Policy Updates Medical Policy & Clinical GuidelinesCommercialJuly 11, 2024

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Medical Policies and Clinical Guidelines updates — August 2024

The following Medical Policies and Clinical Guidelines were reviewed for Anthem for the following states: Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Clinical 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 Clinical 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:

Policy/guideline

Information

Effective date

CG-DME-45 Ultrasound Bone Growth Stimulation

Addresses the medical necessity of use of low-intensity pulsed ultrasound devices as a non-invasive treatment to promote healing of some fresh fractures and to accelerate healing for nonunion of other fracture sites. Transitioned to Carelon Medical Benefits Management, Inc. guidelines.

10/1/24

CG-MED-65 Manipulation Under Anesthesia

Addresses the medical necessity of use of manipulation under anesthesia of the spine. Also addresses the use of manipulation under anesthesia of joints other than the knee and shoulder. Anesthesia types may include local, regional, intravenous (IV) monitored sedation, and general. Transitioned to Carelon Medical Benefits Management guidelines.

10/1/24

CG-MED-76 Magnetic Source Imaging and Magnetoencephalography

Addresses the medical necessity of magnetic source imaging (MSI) and magnetoencephalography (MEG). Transitioned to Carelon Medical Benefits Management guidelines.

10/1/24

CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures

Addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures. Transitioned to Carelon Medical Benefits Management guidelines.

10/1/24

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

Addresses the use of radiofrequency (RF) neurolysis and pulsed radiofrequency (PRF) therapy for the treatment of trigeminal neuralgia. Updated MN criteria to remove criteria referencing other surgical options. Transitioned to Carelon Medical Benefits Management guidelines.

10/1/24

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-061943-24

PUBLICATIONS: August 2024 Provider Newsletter