Coverage and Clinical Guidelines update

Special note:
The services addressed in the coverage guidelines presented in this article will require authorization for all our products offered by Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., except for 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 PPO products.

Anthem will implement the following new and revised Coverage Guidelines effective November 1, 2024. These guidelines impact all our products except for Anthem HealthKeepers Plus, Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 9, 2024.

The guidelines addressed in this edition of Provider News are:

• MED.00055 Wearable Cardioverter Defibrillators.
• CG-MED-59 Upper Gastrointestinal Endoscopy in Adults.

Wearable cardioverter defibrillators (MED.00055)

This revised Coverage Guideline addresses the wearable cardioverter defibrillator, an external vest‑like garment device that is intended to perform the same tasks as an implantable cardioverter defibrillator (ICD), without requiring any invasive procedures.

A wearable cardioverter defibrillator is considered not medically necessary when the individual has an automated external defibrillator for home use.

The CPT^® and HCPCS codes associated with this revised Coverage Guideline are 93745 and K0606.

Upper gastrointestinal endoscopy in adults (CG-MED-59)

This revised Clinical UM Guideline addresses indications for upper gastrointestinal (GI) endoscopy in adults.

Screening EGD in adults for Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC) may be considered medically necessary in individuals with:

1. Chronic symptoms of gastroesophageal reflux disease (GERD) such as heartburn or acid regurgitation (weekly symptoms for five or more years); 
   and
2. Three or more risk factors for BE. 

Major gastroenterological specialty societies recommend screening only for individuals at high risk for the development of Barrett’s esophagus or esophageal adenocarcinoma (abbreviated as BE and EAC, respectively in the guidelines).

The ACG guideline on diagnosis and management of Barrett’s esophagus (Shaheen, 2022) includes the following statement on screening:

We suggest a single screening endoscopy for patients with chronic GERD symptoms and three or more additional risk factors for BE, including male sex, age >50 years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative (strength of recommendation: conditional; quality of evidence: very low).

The ASGE (2012) guideline states, “Risk factors for BE and EAC include male sex, white race, age older than 50 years, family history of BE, increased duration of reflux symptoms, smoking, and obesity.”

Neither the ACG (Shaheen, 2022) nor the ASGE (2012) recommends screening the general population for Barrett’s esophagus.

The CPT codes associated with this revised Clinical UM Guideline are 43233, 43235, 43236, 43239, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43254, 43255, 43266, 43270, 0652T, 0653T, and 0654T.

These coverage guidelines are available for review on our website at anthem.com/provider.

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