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 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 members of your practice and office staff.

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Updates:

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

• 00134 – Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
  • Revised Investigational and Not Medically Necessary indications
• 00156 – Implanted Artificial Iris Devices:
  • Revised Investigational and Not Medically Necessary indications
• 00157 – Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis:
  • Revised Investigational and Not Medically Necessary indications
• CG-DME-07 – Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output:
  • Revised Medically Necessary and Not Medically Necessary indications
• 00052 – Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Revised Medically Necessary indications
• 00077 – Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
  • Expanded scope and revised Investigational and Not Medically Necessary indications
• 00112 – Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
  • Revised scope, and Investigational and Not Medically Necessary indications
• CG-REHAB-12 – Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology:
  • A new clinical UM Guideline was created from content contained in CG-REHAB-04, CG-REHAB-05, CG-REHAB-06.
  • There are no changes to the guideline content.
  • Publish date is scheduled for December 8, 2020.
• The following AIM Specialty Health_®* Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
  • Interventional Pain Management (See August 16, 2020, version.)*
  • Chest Imaging (See August 16, 2020, version.)*
  • Oncologic Imaging (See August 16, 2020, version.)*
  • Sleep Clinical Guidelines (See August 16, 2020, version.)*

 

Medical Policies

On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect December 6, 2020.

 

Publish date	Medical Policy #	Medical Policy title	New or revised
10/7/2020	*MED.00134	Non-invasive Heart Failure and Arrhythmia Management and Monitoring System	New
10/7/2020	*SURG.00156	Implanted Artificial Iris Devices	New
10/7/2020	*SURG.00157	Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis	New
9/1/2020	*GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
10/7/2020	*SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	Revised
10/1/2020	*SURG.00112	Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)	Revised

 

Clinical UM Guidelines

On August 13, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Medicare Advantage members on
September 24, 2020. These guidelines take effect December 6, 2020.

 

Publish date	Clinical UM Guideline #	Clinical UM Guideline title	New or revised
10/7/2020	*CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output	Revised
10/7/2020	CG-DME-25	Seat Lift Mechanisms	Revised
8/20/2020	CG-GENE-03	BRAF Mutation Analysis	Revised
8/20/2020	CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	Revised

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

 

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