Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider and select Change State and pick appropriate state. Then Providers > Policies, Guidelines & Manuals.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities;
• Previously titled: Cosmetic and Reconstructive Services of the Trunk and Groin:
  • Revised title to include “Extremities"
  • Revised Position Statement regarding lipectomy or liposuction for lymphedema and lipedema
• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices:
  • Reformatted bullet points to letters
  • Added lines to Investigational & Not Medically Necessary statement on electrical stimulation wound treatment device, electromagnetic wound treatment devices and pulsed electromagnetic field stimulation
• LAB.00011 - Selected Protein Biomarker Algorithmic Assays:
  • Reformatted bullet points to letters
  • Added IMMray® PanCan-d test to the Investigational & Not Medically Necessary statement
• LAB.00028 - Blood-based Biomarker Tests for Multiple Sclerosis, Previously titled: Serum Biomarker Tests for Multiple Sclerosis:
  • Revised title
  • Expanded scope of document from serum to blood-based biomarker testing for multiple sclerosis (MS)
  • Revised Position Statement to indicate blood-based biomarker tests for multiple sclerosis are considered Investigational & Not Medically Necessary for all uses
• MED.00140 - Lentiviral Gene Therapy for Beta Thalassemia and Sickle Cell Disease; Previously Titled: Gene Therapy for Beta Thalassemia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement on lovotibeglogene autotemcel
• MED.00144 - Gene Therapy for Duchenne Muscular Dystrophy:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the infusion of Delandistrogene moxeparvovec-rokl (ELEVIDYS)
• MED.00147 - Cellular Therapy Products for Allogeneic Stem Cell Transplantation:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the use of ex-vivo expansion of cord blood stem cell products
• SURG.00129 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures:
  • Removed the criteria examples for failed CPAP treatment
  • Added definition for failed CPAP treatment
• SURG.00144 - Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia; Previously titled: Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement for sphenopalatine ganglion nerve blocks
• TRANS.00041 - Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection:
  • Histological analysis using microarray gene expression profiling is considered Investigational & Not Medically Necessary for detection of allograft injury or rejection in kidney transplant recipients
• CG-MED-39 - Bone Mineral Density Testing Measurement:
  • Added phrase “using Dual-X-Ray Absorptiometry” to bullets I and III of Medically Necessary criteria and to bullets I and IV of Not Medically Necessary criteria
  • Added Not Medically Necessary position statement for bone strength and fracture risk assessment using imaging scans other than DXA
• CG-MED-95 - Transanal Irrigation:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for transanal irrigation
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices:
  • Revised formatting of Medically Necessary section
  • Added Repair and Replacement criteria to Clinical Indications section
  • Added new Not Medically Necessary statement regarding enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices
  • Added new Medically Necessary and Not Medically Necessary criteria for device repair and replacement.
• CG-SURG-61 - Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver; Previously titled: Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver:
  • Revised title
  • Added microwave ablation to the Clinical Indications
  • Added cryoablation and microwave ablation to the Medically Necessary indications for NSCLC and malignant tumors that have metastasized to the lung
  • Added Not Medically Necessary statements regarding focal cryoablation of the prostate and microwave ablation for all other indications
  • Revised Medically Necessary indication for cryoablation of the prostate to whole gland cryoablation of the prostate
  • Reordered clinical indications to be based on clinical condition rather than ablative technique

Medical Policies

On August 10, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 5, 2024.

Clinical UM Guidelines

On August 10, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on September 28, 2023. These guidelines take effect April 5, 2024.