pediatric hypodiploid acute lymphoblastic leukemia as a MN indication for germline testing No changes to coding | 1/3/2024
|
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity | Added CPT Category III code 0813T effective 1/1/2024 for adjustment of intragastric balloon, considered NMN; also added CPT NOC code 44238 | 7/1/2024 |
CG-SURG-94 Keratoprosthesis | Reformatted MN section • Revised MN criteria regarding number of previous failed corneal transplants • Added new MN criteria for when corneal transplant is likely to fail Added ICD-10-CM diagnosis codes for high risk for corneal transplant failure considered MN when criteria are met | 1/3/2024 |
CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | • Revised formatting of Clinical Indications section • Revised MN criteria for trial sacral nerve stimulators for urinary incontinence/urgency/frequency and retention to add new examples of conservative treatments • Revised permanent sacral nerve stimulators MN criteria for urinary urgency/frequency • Revised sacral nerve stimulation NMN statement • Added new MN criteria for percutaneous and implantable tibial nerve stimulation • Added new MN and NMN criteria for replacement or revision of percutaneous and Implantable tibial nerve stimulators • Revised percutaneous and implantable tibial nerve stimulation NMN statement Revised codes 0587T, 0588T, 64566 for tibial nerve stim considered MN when criteria are met (were NMN); removed CPT codes 0589T, 0590T for subsequent services; added CPT category III codes 0816T, 0817T, 0818T, 0819T effective 1/1/2024 for integrated TNS systems considered MN when criteria are met | 7/1/2024 |
LAB.00019 Proprietary Algorithms for Liver Fibrosis
Previously titled: Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | • Revised title Added new CPT code 81517 effective 1/1/2024 for the ELF test considered INV&NMN, replacing deleted code 0014M | 7/1/2024 |
LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer
Previously titled: Systems Pathology Testing for Prostate Cancer | • Revised title • Added “Multimodal Artificial Intelligence” to the Position Statement No changes to coding | 1/3/2024 |
LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease | • Added MN criteria for measurement of amyloid beta • Revised INV&NMN statement CPT codes 83520 and 0358U will be considered MN for dementia diagnoses when criteria are met (was NMN) | 1/3/2024 |
LAB.00050 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting | • Moved content from GENE.00053 Added CPT PLA codes 0112U; 0152U; 0323U considered INV&NMN and NOC code 87999 previously addressed in GENE.00053 | 7/1/2024 |
MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications | • Added MN criteria for Parkinson's Disease CPT Category III code 0398T will be considered MN for Parkinson's diagnosis codes when criteria are met (was Inv&NMN) | 1/3/2024 |
MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring | Added existing HCPCS code E0746 when specified as home biofeedback SPEAC device considered INV&NMN | 7/1/2024 |
MED.00140 Gene Therapy for Beta Thalassemia
Previously titled: Lentiviral Gene Therapy for Beta Thalassemia and Sickle Cell Disease | • Revised title • Revised MN statement • Removed INV&NMN statement on lovotibeglogene Autotemcel Removed ICD-10-PCS codes XW133H9, XW143H9 specific to lovotibeglogene autotemcel, now addressed in MED.00146 | 1/18/2024 |
SURG.00010 Treatments for Urinary Incontinence | • Revised MN statements and changed to alphanumeric • Revised Note • Added NMN statement on periurethral bulking agents and revised existing NMN statement • Removed line on periurethral bulking agents from INV&NMN statement and changed to alphanumeric CPT code 51715 and associated ICD-10-PCS codes for bulking agents will be considered NMN when criteria are not met (was INV&NMN) | 1/3/2024 |
SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures | • Revised formatting of Position Statement • Revised reconstructive statement related to procedures done in advance of mastectomy or lumpectomy • Moved reconstructive text related to procedure timing to Background section • Revised Position Statement section with text updates No changes to coding | 1/3/2024 |
SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation | • Reformatted Position Statement and added headers • Reformatted MN statements to move target treatment areas into criteria • Revised MN statement for primary dystonia to remove dystonia manifestation types • Reformatted MN statements for DBS for Parkinson’s, primary dystonia, and OCD • Reformatted MN statements for epilepsy • Revised DBS for epilepsy MN statement regarding non-epileptic seizures • Revised Position Statement to add revision/replacement MN and INV&NMN statements for DBS, cortical stimulation, and battery • Revised and reformatted INV&NMN statements Added existing ICD-10-PCS code 0NH00NZ and new CPT codes 61889, 61891 effective 1/1/2024 for skull-mounted systems, considered MN when criteria are met; also added existing HCPCS code C1778 device code considered MN when criteria are met | 7/1/2024 |
SURG.00097 Scoliosis Surgery | • Revision to Position Statement formatting • Added MN and INV&NMN criteria for revision, replacement, or removal of vertebral body tethering to Position Statement Added CPT codes 22836, 22837, 22838 effective 1/1/2024 for thoracic tethering, and Category III code 0790T for thoracolumbar or lumbar tethering revision considered MN when criteria are met; also revised descriptors for 0656T, 0657T | 7/1/2024 |
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 INV&NMN Added existing CPT code 37242 for arterial embolization, considered INV&NMN when specified as genicular artery embolization for knee pain | 7/1/2024 |
SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | Added new CPT codes 64596, 64597 effective 1/1/2024 for integrated systems, updated descriptor for CPT code 64590 | 7/1/2024 |
TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation | No changes to coding; added diagnosis code examples K90.821-K90.829, K90.83 to document | 1/3/2024 |
TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors | • Added definition of tandem to Position Statement • Revised MN criteria for autologous hematopoietic stem cell transplantation for stage IVa and stage IVb retinoblastoma • Revised INV&NMN statement for allogeneic (ablative or non-myeloablative [mini transplant]) for retinoblastoma Autologous transplant codes will be considered MN for retinoblastoma diagnosis codes when criteria are met (was INV&NMN) | 1/3/2024 |
DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Added new HCPCS codes A4540, E0732 effective 1/1/2024 for cranial electrotherapy considered INV&NMN replacing deleted codes K1002, K1023; removed CPT Category III codes 0768T, 0769T deleted as of 1/1/2024; updated descriptors for 0766T, 0767T effective 1/1/2024 | 7/1/2024 |
DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea | Added new HCPCS code E0530 effective 1/1/2024 considered INV&NMN, replacing deleted code K1001 | 7/1/2024 |
DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring | Added new HCPCS codes E0492, E0493 effective 1/1/2024 for the Snoozeal device using phone application considered INV&NMN, replacing deleted codes K1028, K1029 | 7/1/2024 |
DME.00046 Intermittent Abdominal Pressure Ventilation Devices | Added new HCPCS code A4468 effective 1/1/2024 for exsufflation belt considered INV&NMN, replacing deleted code K1021 | 7/1/2024 |
DME.00049 External Upper Limb Stimulation for the Treatment of Tremors | Added new HCPCS codes A4542, E0734 effective 1/1/2024 for the Cala Trio and Cala kIQ devices considered INV&NMN; replacing deleted codes K1018, K1019 | 7/1/2024 |
GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | Added new CPT PLA codes 0423U, 0434U, 0438U effective 1/1/2024 for Genomind, RightMed and EffectiveRx tests considered INV&NMN | 7/1/2024 |
GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Added new CPT gene panel codes 81457, 81458, 81459, 81462, 81463, 81464, 0428U considered MN when criteria are met, codes 0422U, 0424U, 0436U considered NMN, and 0425U, 0426U considered INV&NMN effective 1/1/2024; also revised descriptors for codes 81445, 81449, 81450, 81451, 81455, 81456, 0356U. | 7/1/2024 |
GENE.00056 Gene Expression Profiling for Bladder Cancer | Added new CPT PLA code 0420U effective 1/1/2024 for Cxbladder Detect+ test considered INV&NMN | 7/1/2024 |
LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | Added new CPT PLA code 0435U effective 1/1/2024 for ChemoID test considered NMN | 7/1/2024 |
LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders | Added new CPT PLA code 0430U effective 1/1/2024 for a malabsorption panel considered INV&NMN | 7/1/2024 |
MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s) | Removed CPT Category III codes 0533T-0536T deleted as of 1/1/2024, replaced by 95999 NOC already on document | 12/28/2023 |
MED.00120 Gene Therapy for Ocular Conditions | Added existing CPT Category III code 0810T for subretinal injection considered MN when criteria are met; removed HCPCS code C9770 for subretinal injection deleted as of 1/1/2024 | 7/1/2024 |
MED.00135 Gene Therapy for Hemophilia | Added new HCPCS code J1412 effective 1/1/2024 for Roctavian considered MN when criteria are met, replacing NOC codes | 7/1/2024 |
MED.00144 Gene Therapy for Duchenne Muscular Dystrophy | Added new HCPCS code J1413 effective 1/1/2024 for ELEVIDYS considered MN when criteria are met, replacing NOC codes for this product | 7/1/2024 |
SURG.00007 Vagus Nerve Stimulation | Added new HCPCS code E0735 effective 1/1/2024 for non-invasive VNS device considered INV&NMN, replacing deleted code K1020 | 7/1/2024 |
SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Added new HCPCS codes Q4279, Q4287, Q4288, Q4289, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304 for products considered INV&NMN, added Q4290 considered MN for ocular indications, revised descriptor for Q4225 all effective 1/1/2024 | 7/1/2024 |
SURG.00037 Treatment of Varicose Veins (Lower Extremities) | No changes to coding Added wording to clarify when codes 36465, 36466 may be MN based on criteria | 1/3/2024 |
SURG.00045 Extracorporeal Shock Wave Therapy | Added new CPT Category III code 0864T effective 1/1/2024 for ESWT to corpus cavernosum considered INV&NMN, replacing NOC code 55899 | 7/1/2024 |
SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques | Added new CPT code 58580 effective 1/1/2024 for transcervical RF ablation considered MN when criteria are met, replacing deleted code 0404T | 7/1/2024 |
SURG.00150 Leadless Pacemaker | Added new CPT Category III codes 0823T, 0824T, 0825T, 0826T effective 1/1/2024 for leadless atrial pacemakers considered INV&NMN | 7/1/2024 |
SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing | Added new CPT Category III codes 0861T, 0862T, 0863T effective 1/1/2024 considered INV&NMN, also revised descriptors for 0517T, 0518T, 0519T, 0520T | 7/1/2024 |
SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | Added new CPT codes 31242, 31243 effectives 1/1/2024 for RF and cryoablation of posterior nasal nerve considered INV&NMN, replacing deleted HCPCS code C9771 | 7/1/2024 |
CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis | Added new HCPCS code L5615 for a lower extremity prosthesis addition considered MN when criteria are met, replacing deleted code K1014 | 7/1/2024 |
CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants | Added ICD-10-CM diagnosis codes for hearing loss with unrestricted hearing in the contralateral ear considered MN for cochlear implants when criteria are met | 12/28/2023 |
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-052941-24
PUBLICATIONS: April 2024 Provider Newsletter
To view this article online:
Or scan this QR code with your phone