CommercialNovember 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
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