Coverage and Clinical Guidelines update (effective January 1, 2024) 

Special note:

All services addressed in the Coverage Guidelines below require prior authorization except for the following plans:

• Anthem HealthKeepers Plus
• Medicare Advantage
• Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program^® or FEP^®).

Prior authorization requests can be submitted for Anthem PPO products.

Anthem Blue Cross and Blue Shield (Anthem) in Virginia and our affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective January 1, 2024. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus members, 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 August 10, 2023.

The guidelines addressed in this edition of Provider News are:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices 
• LAB.00011 Selected Protein Biomarker Algorithmic Assays
• MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation (Omidubicel)
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring   
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
• TRANS.00041 Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection 
• CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices 
• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside of Liver 

Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities (ANC.00009)

This coverage guideline addresses a variety of surgical procedures that may be considered medically necessary, cosmetic, or reconstructive in nature. 

The position regarding lipectomy or liposuction for lymphedema and lipedema has been revised. 

Lipectomy or liposuction is considered medically necessary in individuals with documented lymphedema (primary or secondary, for example, related to surgical mastectomy) when all of the following criteria are met (A through E):

A. Signs and symptoms have not responded to at least three consecutive months of optimal medical management, including one or more of the following:

1. Compression garments; or
2. Manual lymph drainage; or
3. Complex/complete decongestive therapy (CDT); 

and

B. There is documented significant functional impairment (for example, difficulty ambulating or performing activities of daily living) or medical complication, such as recurrent cellulitis as a result of lymphedema for each anatomical region being considered for treatment; and

C. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and

D. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and 

E. Photographic documentation is consistent with the diagnosis of lymphedema in the affected extremities, including limb asymmetry.

Lipectomy or liposuction is considered medically necessary in individuals with lipedema when all of the following criteria are met (A through F):

A. A diagnosis of lipedema has been documented, including all of the following:

1. Bilateral, symmetrical, disproportionate fatty tissue hypertrophy on the limbs sparing the hands and feet; and
2. Negative Stemmer sign; and
3. Marked tendency to bruise or form hematomas; and
4. Stable limb circumference with weight reduction or caloric restriction (if applicable); and
5. Pain on pressure and touch; 

and

B. Signs and symptoms have not responded to at least three consecutive months of optimal medical management, including both of the following:

1. Compression garments; and
2. Manual lymphatic drainage; 

and

C. There is documented significant functional impairment (for example, difficulty ambulating or performing activities of daily living) as a result of lipedema for each anatomical region being considered for treatment; and

D. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and

E. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and

F. Photographic documentation is consistent with the diagnosis of lipedema in the affected extremities, including limb symmetry.

Correction of lymphedema (for example, related to surgical mastectomy) or lipedema using lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal.

Lipectomy or liposuction is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met or when the medically necessary criteria in this section are not met, including for treatment of obesity in the absence of a documented diagnosis of lymphedema or lipedema.

The CPT^® and HCPCS codes associated with this revised coverage guideline are 15832, 15833, 15834, 15835, 15836, 15837, 15839, 15877, 15878, 15879, 21740, 21742, 21743, 54360, 54440, 55899, 56800, 56805, 56810, 57291, 57292, 57335, and 58999. 

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices (DME.00011)

This coverage guideline addresses certain types of electrical stimulation devices. 

It has been revised to include electrical stimulation wound treatment device, electromagnetic wound treatment device and pulsed electromagnetic field stimulation (PENFS).

Electrical stimulation wound treatment device, electromagnetic wound treatment device, and pulsed electromagnetic field stimulation (PENFS) are considered investigational and not medically necessary for all indications. 

The CPT and HCPCS codes associated with this revised coverage guideline are 64999, 0278T, 0720T, 0766T, 0767T, 0768T, 0769T, 0783T, A4596, E0761, E0762, E0769, E1399, K1002, K1023, S8130, S8131, and S8930. 

Selected Protein Biomarker Algorithmic Assays (LAB.00011)

This coverage guideline addresses the use of selected protein biomarker algorithmic assays, which involve the qualitative and/or quantitative analysis of protein constituents in a biological sample that are reported as a predictive, diagnostic, or prognostic algorithmic result. Protein biomarker algorithmic assays are under investigation in certain tumors and for other applications such as predicting the likelihood of preterm delivery in pregnancy. 

It has been revised to include the IMMray® PanCan-d test to be considered investigational and not medically necessary for all indications. 

The CPT codes associated with this revised coverage guideline are 81538, 81599, 0080U, 0092U, 0174U, 0247U, 0249U, 0342U, and 0360U. 

Cellular Therapy Products for Allogeneic Stem Cell Transplantation (MED.00147)

This new coverage guideline addresses stem cell therapy products such as omidubicel (Omisirge^®, Gamida Cell, Ltd. Boston, MA) for hematologic malignancies (blood cancers) which are amenable to stem cell transplantation. Omidubicel is the first U. S. Food and Drug Administration (FDA) approved stem cell therapy product for allogeneic stem cell transplantation.

Use of ex-vivo expansion of cord blood stem cell products (for example, omidubicel) is considered medically necessary for individuals when the following criteria are met:

1. 12 years of age or older; and
2. Is a candidate for myeloablative allogeneic hematopoietic stem cell transplantation to treat a hematologic malignancy; and 
3. The appropriate stem cell transplant criteria are met; and 
4. Is eligible and planned for umbilical cord blood transplantation following myeloablative conditioning; and
5. Use is intended to reduce the time to neutrophil recovery and the incidence of infection; and

Use of ex-vivo expansion of cord blood stem cell products (for example, omidubicel) is considered investigational and not medically necessary when the criteria above are not met and for all other indications.

The CPT and HCPCS codes associated with this new coverage guideline are 38999, C9399, J3490, and J3590. 

Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring (SURG.00129)   

This coverage guideline addresses surgical treatments for obstructive sleep apnea (OSA). 

It has been revised to include the definition of failed CPAP treatment. Failed CPAP treatment is demonstrated by an AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights.

The CPT and HCPCS codes associated with this revised coverage guideline are 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 41512, 41530, 42145, 42299, 64582, C1767, C1778, C1787, C9727, S2080, D7940, D7941, D7943, D7944, D7945, D7946, D7947, L8680, L8681, L8688. 

Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia (SURG.00144)

This coverage guideline addresses occipital nerve blocks (or blockade) and sphenopalatine ganglion nerve blocks as a therapy for treatment of headache syndromes.

The scope has been revised to include sphenopalatine ganglion nerve blocks. 

Sphenopalatine ganglion nerve block therapy is considered investigational and not medically necessary for all indications including, but not limited to, the treatment of migraines and non -migraine headaches. 

The CPT codes associated with this revised coverage guideline are 64405, 64450, and 64505.

Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection (TRANS.00041)

This new coverage guideline addresses histological analysis using microarray gene expression profiling (for example, Molecular Microscope^® Diagnostic System MMDx^®, Kashi Clinical Laboratories, Portland, or) as a complement to conventional biopsy processing when assessing for allograft injury or rejection in kidney transplant recipients. 

Histological analysis using microarray gene expression profiling is considered investigational and not medically necessary for detection of allograft injury or rejection in kidney transplant recipients and for all indications.

The CPT code associated with this new coverage guideline is 0088U. 

Myoelectric Upper Extremity Prosthetic Devices (CG-OR-PR-05)

This Clinical UM Guideline addresses the use of myoelectric prosthetic devices for individuals with an amputation or absence of a portion of an upper extremity at any level from the hand, including partial-hand, to the shoulder. 

It has been revised to include criteria for the repair and replacement of myoelectric upper extremity prosthetic devices. 

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered medically necessary when either A or B below are met:

A. Needed for normal wear or accidental damage; or

B. The changes in the individual’s condition warrant additional or different equipment, based on clinical documentation.

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered not medically necessary when the criteria above have not been met.

Enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices have also been added to the scope. 

Enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices (for example, Life Under Kinetic Evolution [LUKE] Arm) are considered not medically necessary for all indications.

The HCPCS codes associated with this revised clinical UM Guideline are L6026, L6925, L6935, L6945, L6955, L6965, L6975, L6611, L6677, L6715, L6880, L6881, L6882, L7007, L7008, L7009, L7045, L7180. L7181, L7190, L7191, L7510, L7520, and L7499.

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside of Liver (CG-SURG-61)

This Clinical UM Guideline focuses on the use of cryosurgical (also known as cryosurgery or cryoablation), radiofrequency, microwave, or laser ablation as a treatment of:

• Primary or secondary malignancies outside the liver; and
• Benign tumors outside the liver.

Microwave ablation has been added to the scope of this revised Clinical UM Guideline and is considered medically necessary when the medical necessity criteria are met. 

Focal cryosurgical ablation of prostate tumors is also addressed and is considered not medically necessary. 

The CPT and HCPCS codes associated with this revised Clinical UM Guideline are 19105, 19499, 20982, 20983, 32994, 32998, 48999, 50250, 50542, 50592, 50593, 53850, 55873, 60699, 61736, 61737, 0581T, 0673T, and C9751. 

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