Guideline Updates Coverage and Clinical GuidelinesAnthem Blue Cross and Blue Shield | CommercialApril 1, 2024

Coverage and Clinical Guidelines update July 1, 2024

Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective July 1, 2024. These guidelines impact 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). A pre-determination can be requested for our Anthem PPO products. These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 15, 2024.

The guidelines addressed in this edition of Provider News are:

  • LAB.00039 Combined Pathogen Identification and Drug Resistance Testing
  • OR-PR.00008 Osseointegrated Limb Prosthesis
  • SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
  • SURG.00135 Renal Sympathetic Nerve Ablation
  • SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis

Combined Pathogen Identification and Drug Resistance Testing (LAB.00039)

This revised coverage guideline addresses combined pathogen identification and drug resistance testing, including pooled antibiotic sensitivity testing (P-AST). This type of test involves a combination of Multiplex Polymerase Chain Reaction (M-PCR) assay for the identification pathogens in a biological sample with genotyping for antibiotic resistance genes. This type of testing has been proposed for the treatment of recurrent, persistent, and complicated urinary tract infections (UTI) and other conditions that have been refractory to conventional pharmacotherapy.

Combined pathogen identification and drug resistance testing is considered investigational and not medically necessary in the outpatient setting for all indications.

The CPT® codes associated with this revised coverage guideline are 87999, 0141U, 0142U, 0321U, 0369U, 0370U, 0372U, 0373U, and 0374U.

Osseointegrated Limb Prosthesis (OR-PR.00008)

This new coverage guideline addresses the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss.

Osseointegrated limb prostheses are considered medically necessary for individuals with transfemoral, transtibial, transhumeral, or forearm amputations when all of the criteria set forth in (A) and (B) below have been met:

A. Selection criteria:

  • Individual is skeletally mature
  • Has normal skeletal anatomy
  • Is between 18 years old and 70 years old
  • Does not have diabetes
  • Does not have peripheral vascular disease
  • Does not have metabolic bone disease (for example, osteoporosis with T score ≤ -2.5)

B. Documentation and performance criteria:

  • Cannot tolerate or use a conventional socket-type prosthesis (for example, there is documentation of problems that prohibit functional prosthetic use, including but not limited to: frequent or recurrent skin infections, ulcerations, severe pain, frequent physiological changes in residual limb, pistoning not corrected with adjustments of prosthetic sockets, inadequate limb length or musculature, or excessive and uncontrolled perspiration)
  • Has a multidisciplinary treatment team comprised of, at minimum, a surgeon, a physiatrist, and a prosthetist who attest that the individual
  • Understands the use and risks of the osseointegrated prosthetic system
  • Is likely to be able to comply with the system’s requirements

Osseointegrated limb prostheses are considered 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 24999, 27599, L5991, L7499, and L8699.

Percutaneous Vertebral Disc and Vertebral Endplate Procedures (SURG.00052)

This revised coverage guideline addresses several minimally invasive surgical procedures designed to destroy nociceptive nerve fibers with or without structural changes to the intervertebral discs.

The medically necessary criteria for Intraosseous basivertebral nerve ablation (BVNA) have been expanded to include:

  • Magnetic resonance imaging (MRI)-demonstrated Modic Type 1 or 2 changes in at least one vertebral endplate, at one or more levels from L3 to S1, including one of the following:
    • Fibrovascular bone marrow changes are present (hypointense MRI signal for Modic Type 1)
    • Fatty bone marrow changes are present (hyperintense MRI signal for Modic Type 2)
  • There is no previous history of lumbar spine surgery
  • There is no previous history of BVNA at the planned level of treatment
  • No evidence on imaging (MRI, flexion/extension radiographs, CT) of other causes of low back pain (including, but not limited to: lumbar stenosis, degenerative scoliosis, spondylolisthesis, segmental instability, facet arthropathy, and disc disease)
  • No evidence of lumbar radiculopathy or radicular pain
  • No evidence of metabolic bone disease (for example, osteoporosis with T score ≤ -2.5)

BVNA is considered not medically necessary when the medically necessary criteria are not met.

The CPT codes associated with this revised coverage guideline are 22526, 22527, 22899, 64628, and 64629.

Renal Sympathetic Nerve Ablation (SURG.00135)

This revised coverage guideline addresses ablation (for example, radiofrequency ablation [RFA] or high-intensity focused ultrasound [HIFU]) of the renal sympathetic nerves).

The scope has been expanded to include HIFU.

High-intensity focused ultrasound of the renal sympathetic nerves is considered investigational and not medically necessary for all indications.

The CPT codes associated with this revised coverage guideline are 0338T and 0339T.

Implantable Shock Absorber for Treatment of Knee Osteoarthritis (SURG.00162)

This new coverage guideline addresses the use of an implantable shock absorber device (for example, MISHA Knee System [Moximed, Inc., Fremont, CA]) for the treatment of osteoarthritis of the knee.

Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered investigational and not medically necessary.

The CPT and HCPCS codes associated with this new coverage guideline are 27599, A4649, and C1734.

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

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: April 2024 Provider Newsletter