HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsNovember 30, 2018
Coverage Guidelines and Clinical Utilization Management Guidelines update
The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Note:
- Effective November 1, 2018, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.
- When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.
Please share this notice with other members of your practice and office staff.
To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.
Coverage Guidelines
On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.
|
Publish date |
Medical Policy number |
Medical Policy title |
New or revised |
|
8/29/2018 |
DRUG.00096 |
Ibalizumab-uiyk (Trogarzo™) |
New |
|
8/29/2018 |
GENE.00049 |
Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) |
New |
|
8/29/2018 |
ADMIN.00007 |
Immunizations |
Revised |
|
8/29/2018 |
DRUG.00046 |
Ipilimumab (Yervoy®) |
Revised |
|
8/29/2018 |
DRUG.00050 |
Eculizumab (Soliris®) |
Revised |
|
8/2/2018 |
DRUG.00067 |
Ramucirumab (Cyramza®) |
Revised |
|
8/2/2018 |
DRUG.00071 |
Pembrolizumab (Keytruda®) |
Revised |
|
8/29/2018 |
DRUG.00075 |
Nivolumab (Opdivo®) |
Revised |
|
8/29/2018 |
DRUG.00088 |
Atezolizumab (Tecentriq®) |
Revised |
|
8/29/2018 |
DRUG.00098 |
Lutetium Lu 177 dotatate (Lutathera®) |
Revised |
|
8/29/2018 |
GENE.00006 |
Epidermal Growth Factor Receptor (EGFR) Testing |
Revised |
|
8/2/2018 |
GENE.00011 |
Gene Expression Profiling for Managing Breast Cancer Treatment |
Revised |
|
8/29/2018 |
GENE.00025 |
Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors |
Revised |
|
8/29/2018 |
GENE.00029 |
Genetic Testing for Breast and/or Ovarian Cancer Syndrome |
Revised |
|
8/2/2018 |
MED.00124 |
Tisagenlecleucel (Kymriah®) |
Revised |
|
8/2/2018 |
SURG.00023 |
Breast Procedures including Reconstructive Surgery, |
Revised |
|
8/2/2018 |
SURG.00032 |
Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention |
Revised |
Clinical UM Guidelines
On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.
|
Publish date |
Clinical UM Guideline number |
Clinical UM Guideline title |
New or Revised |
|
9/20/2018 |
CG-DME-45 |
Ultrasound Bone Growth Stimulation |
New |
|
9/20/2018 |
CG-DRUG-103 |
Botulinum Toxin |
New |
|
9/20/2018 |
CG-DRUG-104 |
Omalizumab (Xolair®) |
New |
|
9/20/2018 |
CG-DRUG-105 |
Abatacept (Orencia®) |
New |
|
9/20/2018 |
CG-DRUG-106 |
Brentuximab Vedotin (Adcetris®) |
New |
|
9/20/2018 |
CG-DRUG-107 |
Pharmacotherapy for Hereditary Angioedema |
New |
|
9/20/2018 |
CG-DRUG-108 |
Enteral Carbidopa and Levodopa Intestinal Gel Suspension |
New |
|
9/20/2018 |
CG-DRUG-109 |
Asfotase Alfa (Strensiq™) |
New |
|
9/20/2018 |
CG-DRUG-110 |
Naltrexone Implantable Pellets |
New |
|
9/20/2018 |
CG-DRUG-111 |
Sebelipase alfa (KANUMA™) |
New |
|
9/20/2018 |
CG-DRUG-112 |
Abaloparatide (Tymlos™) Injection |
New |
|
9/20/2018 |
CG-MED-73 |
Hyperbaric Oxygen Therapy (Systemic/Topical) |
New |
|
9/20/2018 |
CG-MED-74 |
Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry |
New |
|
9/20/2018 |
CG-MED-75 |
Medical and Other Non-Behavioral Health-Related Treatments for Autism Spectrum Disorders and Rett Syndrome |
New |
|
9/20/2018 |
CG-MED-76 |
Magnetic Source Imaging and Magnetoencephalography |
New |
|
9/20/2018 |
CG-MED-77 |
SPECT/CT Fusion Imaging |
New |
|
9/20/2018 |
CG-REHAB-11 |
Cognitive Rehabilitation |
New |
|
9/20/2018 |
CG-SURG-81 |
Cochlear Implants and Auditory Brainstem Implants |
New |
|
9/20/2018 |
CG-SURG-82 |
Bone-Anchored and Bone Conduction Hearing Aids |
New |
|
10/31/2018 |
CG-SURG-83 |
Bariatric Surgery and Other Treatments for Clinically Severe Obesity |
New |
|
9/20/2018 |
CG-SURG-84 |
Mandibular/Maxillary (Orthognathic) Surgery |
New |
|
10/31/2018 |
CG-SURG-85 |
Hip Resurfacing |
New |
|
10/31/2018 |
CG-SURG-86 |
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection |
New |
|
9/20/2018 |
CG-SURG-87 |
Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring |
New |
|
9/20/2018 |
CG-SURG-88 |
Mastectomy for Gynecomastia |
New |
|
9/20/2018 |
CG-SURG-89 |
Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia |
New |
|
8/29/2018 |
CG-ADMIN-02 |
Clinically Equivalent Cost Effective Services — Targeted Immune Modulators |
Revised |
|
8/29/2018 |
CG-DRUG-09 |
Immune Globulin (Ig) Therapy |
Revised |
|
8/29/2018 |
CG-DRUG-65 |
Tumor Necrosis Factor Antagonists |
Revised |
|
8/29/2018 |
CG-DRUG-68 |
Bevacizumab (Avastin®) for Non-Ophthalmologic Indications |
Revised |
|
8/29/2018 |
CG-DRUG-73 |
Denosumab (Prolia®, Xgeva®) |
Revised |
|
8/29/2018 |
CG-DRUG-81 |
Tocilizumab (Actemra®) |
Revised |
|
8/29/2018 |
CG-GENE-03 |
BRAF Mutation Analysis |
Revised |
|
8/29/2018 |
CG-MED-35 |
Retinal Telescreening Systems |
Revised |
|
8/29/2018 |
CG-MED-71 |
Wound Care in the Home Setting |
Revised |
|
8/2/2018 |
CG-SURG-24 |
Functional Endoscopic Sinus Surgery (FESS) |
Revised |
|
8/29/2018 |
CG-SURG-49 |
Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities |
Revised |
|
8/2/2018 |
CG-SURG-73 |
Balloon Sinus Ostial Dilation |
Revised |
PUBLICATIONS: December 2018 Anthem Provider Newsletter - Virginia
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