Policy Updates Medical Policy & Clinical GuidelinesMedicaid Managed CareNovember 21, 2024

Medical Policies and Clinical Utilization Management Guidelines update

Effective January 1, 2025

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during quarters three and four of 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.

Notes/Updates:

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

  • SURG.00129:
    • Removed the criteria examples for failed CPAP treatment
    • Added definition for failed CPAP treatment
  • SURG.00142 — Genicular Procedures for Treatment of Knee Pain. Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain:
    • Revised title
    • Added genicular artery embolization to the scope of document
    • Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary

Medical Policies

On August 10, 2023, and November 9, 2023, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect January 1, 2025.

Publish Date

Medical Policy Number

Medical Policy Title

New or Revised

9/27/2023

*SURG.00129

Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Revised

1/3/2024

*SURG.00142

Genicular Procedures for Treatment of Knee Pain
Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

Revised

Please share this notice with other members of your practice and office staff.

To view a guideline, visit the Medical Policies and Clinical UM Guidelines website.

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OHBCBS-CD-072638-24

PUBLICATIONS: December 2024 Provider Newsletter