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 Quarter One, 2024. Note that 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 Medical Policies and Clinical Guidelines.

Notes/updates

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

• LAB.00039 - Combined Pathogen Identification and Drug Resistance Testing; Previously Titled: Pooled Antibiotic Sensitivity Testing:
  • Revised title
  • Revised Position Statement to address “combined pathogen identification and drug resistance” testing
• CG-MED-94 - Vestibular Function Testing:
  • Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect October 20, 2024.

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on March 28, 2024. These guidelines take effect October 20, 2024.