March 2021 Anthem Provider News - Ohio

Contents

Medical Policy & Clinical GuidelinesCommercialMarch 1, 2021

Update: Notice of changes to the AIM Small Joint Surgery guideline

Reimbursement PoliciesCommercialMarch 1, 2021

Claims editing update for ICD-10-CM Excludes 1 notes

State & FederalMedicare AdvantageMarch 1, 2021

Medicare News - March 2021

State & FederalMedicare AdvantageMarch 1, 2021

Access to more claim denial information is now self-service

State & FederalMedicare AdvantageMarch 1, 2021

New provider directory indicator for telehealth services

State & FederalMedicare AdvantageMarch 1, 2021

Medical policies and clinical utilization management guidelines update

AdministrativeCommercialMarch 1, 2021

Notice of Material Changes/Amendments to Contract and Prior Authorization Changes - March 2021

Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

 

  • Site of Care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021*
  • Updates for specialty pharmacy are available – March 2021*
  • Some HIV medication combinations may require prior authorization
  • Anthem clarifies guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNF) facilities*
  • Update: Notice of changes to the AIM Small Joint Surgery guideline

AdministrativeCommercialMarch 1, 2021

Medical attachment capability now includes itemized bills and more!

Unsolicited medical attachments

 

To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Including the itemized bill with the high dollar claim just got easier by submitting it as an unsolicited medical attachment (documentation submitted without a formal request from the payer).

 

Did you know there is an “itemized bill” submission option under Attachments – New!

  • Log in to Availity Portal
  • Select Claims & Payments | Attachments – New
  • Select Send Attachment
  • Under the Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK.


  • Provide provider, patient and claim information
  • Attach Supporting Documentation and Reason
  • Send Attachment(s)

 

Solicited medical attachments

 

Also available to you is the option to submit a claim attachment using Availity Portal for solicited medical attachments (documentation submitted in response to a specific request from payer).

 

Submit supporting documentation in response to a formal (solicited) request from the payer.

  • Log in to Availity Portal
  • Select Claims & Payments | Attachments – New
  • Select Send Attachment
  • Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number
  • Add supporting documentation and Reason
  • Submit

 

As an added bonus, if you attended a previous webinar there is updated information we want to share with you around submitting an EDI 837 batch, which includes a PWK segment in loops 2300/2400; this detail is the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

 

What does this mean for you?

 

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

Here are the steps:

  • Log in to Availity Portal
  • Select Claims & Payments I Attachments - New
  • From the Inbox tab, select the appropriate claim or open the request in your work queue
  • Add files with supporting documentation
  • Submit

 

Get trained

 

Attend an Availity hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here.

or

Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

  • Search by keyword (Medattach) to find on-demand and live training options
  • Click Enroll to enroll for a course and then go to your Dashboard to access it any time

 

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

 

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Medical Policy & Clinical GuidelinesCommercialMarch 1, 2021

Update: Notice of changes to the AIM Small Joint Surgery guideline

As of November 1, 2020, AIM Specialty Health® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem Blue Cross fully insured members and some ASO groups.   

 

Effective March 14, 2021, the AIM Small Joint Surgery Guideline has been updated with the following:

  • Clarified requirements for imaging reports.
  • Removed radiographic requirement for confirmation of lesser toe deformities.
  • Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
  • Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
  • Clarified contraindications only apply to total ankle arthroplasty.

 

Providers should continue to submit prior authorization review requests to AIM using one of the following ways:

  • Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Portal at availity.com
  • Call the AIM toll-free number at 800-554-0580, Monday through Friday, 8:30 a.m. to 7 p.m. ET.

 

For questions, please contact the provider number on the back of the member ID card.

 

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Medical Policy & Clinical GuidelinesCommercialMarch 1, 2021

Anthem clarifies guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs)*

Note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) local Commercial health plans in Indiana and Ohio only.

 

In the January 2021 newsletter, you were previously notified that effective November 1, 2020, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network skilled nursing facility (SNF) facility for Indiana and Ohio members.

 

To clarify, this process only applies to hospital inpatient transfers to a skilled nursing facility (SNF).

It does not apply to transfers from acute inpatient rehab to SNF, LTAC to SNF, or SNF to SNF.

 

  • Facility and physician must be in-network for the member.
  • Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channels to aid in our members’ care coordination and management.
  • Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
  • SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission and prior to the last covered day for concurrent review.
  • Concurrent review will be required starting on day 5 of the SNF stay.
  • Anthem may apply monetary penalties, such as a reduction in payment, for failure to provide timely notice of admission.
  • Indiana and Ohio will pilot this process through June 1, 2021 and will conduct random audits and monitor trends to evaluate the effectiveness of the pilot

 

*Note: This process does not apply to admissions to out-of-network SNF facilities.

 

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Reimbursement PoliciesCommercialMarch 1, 2021

Claims editing update for ICD-10-CM Excludes 1 notes

Beginning with dates of service on or after February 1, 2021 Anthem has implemented revised claims editing logic tied to Excludes 1 notes from ICD-10-CM 2020 coding guidelines.  To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes 1 notes that may prohibit billing a specific code combination.

 

For assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm

 

One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 note. These notes appear below the affected codes – if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category.  If the Excludes 1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code 

 

In ICD-10-CM, when a category includes an Excludes 1 note, it outlines what codes should NOT be billed together.  Examples of this code scenario would include but are not limited to the following:

  • Reporting Z01.419 with Z12.4
    • 41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix)
  • Reporting Z79.891with F11.2X
    • 891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
  • Reporting M54.2 with M50.XX
    • 2 (Cervicalgia) has an Excludes 1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
  • Reporting M54.5 with S39.012X and/or M54.4x
    • 5 (low back pain) has an Excludes 1 note below it which includes; S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
  • Reporting J03.XX with J02.XX, J35.1, J36, J02.9
    • - (Acute tonsillitis) has an Excludes 1 note below it which includes; J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (Peritonsillar abscess)
  • Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, 00
    • N89 (Other inflammatory disorders of the vagina) has an Excludes 1 note below the category for R87.62X(abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623(HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis), A59.00 (trichomonal leukorrhea)

 

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM code book to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.

 

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PharmacyCommercialMarch 1, 2021

Site of Care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021*

Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Anthem Commercial plan members:  

  • Neulasta® & Neulasta Onpro® (pegfilgrastim)
  • Fulphila® (pegfilgrastim-jmdb)
  • Udenyca® (pegfilgrastim-cbqv)
  • Ziextenzo® (pegfilgrastim-bmez)
  • Nyvepria™ (pegfilgrastim-apgf)

 

The review will be administered by AIM Specialty Health® (AIM).

 

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Clinical Criteria page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

 

The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

 

Submit a request for review

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

  • Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Web Portal at availity.com.
  • Call the AIM Contact Center toll-free number: 800-554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. Eastern time.

 

Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Clinical Criteria page.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the member’s ID card.

 

Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”

 

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PharmacyCommercialMarch 1, 2021

Updates for specialty pharmacy are available - March 2021*

 

Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0185

J3490

C9399

Oxlumo

**ING-CC-0184

J3490

J3590

J9999

Danyelza

* Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Prior authorization update – change in effective date

 

Please note the change in effective date of prior authorization for injectable iron deficiency anemia products listed below.

 

The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0182

J1756

Venofer

*ING-CC-0182

J2916

Ferrlecit

*ING-CC-0182

J1750

Infed

*ING-CC-0182

J1439

Injectafer

*ING-CC-0182

Q0138

Feraheme

*ING-CC-0182

J1437

Monoferric

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Step therapy update – change in effective date

 

Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.

 

The effective date has been changed to dates of service on and after May 1, 2021 for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.

 

To access the Clinical Criteria information with step therapy drug lists, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

Status

Drug(s)

HCPCS Codes

*ING-CC-0182

Preferred

Venofer

J1756

*ING-CC-0182

Preferred

Ferrlecit

J2916

*ING-CC-0182

Preferred

Infed

J1750

*ING-CC-0182

Non-preferred

Injectafer

J1439

*ING-CC-0182

Non-preferred

Feraheme

Q0138

*ING-CC-0182

Non-preferred

Monoferric

J1437

* Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

Prior authorization update – change in code list

 

In a recent notification, we shared that effective April 1, 2021 the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0095

J9041

Velcade (Bortezomib)

**ING-CC-0095

J9041

Velcade (Bortezomib)

*ING-CC-0095

J9044

Bortezomib

**ING-CC-0095

J9044

Bortezomib

*ING-CC-0093

J9171

Docetaxel

**ING-CC-0093

J9171

Docetaxel

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

**Oncology use is managed by AIM.

 

Prior authorization update – medical specialty pharmacy update

 

In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.

 

Drug

Code

Code description

*Avastin

C9257

J9035

intravitreal bevacizumab

*Mvasi

Q5107

bevacizumab-awwb

*Zirabev

Q5118

bevacizumab-bvzr

*Non-oncology use is managed by Anthem’s medical specialty drug review team.

 

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PharmacyCommercialMarch 1, 2021

Some HIV medication combinations may require prior authorization

Starting May 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new prior authorization for HIV medications to help ensure patients are not receiving therapeutic duplications when taking certain combinations. Providers and members expected to be impacted by this policy will receive advanced notice by mail.

 

In order for members to continue to receive coverage for the drug combination, providers must submit a separate prior authorization form for each drug and provide the medical necessity rationale for why the drug combination is clinically needed.

 

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

 

The duplicate therapy policy may trigger as a result of one of the following drug combinations:

 

Duplicate Name

Duplicate Description

Example

Integrase stand transfer inhibitors (INSTI)

Two drug products each containing a drug with an INSTI mechanism of action.

Isentress (raltegravir) and Dovato (dolutegravir/ lamivudine).

Non-nucleoside reverse transcriptase inhibitors (NNRTI)

Two drug products each containing a drug with an NNRTI mechanism of action.

Edurant (rilpivirine) and Symfi (efavirenz/lamivudine/TDF).

Protease inhibitors (PI)

Two drug products each containing a drug with a PI mechanism of action.

Prezcobix (darunavir/cobicistat) and Reyataz (atazanavir).

Nucleoside reverse transcriptase inhibitors (NRTI)

Two drug products that together result in four NRTI active ingredients.

Truvada (emtricitabine/TDF) and Biktarvy (bictegravir/ emtricitabine/TAF).

Boosters

Two drug products that result in a combination of the protease inhibitor boosters, ritonavir and cobicistat.

Prezcobix (darunavir/cobicistat) and Kaletra (lopinavir/ritonavir).

 

As a reminder, prior authorizations may be submitted via phone, fax, or online (through CoverMyMeds.com).

If you have any questions regarding this policy, please contact Provider Services.

 

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State & FederalMedicare AdvantageMarch 1, 2021

Access to more claim denial information is now self-service

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

 

Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC are committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem and AMH Health have the answers before you ask the questions. With an initial focus on claim-level insights, Anthem and AMH Health have streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

 

Access the Claims Status Listing on Payer Spaces from  https://www.anthem.com/medicareprovider using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

 

Claim resolution daily

 

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim

status changes, other claims needing resolution are added, and claims are resolved faster.

 

Anthem and AMH Health made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

 

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem and AMH Health are using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and AMH Health, LLC.

 

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State & FederalMedicare AdvantageMarch 1, 2021

New provider directory indicator for telehealth services

Anthem Blue Cross and Blue Shield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

 

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

 

Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

 

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State & FederalMedicare AdvantageMarch 1, 2021

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 that several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

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

 

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search/

 

Notes/updates:

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

  • *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
    • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
  • *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
    • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and
    • anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
  • *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
    • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
    • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
    • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
  • *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
    • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
  • *CG-LAB-15 – Red Blood Cell Folic Acid Testing
    • RBC folic acid testing is considered not medically necessary in all cases
  • *CG-LAB-16 – Serum Amylase Testing
    • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
  • *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
    • Added the Afirma Xpression Atlas as not medically necessary
  • 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
    • A new Medical Policy was created from content contained in DME.00011.
    • There are no changes to the policy content.
    • Publish date is December 16, 2020.
  • CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
    • A new Clinical Guideline was created from content contained in GENE.00026.
    • There are no changes to the guideline content.
    • Publish date is December 16, 2020.

 

Medical Policies

On November 5, 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 March 8, 2021.

 

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

Publish date

Medical Policy number

Medical Policy title

New or revised

12/16/2020

*GENE.00055

Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

New

12/16/2020

*LAB.00037

Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

New

11/12/2020

ANC.00009

Cosmetic and Reconstructive Services of the Trunk and Groin

Revised

12/16/2020

*DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Revised

11/12/2020

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

Revised

11/12/2020

MED.00129

Gene Therapy for Spinal Muscular Atrophy

Revised

12/16/2020

SURG.00011

Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Revised

12/16/2020

*SURG.00062

Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Revised

 

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.

 

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

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

12/16/2020

*CG-LAB-15

Red Blood Cell Folic Acid Testing

New

12/16/2020

*CG-LAB-16

Serum Amylase Testing

New

11/12/2020

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

12/16/2020

*CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

Revised

12/16/2020

CG-GENE-18

Genetic Testing for TP53 Mutations

Revised

12/16/2020

CG-GENE-20

Epidermal Growth Factor Receptor (EGFR) Testing

Revised

11/12/2020

CG-MED-87

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

 

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