Clinical Guideline update (effective May 1, 2023)

Special note:
The services addressed in the Clinical Guideline presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers 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 Clinical Guideline effective May 1, 2023. This guideline impacts all our products with the exception of Anthem HealthKeepers Plus; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

The guideline addressed in this edition of Provider News is:

• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (CG-SURG-106)

This Clinical UM Guideline addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including but not limited to venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

Venous angioplasty with or without stent placement or venous stenting alone is considered medically necessary for treatment of the following conditions:

1. Venous thoracic outlet syndrome; or
2. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome); or
3. Superior vena cava syndrome; or
4. Iliac vein compression syndrome (for example, May-Thurner Syndrome);or
5. Pulmonary vein stenosis; or
6. Congenital heart disease, including but not limited to:
   1. Stenosis or hypoplasia of a pulmonary artery in a child; or
   2. Symptomatic stenosis/occlusion of superior or inferior vena cava;or
   3. Venous narrowing due to repair of sinus venosus atrial septal defect (ASD); or
   4. Venous obstruction of an atrial baffle following Mustard or Senning repair of transposition of the great arteries.

 Venous angioplasty with or without stent placement or venous stenting alone is considered not medically necessary for the treatment of all other conditions not listed above, including but not limited to:

1. Multiple sclerosis; or
2. Chronically occluded iliac veins; or
3. Idiopathic intracranial hypertension (pseudotumor cerebri); or
4. Ilio-femoral venous thrombosis; or
5. Nutcracker syndrome.

This guideline is available for review on our website at anthem.com.