The following guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 13, 2021. Revisions have been made to the coding which may result in services previously considered medically necessary to now be considered not medically necessary for dates of service (DOS) on or after November 1, 2021.


These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). 


The services addressed in these guidelines will require authorization for all of our HealthKeepers, Inc. products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Commonwealth Coordinated Care Plus plan. A pre-determination can be requested for our PPO products. Please note that FEP is excluded from this requirement as well.




CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)

31237, 31253, 31257, 31259

CG-SURG-27 Gender Affirming Surgery

53410, 53420, 53425, 53430

CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver





Featured In:
August 2021 Anthem Provider News - Virginia