Special note:

The services addressed in ALL the Coverage Guidelines presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus). 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 Coverage Guidelines effective April 1, 2023. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus, Medallion and Anthem CCC Plus offered by HealthKeepers, Inc.; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on November 10, 2022.

 

The guidelines addressed in this edition of Provider News are:

  • Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling (GENE.00052).
  • Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring (MED.00130).
  • Ingestible Devices for the Treatment of Constipation (MED.00143).
  • Scoliosis Surgery (SURG.00097).
  • Powered Wheeled Mobility Devices (CG-DME-31).

 

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling (GENE.00052)

This coverage guideline addresses several tests including:

  • Gene panel testing (For the purposes of this document, a gene panel is defined by five or more genes or gene variants tested on the same day on the same member by the same rendering provider.)
  • Whole genome sequencing
  • Whole exome sequencing
  • Molecular profiling (also called comprehensive genomic profiling)
  • Polygenic risk score testing
  • Chromosome conformation signatures

 

The scope has been expanded to include chromosome confirmation signature testing.

 

Chromosome confirmation signature testing is considered investigational and not medically necessary for all indications.

 

The CPT® code associated with this revised coverage guideline and used to report chromosome confirmation signature testing is 0332U.   

 

Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring (MED.00130)

This coverage guideline addresses devices that use surface electromyography (sEMG) and electrodermal activity sensor devices to monitor seizures.

 

The scope has been expanded to include electrodermal activity sensor devices.

 

The use of surface electromyography (sEMG) or electrodermal activity sensor devices for seizure monitoring is considered investigational and not medically necessary.  

 

The HCPCS codes associated with this revised coverage guideline are E1399 and S3900.

 

Ingestible Devices for the Treatment of Constipation (MED.00143)

This new coverage guideline addresses the use of ingestible devices to mechanically stimulate the colon using vibration to treat constipation.

 

Ingestible devices for the treatment of constipation are considered investigational and not medically necessary.

 

The HCPCS code associated with this new coverage guideline is A9999.

 

Scoliosis Surgery (SURG.00097)

This coverage guideline addresses surgical treatments for scoliosis, specifically, use of a minimally invasive deformity correction system (for example, ApiFix, Ltd, Misgav Business Park, Israel), vertebral body tethering, vertebral body stapling, and magnetically controlled growing rods.  

 

The scope has been expanded to include magnetically controlled growing rods.

 

Use of magnetically controlled growing rods for the treatment of scoliosis is considered investigational and not medically necessary.   

 

The CPT codes associated with this revised coverage guideline are 0656T, 0657T, and 22899.

 

Powered Wheeled Mobility Devices (CG-DME-31)

This Clinical UM Guideline addresses criteria for powered wheeled mobility devices (also referred to as power mobility devices).

 

The scope has been revised to include powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT® Personal Mobility Device [iBOT PMD], Mobius Mobility, Manchester, NH).

 

Powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT PMD) are considered not medically necessary for all indications

 

The HCPCS codes associated with this revised clinical UM guideline are E1230; E1239; K0010; K0011; K0012; K0013; K0014, K0800; K0801; K0802; K0806; K0807; K0808; K0812, K0813; K0814; K0815; K0816, K0820; K0821; K0822; K0823; K0824; K0825; K0826; K0827; K0828; K0829; K0830; K0831; K0835; K0836; K0837; K0838; K0839; K0840; K0841; K0842; K0843, K0848; K0849; K0850; K0851; K0852; K0853; K0854; K0855; K0856; K0857; K0858; K0859; K0860; K0861; K0862; K0863; K0864, K0868; K0869; K0870; K0871; K0877; K0878; K0879; K0880; K0884; K0885; K0886, K0890; K0891, K0898; K0899, E1002; E1003; E1004; E1005; E1006; E1007; E1008; E1009; E1010; E1012; E2300,  and E0986.

 

These coverage guidelines are available for review on our website at anthem.com.

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January 2023 Anthem Provider News - Virginia