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 https://providers.anthem.com/ohio-provider/resources/manuals-and-guides

Notes/updates

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

• 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 and 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 and Not Medically Necessary statement
• CG-MED-95 - Transanal Irrigation:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for transanal irrigation

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 May 23, 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 Medicaid members on September 28, 2023. These guidelines take effect May 23, 2024.