Medical Policies update

 

On January 25, 2018, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem HealthKeepers Plus members. These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

 

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.


Please note:

 

  • Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

 

  • For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

 

Publish date

Medical Policy number

Medical Policy title

New or revised

2/28/2018

DRUG.00116

Vestronidase alfa (Mepsevii™)

New

2/28/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

2/28/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

2/28/2018

DRUG.00077

Monoclonal Antibodies to Interleukin-17A

Revised

2/1/2018

DRUG.00080

Monoclonal Antibodies for the Treatment of Eosinophilic Conditions

Revised

2/28/2018

DRUG.00082

Daratumumab (DARZALEX™)

Revised

2/28/2018

DRUG.00099

Cerliponase Alfa (Brineura™)

Revised

2/28/2018

GENE.00028

Genetic Testing for Colorectal Cancer Susceptibility

Revised

2/1/2018

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

2/28/2018

GENE.00035

Genetic Testing for TP53 Mutations

Revised

2/28/2018

MED.00100

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

Revised

2/1/2018

SURG.00011

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

Revised

2/1/2018

SURG.00098

Mechanical Embolectomy for Treatment of Acute Stroke

Revised

2/28/2018

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

Revised

 


Clinical Utilization Management Guidelines
update

 

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines to Anthem HealthKeepers Plus members. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

 

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

Please note:

 

  • Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

 

  • For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

5/1/2018

CG-DME-42

Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices

New

5/1/2018

CG-DME-43

High-Frequency Chest Compression Devices for Airway Clearance

New

5/1/2018

CG-DRUG-82

Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension

New

5/1/2018

CG-DRUG-83

Growth Hormone

New

5/1/2018

CG-DRUG-84

Belimumab (Benlysta®)

New

5/1/2018

CG-DRUG-85

Tesamorelin (Egrifta®)

New

5/1/2018

CG-DRUG-86

Ocriplasmin (Jetrea®) Intravitreal Injection Treatment

New

5/1/2018

CG-DRUG-87

Vedolizumab (Entyvio®)

New

5/1/2018

CG-DRUG-88

Dupilumab (Dupixent®)

New

5/1/2018

CG-SURG-70

Gastric Electrical Stimulation

New

5/1/2018

CG-SURG-71

Reduction Mammaplasty

New

5/1/2018

CG-SURG-72

Endothelial Keratoplasty

New

7/1/2018

CG-THER-RAD-03

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

New

7/1/2018

CG-THER-RAD-04

Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors

New

5/1/2018

CG-DRUG-29

Hyaluronan Injections

Revised

2/28/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

2/28/2018

CG-DRUG-59

Testosterone Injectable

Revised

2/28/2018

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

Revised

2/28/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

2/28/2018

CG-MED-39

Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Revised

2/28/2018

CG-MED-53

Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing

Revised

2/28/2018

CG-SURG-33

Lumbar Fusion and Lumbar Total Disc Arthroplasty

Revised

 

 

Coverage Guidelines and Clinical Utilization Management Guidelines update

 

The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed or revised to support clinical coding edits. Note, several 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 search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

Coverage Guidelines

 

On March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

 

 

Publish date

Coverage Guidelines number

Coverage Guidelines title

New or revised

3/29/2018

MED.00120

Voretigene neparvovec-rzyl (Luxturna™)

New

4/25/2018

SURG.00151

Balloon Dilation of Eustachian Tube

New

4/25/2018

DME.00009

Vacuum-Assisted Wound Therapy in the Outpatient Setting

Revised

3/29/2018

GENE.00028

Genetic Testing for Colorectal Cancer Susceptibility

Revised

4/25/2018

RAD.00029

CT Colonography (Virtual Colonoscopy) for Colorectal Cancer

Revised

4/25/2018

SURG.00033

Cardioverter Defibrillators

Revised

4/25/2018

SURG.00098

Mechanical Embolectomy for Treatment of Acute Stroke

Revised

4/25/2018

SURG.00121

Transcatheter Heart Valve Procedures

Revised



Clinical UM Guidelines

 

On March 22, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/28/2018

CG-BEH-15

Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

New

6/22/2018

CG-DRUG-89

Implantable and Extended-Release Buprenorphine-Containing Products

New

6/28/2018

CG-DRUG-90

Intravitreal Treatment for Retinal Vascular Conditions

New

6/28/2018

CG-DRUG-91

Intravitreal Corticosteroid Implants

New

6/28/2018

CG-DRUG-92

Alpha-1 Proteinase Inhibitor Therapy

New

6/28/2018

CG-DRUG-93

Sarilumab (Kevzara®)

New

6/28/2018

CG-LAB-13

Skin Nerve Fiber Density Testing

New

6/28/2018

CG-MED-69

Inhaled Nitric Oxide

New

6/28/2018

CG-MED-70

Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

New

6/28/2018

CG-SURG-73

Balloon Sinus Ostial Dilation

New

6/28/2018

CG-SURG-74

Total Ankle Replacement

New

6/28/2018

CG-SURG-75

Transanal Endoscopic Microsurgical Excision of Rectal Lesions

New

6/28/2018

CG-THER-RAD-07

Intravascular Brachytherapy (Coronary and Noncoronary)

New

4/25/2018

CG-SURG-31

Treatment of Keloids and Scar Revision

Revised

4/25/2018

CG-SURG-49

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

Revised

 


Coverage Guidelines

 

Note:

 

  • Effective November 1, 2018, MCG Health Care Guidelines® will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).

 

  • Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

 

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

 

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

 

Publish date

Coverage Guidelines number

Coverage Guidelines title

New or revised

6/6/2018

DRUG.00098

Lutetium Lu 177 dotatate (Lutathera®)

New

6/6/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

5/10/2018

DRUG.00047

Brentuximab Vedotin (Adcetris®)

Revised

5/10/2018

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

6/6/2018

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

6/6/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

5/10/2018

DRUG.00076

Blinatumomab (Blincyto®)

Revised

6/6/2018

DRUG.00111

Monoclonal Antibodies to Interleukin-23

Revised

5/10/2018

SURG.00026

Deep Brain, Cortical and Cerebellar Stimulation

Revised

 


Clinical Utilization Management (UM) Guidelines

 

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/6/2018

CG-LAB-12 

Testing for Oral and Esophageal Cancer

New

6/6/2018

CG-MED-71

Wound Care in the Home Setting

New

6/28/2018

CG-DME-44

Electric Tumor Treatment Field (TTF)

New

6/28/2018

CG-DRUG-67

Cetuximab (Erbitux®)

New

6/28/2018

CG-DRUG-94

Rituximab (Rituxan®) for Nononcologic Indications

New

6/28/2018

CG-DRUG-95

Belatacept (Nulojix®)

New

6/28/2018

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

New

6/28/2018

CG-DRUG-97

Rilonacept (Arcalyst®)

New

6/28/2018

CG-DRUG-98

Bendamustine Hydrochloride

New

6/28/2018

CG-DRUG-99

Elotuzumab (Empliciti™)

New

6/28/2018

CG-DRUG-100

Interferon gamma-1b (Actimmune®)

New

6/28/2018

CG-DRUG-101

Ixabepilone (Ixempra®)

New

6/28/2018

CG-DRUG-102

Olaratumab (Lartruvo™)

New

6/28/2018

CG-MED-72

Hyperthermia for Cancer Therapy

New

6/28/2018

CG-SURG-76

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

New

6/28/2018

CG-SURG-77

Refractive Surgery

New

6/28/2018

CG-SURG-78

Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

New

6/28/2018

CG-SURG-79

Implantable Infusion Pumps

New

6/28/2018

CG-SURG-80

Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors

New

5/10/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

6/6/2018

CG-DRUG-60

Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications

Revised

6/6/2018

CG-DRUG-62

Fulvestrant (FASLODEX®)

Revised

6/6/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

 

 



Featured In:
October 2018 Anthem Provider Newsletter - Virginia