Archived coverage guideline numbers effective September 20, 2018

 

The following coverage guideline numbers have been archived:

DME.00027 Ultrasound Bone Growth Stimulation [Note: Content of DME.00027 has been transferred to new clinical UM guideline CG-DME-45.] 


DRUG.00006
Botulinum Toxin [Note: Content of DRUG.00006 has been transferred to clinical UM guideline CG-DRUG-103.]  


DRUG.00024
Omalizumab (Xolair®) [Note: Content of DRUG.00024 has been transferred to new clinical UM guideline CG-DRUG-104.]


DRUG.00040
Abatacept (Orencia) [Note: Content of DRUG.00040 has been transferred to clinical UM guideline CG-DRUG-105.]


DRUG.00047
Brentuximab Vedotin (Adcetris®) [Note: Content of DRUG.00047 has been transferred to new clinical UM guideline CG-DRUG-106.]


DRUG.00058
Pharmacotherapy for Hereditary Angioedema [Note: Content of DRUG.00058 has been transferred to new clinical UM guideline CG-DRUG-107.]


DRUG.00064
Enteral Carbidopa and Levodopa Intestinal Gel Suspension  [Note: Content of DRUG.00064 has been transferred to new clinical UM guideline CG-DRUG-108.]


DRUG.00087
Asfotase Alfa (Strensiq™) [Note: Content of DRUG.00087 has been transferred to new clinical UM guideline CG-DRUG-109.]


DRUG.00091
Naltrexone Implantable Pellets [Note: Content of DRUG.00091 has been transferred to new clinical UM guideline CG-DRUG-110.]


DRUG.00093
Sebelipase alfa (KANUMA™) [Note: Content of DRUG.00093 has been transferred to new clinical UM guideline CG-DRUG-111.]


DRUG.00103
Abaloparatide (Tymlos™) [Note: Content of DRUG.00103 has been transferred to new clinical UM guideline CG-DRUG-112.]


MED.00005
Hyperbaric Oxygen Therapy (Systemic/Topical) [Note: Content of MED.00005 has been transferred to new clinical UM guideline CG-MED-73.]


MED
.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry [Note: Content of MED.00051 has been transferred to new clinical UM guideline CG-MED-74.]

 

MED.00081 Cognitive Rehabilitation [Note: Content of MED.00081 has been transferred to new clinical UM guideline CG-REHAB-11.]


MED.00107
Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome [Note: Content of MED.00107 has been transferred to new clinical UM guideline CG-MED-75.]


RAD.00019
Magnetic Source Imaging and Magnetoencephalography [Note: Content of RAD.00019 has been transferred to new clinical UM guideline CG-MED-76.]


RAD.00042
SPECT/CT Fusion Imaging [Note: Content of RAD.00042 has been transferred to new clinical UM guideline CG-MED-77.]


SURG.00014
Cochlear Implants and Auditory Brainstem Implants [Note: Content of SURG.00014 has been transferred to new clinical UM guideline CG-SURG-81.]


SURG.00020
Bone-Anchored and Bone Conduction Hearing Aids [Note: Content of SURG.00020 has been transferred to new clinical UM guideline CG-SURG-82.]


SURG.00024
Bariatric Surgery and Other Treatments for Clinically Severe Obesity [Note: Content of SURG.00024 has been transferred to new clinical UM guideline CG-SURG-83.]


SURG.00049
Mandibular/ Maxillary (Orthognathic) Surgery [Note: Content of SURG.00049 has been transferred to new clinical UM guideline CG-SURG-84.]


SURG.00051
Hip Resurfacing [Note: Content of SURG.00051 has been transferred to new clinical UM guideline CG-SURG-85.]


SURG.00054
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection [Note: Content of SURG.00054 has been transferred to new clinical UM guideline CG-SURG-86.]


SURG.00074
Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring [Note: Content of SURG.00074 has been transferred to new clinical UM guideline CG-SURG-87.]


SURG.00085
Mastectomy for Gynecomastia [Note: Content of SURG.00085 has been transferred to new clinical UM guideline CG-SURG-88.]


SURG.00090
Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia [Note: Content of SURG.00090 has been transferred to new clinical UM guideline CG-SURG-89.]


TRANS.00018
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation [Note: Content of TRANS.00018 has been transferred to new clinical UM guideline CG-TRANS-03.]

 



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October 2018 Anthem Provider Newsletter - Virginia