Coverage and Clinical Guidelines update

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. in Virginia will implement the following new Coverage Guideline effective August 1, 2023. This guideline impacts all our products with the exception of Anthem HealthKeepers Plus, Medallion offered by HealthKeepers, Inc.; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). This guideline was among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 16, 2023.

The guideline addressed in this edition of Provider News is:

• Digital Therapy Devices for Treatment of Amblyopia (MED.00145)

Digital Therapy Devices for Treatment of Amblyopia (MED.00145)

This new coverage guideline addresses digital therapy devices for the treatment of amblyopia. These devices incorporate dichoptic (viewing a separate and independent field through each eye) presentations to improve visual acuity of individuals with amblyopia.

Digital therapy devices for treatment of amblyopia are considered investigational and not medically necessary.

The CPT^® codes associated with this new coverage guideline are 0687T, 0688T, 0704T, 0705T, and 0706T.

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