Medical Policies and Clinical Utilization Management Guidelines Update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

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

To view a guideline, visit providers.anthem.com/oh.

Notes/Updates:

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

• CG-MED-94 — Vestibular Function Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing.
• CG-SURG-70 — Gastric Electrical Stimulation:
  • Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator.

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These Medical Policies take effect July 7, 2024.

Clinical UM Guidelines

On November 9, 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 January 4, 2024. These guidelines take effect July 7, 2024.