Medical Policies and Clinical Utilization Management Guidelines update for May 2023

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 http://bit.ly/3GZ8ySE.

Notes/updates

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

• SURG.00161 – Nanoparticle-Mediated Thermal Ablation:
  • Nanoparticle-mediated thermal ablation is considered Investigational & Not Medically Necessary for all indications
• CG-LAB-29 – Gamma Glutamyl Transferase Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing of gamma glutamyl transferase (GGT) in blood
• CG-LAB-30 – Outpatient Laboratory-based Blood Glucose Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for laboratory testing to determine blood glucose concentration

Medical Policies

On May 11, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect March 1, 2024.

Clinical UM Guidelines

On May 11, 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 June 22, 2023. These guidelines take effect March 1, 2024.