The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below 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. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.


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


To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/search.


Notes/updates

 

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

  • *CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
    • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting

 

  • *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
    • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary

  • *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
    • Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry

 

  • *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
    • Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications

 

  • *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
    • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
    • Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
    • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications

 

  • CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
    • A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021

 

  • CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
    • A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021

 

  • CG-SURG-110 - Lung Volume Reduction Surgery
    • A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

 

AIM Specialty Health®* Clinical Appropriateness Guideline updates. To view AIM guidelines, visit the AIM Specialty Health page.

 

  • The Small Joint Surgery Guideline has been revised and became effective on March 14, 2021.

 

  • The following guidelines have been revised and will be effective on June 4, 2021:

 

* Imaging of the Spine

* Imaging of the Extremities

* Vascular Imaging

* Joint Surgery

* Spine Surgery

 

 

Medical Policies

 

On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2021.

 

Publish date

Medical Policy number

Medical Policy title

New or revised

4/7/2021

*ANC.00008

Cosmetic and Reconstructive Services of the Head and Neck

Revised

2/18/2021

SURG.00121

Transcatheter Heart Valve Procedures

Revised

2/18/2021

SURG.00145

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

Revised



Clinical UM Guidelines

 

On February 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect June 4, 2021.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

4/7/2021

*CG-LAB-17

Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting

New

2/18/2021

CG-GENE-21

Cell-Free Fetal DNA-Based Prenatal Testing

Revised

4/7/2021

CG-MED-26

Neonatal Levels of Care

Revised

2/18/2021

CG-MED-87

Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

Revised

4/7/2021

*CG-OR-PR-04

Cranial Remodeling Bands and Helmets (Cranial Orthotics)

Revised

2/18/2021

CG-SURG-55

Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation

Revised

4/7/2021

CG-SURG-71

Reduction Mammaplasty

Revised

4/7/2021

*CG-SURG-78

Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies

Revised

4/7/2021

*CG-SURG-82

Bone-Anchored and Bone Conduction Hearing Aids

Revised

4/7/2021

CG-SURG-97

Cardioverter Defibrillators

Revised

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0225-21                               518566MUPENMUB



Featured In:
June 2021 Anthem Provider News - Virginia