Clinical Guidelines update (effective May 1, 2023)
The services addressed in all the Clinical Guidelines presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus members. Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP®). A pre-determination can be requested for our Anthem PPO products.
Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. will implement the following new and revised Clinical Guidelines effective May 1, 2023. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus members, Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
The guidelines addressed in this edition of Provider News are:
- CG-MED-92 Foot Care Services.
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.
Foot Care Services (CG-MED-92)
This new Clinical UM Guideline addresses the following foot care services: cutting or removal of corns or calluses, trimming, cutting, clipping, or debriding of nails (including mycotic nails), and cleaning and soaking of the feet.
Foot care services including cutting or removal of corns or calluses, or trimming, cutting, clipping, or debriding of nails are considered medically necessary when the following criteria are met:
- The individual has a systemic condition resulting in circulatory insufficiency or desensitization of the lower extremity, including but not limited to one or more of the conditions listed below:
- Arteriosclerosis; or
- Chronic thrombophlebitis; or
- Diabetes mellitus; or
- Peripheral vascular disease; or
- Peripheral neuropathy; or
- Raynaud’s disease; and
- The individual is at risk of impeded healing that could potentially jeopardize life of limb (for example, evidence of sensory loss or prior ulceration or amputation, Charcot foot, history of angioplasty or vascular surgery, retinopathy, renal disease, or current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication)); and
- Performance of foot care services by a nonprofessional person would put the individual at risk; and
- Foot care services are not provided more frequently than once every two months (unless documentation demonstrates clinical appropriateness).
Debridement of mycotic nails, no more than once every two months (unless documentation demonstrates clinical appropriateness), in the absence of a systemic condition above, is considered medically necessary when the following criteria are met:
- For ambulatory individuals, pain results in difficulty walking and/or abnormality of gait in conventional walking footwear; or
- In non-ambulatory individuals, there is pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
Foot care services, including cutting or removal of corns or calluses, or trimming, cutting, clipping, or debriding of nails (including mycotic nails) are considered not medically necessary when the criteria above are not met and for all other indications.
Cleaning and soaking of the feet are considered not medically necessary for all indications.
The CPT® and HCPCS codes associated with this new Clinical UM Guideline are 11055, 11056, 11057, 11719,11720, 11721, 11730, 11732, 11750, 11765, 97022, G0127, G0247, and S0390.
Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (CG-SURG-106)
This Clinical UM Guideline addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including but not limited to venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).
Venous angioplasty with or without stent placement or venous stenting alone is considered medically necessary for treatment of the following conditions:
- Venous thoracic outlet syndrome; or
- Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome); or
- Superior vena cava syndrome; or
- Iliac vein compression syndrome (for example, May-Thurner syndrome);or
- Pulmonary vein stenosis; or
- Congenital heart disease, including but not limited to:
- Stenosis or hypoplasia of a pulmonary artery in a child; or
- Symptomatic stenosis/occlusion of superior or inferior vena cava;or
- Venous narrowing due to repair of sinus venosus atrial septal defect (ASD); or
- Venous obstruction of an atrial baffle following Mustard or Senning repair of transposition of the great arteries.
Venous angioplasty with or without stent placement or venous stenting alone is considered not medically necessary for the treatment of all other conditions not listed above, including but not limited to:
- Multiple sclerosis; or
- Chronically occluded iliac veins; or
- Idiopathic intracranial hypertension (pseudotumor cerebri); or
- Ilio-femoral venous thrombosis; or
- Nutcracker syndrome.
The CPT codes associated with this Clinical UM Guideline are 37238, 37239, 37248, 37249, 61630, and 61635.
These guidelines are available for review on our website at anthem.com.
February 2023 Anthem Provider News - Virginia