Policy Updates Medical Policy & Clinical GuidelinesCommercialNovember 1, 2023

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

Medical Policies and Clinical Guidelines updates — November 2023

The following Medical Policies and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin for Anthem Blue Cross and Blue Shield (Anthem).

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 current Clinical Guidelines and/or Medical Policies we reviewed, and updates were approved.

* Denotes prior authorization required

Policy/guideline

Information

Effective date

*SURG.00005

Partial Left Ventriculectomy

Add to PA

2/1/2024

*SURG.00007

Vagus Nerve Stimulation

Add to PA

2/1/2024

*SURG.00010 Treatments for Urinary Incontinence

Add to PA

2/1/2024

*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Add to PA

2/1/2024

*SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons

Add to PA

2/1/2024

*SURG.00045 Extracorporeal Shock Wave Therapy

Add to PA

2/1/2024

*SURG.00079 Nasal Valve Repair

Add to PA

2/1/2024

*SURG.00107 Prostate Saturation Biopsy

Add to PA

2/1/2024

*SURG.00113 Artificial Retinal Devices

Add to PA

2/1/2024

*SURG.00114 Facet Joint Allograft Implants for Facet Disease

Add to PA

2/1/2024

*SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

Add to PA

2/1/2024

*SURG.00126 Irreversible Electroporation

Add to PA

2/1/2024

*SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Add to PA

2/1/2024

*SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves

Add to PA

2/1/2024

*SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

Add to PA

2/1/2024

*SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization

Add to PA

2/1/2024

*SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy

Add to PA

2/1/2024

*SURG.00156 Implanted Artificial Iris Devices

Add to PA

2/1/2024

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

Add to PA

2/1/2024

*SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer

Add to PA

2/1/2024

*SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease

Add to PA

2/1/2024

*THER-RAD.00008 Neutron Beam Radiotherapy

Add to PA

2/1/2024

MULTI-BCBS-CM-038927-23

PUBLICATIONS: November 2023 Provider Newsletter