Policy Updates Medical Policy & Clinical GuidelinesCommercialJune 11, 2024

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

Medical Policies and Clinical Guidelines updates for July 2024

The following Anthem Medical Polices and Clinical Guidelines 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®)), 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-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

  • Moved content from SURG.00103 to new Clinical UM Guideline with the same title
  • INV&NMN changed to NMN as a result of MP to CUMG transition

10/1/2024

CG-SURG-119 Treatment of Varicose Veins (Lower Extremities)

  • Moved content from SURG.00037 to new Clinical UM Guideline with the same title
  • INV&NMN changed to NMN as a result of MP to CUMG transition

10/1/2024

CG-SURG-120 Vagus Nerve Stimulation

  • Moved content from SURG.00007 to new Clinical UM Guideline with the same title
  • INV&NMN changed to NMN as a result of MP to CUMG transition

10/1/2024

OR-PR.00008 Osseointegrated Limb Prostheses

  • Outlines the MN and NMN criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss

10/1/2024

SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis

  • Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered INV&NMN

10/1/2024

* Denotes prior authorization required

Below are the current Clinical Guidelines and/or Medical Policies we reviewed and updates that were approved:

Policy/guideline

Information

Effective date

ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

Added existing codes 21086, L8045 related to auricular prostheses considered MN or REC when criteria are met

4/10/2024

CG-BEH-02 Adaptive Behavioral Treatment

Criteria for these services have been transitioned to MCG guidelines

6/1/2024

CG-DME-31 Powered Wheeled Mobility Devices

Added new HCPCS code E2298 effective 4/1/2024 replacing deleted code E2300 for power seating system, also added K0108 NOC code

4/1/2024

CG-MED-68 Therapeutic Apheresis

Added erythropoietic protoporphyria, liver disease to the plasmapheresis and RBC exchange and heart transplantation, desensitization /rejection prophylaxis to the plasmapheresis MN sections
Added ICD-10-CM codes E80.0, K77 considered MN when criteria are met for plasmapheresis and cytapheresis

4/10/2024

LAB.00025 Topographic Genotyping

Added existing NOC code 89240 which may be used for this service

4/10/2024

LAB.00039 Combined Pathogen Identification and Drug Resistance Testing

Previously Titled: Pooled Antibiotic Sensitivity Testing

• Revised title
• Revised Position Statement to address “combined pathogen identification and drug resistance” testing
Added existing CPT® PLA codes 0141U, 0142U, 0321U & 0370U, 0369U previously addressed in CG-LAB-17 (MN criteria), and 0373U previously addressed in CG-LAB-14 (was NMN), all considered INV&NMN; removed 81479 NOC

4/10/2024

LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease

Added CPT PLA code 0445U effective 4/1/2024 for Elecsys® PhosphoTau (181P) CSF (pTau181) and βAmyloid (1-42) CSF II (Abeta 42) Ratio, considered INV&NMN

4/1/2024

MED.00125 Biofeedback and Neurofeedback

Added new HCPCS code S9002 effective 4/1/2024 for home biofeedback device, considered INV&NMN

4/1/2024

RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver

Added new HCPCS code C9797 effective 4/1/2024 for embolization, considered INV&NMN for specific diagnoses

4/1/2024

SURG.00011 Gene Mutation Testing for Cancer Susceptibility and Management

• Revised MN statement to include Cortiva and Surgimend for breast reconstruction
• Revised MN statement to include EPICEL, Integra Omnigraft Dermal Regeneration Template, and ReCell for the treatment of partial and deep thickness burns
• Revised MN statement to include Biovance and Oasis for the treatment of diabetic foot ulcers
• Revised NMN statement to align with revisions to MN statements
• Added new products to the INV&NMN statement

4/1/2024

SURG.00105 Bicompartmental Knee Arthroplasty

Criteria for these services have been transitioned to Carelon Medical Benefits Management, Inc. Musculoskeletal guidelines

6/1/2024

SURG.00126 Irreversible Electroporation

Added new ICD-10-PCS code 02583ZF for irreversible electroporation of cardiac conduction mechanism, considered INV&NMN

4/1/2024

SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

• Revised pVAD criteria to include ECMO as concomitant therapy
• Revised Total Artificial Heart criteria for simplification

4/10/2024

SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema

Added ICD-10-PCS codes 0DXU0ZV, 0DXU0ZW, 0DXU0ZX, 0DXU0ZY, 0DXU4ZV, 0DXU4ZW, 0DXU4ZX, 0DXU4ZY effective 4/1/2024 for omentum transfer, considered INV&NMN for lymphedema diagnoses

4/1/2024

SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

Added note regarding CPT code 30117 when used for posterior nasal nerve ablaton

4/1/2024

SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

Added new HCPCS code A4438 effective 4/1/2024 for a component of the NALU device, considered INV&NMN when specified for peripheral nerve

4/1/2024

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

• Updated formatting in Position Statement section
• In the MN Position Statement section for NHL, created criterion B3
• In the INV&NMN section for NHL, updated bullet “A” by adding “when criteria above are not met, including”
• Added ICD-10-CM diagnosis codes C91.50-C91.52 MN when criteria are met for lymphoma

4/10/2024

TRANS.00033 Heart Transplantation

Added CPT 33929 previously addressed in SURG.00145, considered MN when criteria are met

4/10/2024

TRANS.00038 Thymus Tissue Transplantation

Added endocrine procedure NOC code 60699

4/10/2024

* Denotes prior authorization required

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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-060651-24

PUBLICATIONS: July 2024 Provider Newsletter