The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

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

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Notes/updates:

 

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

 

  • *DME.00037 — Added devices that combine cooling and vibration to the Investigational (INV) & not medically necessary (NMN) statement

 

  • *LAB.00027 — Added Mediator Release Test to INV&NMN statement.

 

  • *LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7

 

  • *OR-PR.00003:

 

Clarified medically necessary (MN) position statement criteria 2 to 4

Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered INV&NMN for all indications

 

  • *SURG.00011:

 

Added new MN and INV&NMN statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera

Added new products to INV&NMN statement

 

 

  • *SURG.00045:

 

Added erectile dysfunction, Peyronie’s disease and wound repair to the INV&NMN statement

Revised title

 

  • *SURG.00121 — Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications

 

  • The following AIM Specialty Health® updates were approved on June 6, 2019:

 

Advanced Imaging:

   Imaging of the Heart

   Oncologic Imaging

   Vascular Imaging

Proton Beam Therapy

Rehabilitative Therapies — Physical Therapy, Occupational Therapy and Speech Therapy (New)

 

 

Coverage Guidelines

 

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

 

Publish date

Medical Policy number

Medical Policy title

New or revised

6/13/2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

New

6/13/2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

6/13/2019

*SURG.00011

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

Revised

6/13/2019

SURG.00023

Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

6/13/2019

SURG.00028

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

Revised

6/27/2019

GENE.00025

Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

Revised

6/27/2019

DRUG.00046

Ipilimumab (Yervoy®)

Revised

6/27/2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

6/27/2019

DRUG.00062

Obinutuzumab (Gazyva®)

Revised

6/27/2019

DRUG.00067

Ramucirumab (Cyramza®)

Revised

6/27/2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

6/27/2019

DRUG.00075

Nivolumab (Opdivo®)

Revised

6/27/2019

DRUG.00107

Avelumab (Bavencio®)

Revised

6/27/2019

GENE.00044

Analysis of PIK3CA Status in Tumor Cells

Revised

6/27/2019

*SURG.00121

Transcatheter Heart Valve Procedures

Revised

6/27/2019

GENE.00001

Genetic Testing for Cancer Susceptibility

Revised

6/27/2019

GENE.00043

Genetic Testing of an Individual’s Genome for Inherited Diseases

Revised

6/27/2019

LAB.00011

Analysis of Proteomic Patterns

Revised

6/27/2019

LAB.00015

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

Revised

7/10/2019

GENE.00051

Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

New

7/10/2019

SURG.00153

Cardiac Contractility Modulation Therapy

New

7/10/2019

*DME.00037

Cooling Devices and Combined Cooling/Heating Devices

Revised

7/10/2019

DME.00038

Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

Revised

7/10/2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

7/10/2019

*LAB.00027

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Revised

7/10/2019

*LAB.00033

Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer

Revised

7/10/2019

MED.00109

Corneal Collagen Cross-Linking

Revised

7/10/2019

*OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

7/10/2019

SURG.00005

Partial Left Ventriculectomy

Revised

7/10/2019

*SURG.00045

Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions

Revised

7/10/2019

SURG.00120

Internal Rib Fixation Systems

Revised

9/4/2019

GENE.00010

Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

 


Clinical UM Guidelines

 

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. These guidelines were adopted by the medical operations committee for Anthem HealthKeepers Plus members on July 5, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/24/2019

CG-SURG-97

Cardioverter Defibrillators

New

6/27/2019

CG-DRUG-48

Azacitidine (Vidaza®)

Revised

6/27/2019

CG-DRUG-62

Fulvestrant (FASLODEX®)

Revised

6/27/2019

CG-DRUG-106

Brentuximab Vedotin (Adcetris)

Revised

6/27/2019

CG-DRUG-98

Bendamustine Hydrochloride

Revised

6/27/2019

CG-LAB-09

Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain

Revised

6/27/2019

CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

Revised

7/10/2019

CG-SURG-100

Laser Trabeculoplasty and Laser Peripheral Iridotomy

New

7/10/2019

CG-ADMIN-01

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Revised

7/10/2019

CG-ANC-06

Ambulance Services: Ground; Non-Emergent

Revised

7/10/2019

CG-DME-03

Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Revised

7/10/2019

CG-DME-07

Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

Revised

7/10/2019

CG-DME-08

Infant Home Apnea Monitors

Revised

7/10/2019

CG-DME-39

Dynamic Low-Load Prolonged-Duration Stretch Devices

Revised

7/10/2019

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

7/10/2019

CG-DME-45

Ultrasound Bone Growth Stimulation

Revised

7/10/2019

CG-MED-41

Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Revised

7/10/2019

CG-MED-49

Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

Revised

7/10/2019

CG-MED-57

Cardiac Stress Testing with Electrocardiogram

Revised

7/10/2019

CG-MED-59

Upper Gastrointestinal Endoscopy in Adults

Revised

7/10/2019

CG-SURG-11

Surgical Treatment for Dupuytren's Contracture

Revised

7/10/2019

CG-SURG-17

Trigger Point Injections

Revised

7/10/2019

CG-SURG-35

Intracytoplasmic Sperm Injection (ICSI)

Revised

7/10/2019

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Revised

7/10/2019

CG-SURG-81

Cochlear Implants and Auditory Brainstem Implants

Revised

7/10/2019

CG-SURG-85

Hip Resurfacing

Revised

7/10/2019

CG-SURG-93

Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

Revised

9/4/2019

CG-GENE-11

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

New

9/4/2019

CG-GENE-10

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

New

9/4/2019

CG-SURG-101

Ablative Techniques as a Treatment for Barrett’s Esophagus

New

9/4/2019

CG-SURG-102

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

New

 

 



Featured In:
October 2019 Anthem Provider News - Virginia