Coverage and Clinical Guidelines update August 1, 2025

Special note: The services addressed in the coverage guidelines presented in this document will require authorization for all our products offered by Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. except for services offered to Anthem HealthKeepers Plus members. 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 will implement the following new and revised Coverage Guidelines effective August 1, 2025. 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 February 20, 2025.

The guidelines addressed in this edition of Provider News are:

• CG‑SURG‑119: Treatment of Varicose Veins (Lower Extremities)
• CG‑SURG‑123: Autologous Fat Grafting and Injectable Soft Tissue Fillers
• SURG.00011: Products for Wound Healing and Soft Tissue Grafting: Investigational (previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting)
• SURG.00155: Cryosurgery of Peripheral Nerves (previously titled: Cryoneurolysis)

Treatment of Varicose Veins (Lower Extremities) (CG‑SURG‑119)

This clinical guideline addresses various modalities for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV), anterior accessory great saphenous vein (AAGSV)/anterior saphenous vein (ASV), or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins.

Revisions include addition of the VenoValve device which is considered not medically necessary for the treatment of chronic venous insufficiency in the lower extremities.

The CPT® and HCPCS codes associated with this revised clinical guideline are: 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37799, 36473, 36474, 36482, 36483, 0524T, 37241, 36468, 96999, and S2202.

Autologous Fat Grafting and Injectable Soft Tissue Fillers (CG‑SURG‑123)

This guideline addresses autologous fat grafting (autologous fat transfer) and injectable soft tissue fillers.

The revision to this guideline includes the addition of code D9914.

Other CPT and HCPCS codes associated with this guideline are: 11950‑11954, 17999, 31574, C1878, G0429, L8607, L8699, Q2026, and Q2028.

Products for Wound Healing and Soft Tissue Grafting: Investigational (previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting) (SURG.00011)

This guideline addresses the use of soft tissue (for example, skin, ligament, cartilage) substitutes in wound healing and surgical procedures. It now addresses products that are considered investigational and not medically necessary for all uses. The product list has been updated, and products with medical necessity criteria have been moved to CG‑SURG‑127.

The CPT codes associated with this guideline are: 31574, 46707, 0627T, 0628T, 0629T, 0630T, 15150, 15151, 15152, 15155, 15156, 15157, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777, 29999, 17999, 65778, 65779, 65780, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278, A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2017, A2018, A2019, A2020, A2021, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2029, C1763, C9352, C9353, C9354, C9355, C9356, C9361, C9364, C9399, C9796, G0428, Q4100, Q4103, Q4108, Q4111, Q4112, Q4113, Q4114, Q4117, Q4118, Q4123, Q4125, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4152, Q4153, Q4155, Q4156, Q4157, Q4159, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4183, Q4184, Q4185, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4284, Q4285, Q4286, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367.

Cryosurgery of Peripheral Nerves (Previously Titled: Cryoneurolysis) (SURG.00155)

This guideline addresses cryosurgical techniques for peripheral nerves that create a temporary nerve block through application of extreme cold to the selected site for treatment. These techniques are known as cryoneurolysis, cryoanalgesia, and cryoablation of peripheral nerves.

Revisions include coding additions and a change to the position statement that cryosurgical techniques (for example, cryoneurolysis and cryoablation) of peripheral nerves are considered investigational and not medically necessary for all indications.

The CPT and HCPCS codes associated with this coverage guideline are: 0440T, 0441T, 0442T, 64999, C9808, C9809.

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