Guideline Updates Coverage and Clinical GuidelinesAnthem Blue Cross and Blue Shield | CommercialDecember 26, 2024

Coverage Guidelines and Clinical Guidelines update, April 1, 2025

Special note

The services mentioned in the Coverage Guidelines in this document will require authorization for all our products offered by Anthem Blue Cross and Blue Shield, with the exception of the Anthem HealthKeepers Plus program. Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). A predetermination can be requested for our PPO products.

Anthem Blue Cross and Blue Shield will implement the following new and revised Coverage Guidelines effective April 1, 2025. These guidelines impact all our products with the exception of the Anthem HealthKeepers Plus program, 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 November 14, 2024.

The guidelines addressed in this edition of Provider News are:

  • DME.00053 Home Video‑Assisted Robotic Rehabilitation Systems
  • DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • TRANS.00033 Heart Transplantation
  • MED.00152 Outpatient Intravenous Insulin Therapy
  • CG‑SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
  • SURG.00165 Histotripsy

Home Video‑Assisted Robotic Rehabilitation Systems (DME.00053)

This new coverage guideline addresses home use of video‑assisted robotic rehabilitation systems such as the Motus Hand or Motus Foot devices. Home video‑assisted robotic rehabilitation systems are considered investigational and not medically necessary for all indications. The HCPCS code associated with this revised coverage guideline is E0739.

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. Bimodal (acoustic and peripheral nerve electrical stimulation) neuromodulation therapy was added to the guideline and is 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, 0783T, A4540, A4543, A4544, A4596, E0721, E0732, E0743, E0761, E0762, E0769, E1399, S8130, S8131, and S8930.

Heart Transplantation (TRANS.00033)

This coverage guideline addresses heart transplantation. Revisions involve cardiopulmonary exercise testing results criteria to include any of the following:

  • Individuals on beta‑blocker maximal VO2 less than or equal to 12 ml/kg/min
  • Individuals off beta‑blocker maximal VO2 less than or equal to 14 ml/kg/min
  • Individuals with obesity (BMI greater than or equal to 30kg/m2) with a peak VO2 adjusted for lean body mass less than or equal to 19 ml/kg/min.

In heart transplant candidates with a history of malignancy, documentation of consultation with an oncology specialist that confers suitability of the individual for heart transplantation.

The CPT codes associated with this guideline are 00580, 33929, 33940, 33944, and 33945.

Outpatient Intravenous Insulin Therapy (MED.00152)

This new coverage guideline addresses outpatient intravenous insulin therapy, which is considered investigational and not medically necessary as a treatment for all indications, including diabetes. The HCPCS code associated with this new coverage guideline is G9147.

Bariatric Surgery and Other Treatments for Clinically Severe Obesity (CG‑SURG-83)

This clinical guideline was revised to address endoluminal reoperative bariatric procedures. Endoluminal reoperative bariatric procedures , including, but not limited to, transoral outlet reduction (TORe) or restorative obesity surgery endoluminal (ROSE) are considered not medically necessary for all indications . The CPT and HCPCS codes associated with this guideline are 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 37242, 43290, 43291, 43632, 43633, 43659, 43999, 44238, 64999, 0813T, C9784, C9785.

Histotripsy (SURG.00165)

This new coverage guideline was adapted from CG‑SURG-78 and addresses the use of histotripsy to ablate tissue. Histotripsy is considered investigational and not medically necessary for all indications. The CPT codes associated with this new coverage guideline are 0686T, 0888T, 55899.

These coverage guidelines are available for review 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: January 2025 Provider Newsletter