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 during Quarter Two, 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 UM Guidelines.

Notes/updates

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

• MED.00148 - Gene Therapy for Metachromatic Leukodystrophy:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for gene therapy for metachromatic leukodystrophy

Medical Policies

On May 9, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect December 1, 2024.

Clinical UM Guidelines

On May 9, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members on June 27, 2024. These guidelines take effect December 1, 2024.