State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsSeptember 1, 2020

Coverage Guidelines and Clinical Utilization Management Guidelines update

The Coverage Guidelines, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below, which are applicable to Anthem HealthKeepers Plus members, were developed and/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.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Notes/updates:

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

 

  • CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

Expanded scope of document and revised Medically Necessary statement



  • CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure

Revised Medically Necessary and Discussion/General Information sections



  • CG-GENE-02 — Analysis of RAS Status

 

Clarified scope of document and revised the Not Medically Necessary and Coding sections



  • CG-MED-64 — Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

 

Revised the Medically Necessary statement



  • CG-MED-68 — Therapeutic Apheresis

 

Revised Medically Necessary, Not Medically Necessary, Coding and Discussion/General Information sections



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

Revised Investigational and Not Medically Necessary, Rationale and Coding sections



  • MED.00004 — Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

Revised the Not Medically Necessary, Rationale and Coding sections

 


Coverage Guidelines 

 

On November 7, 2019, February 20, 2020, and May 14, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to Anthem HealthKeepers Plus members.

 

Publish date

Coverage Guidelines number

Coverage Guidelines title

New or revised

7/8/2020

*DME.00042

Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

New

7/8/2020

*MED.00131

Electronic Home Visual Field Monitoring

New

7/1/2020

*MED.00132

Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

New

7/8/2020

*MED.00133

Ingestion Event Monitors

New

7/8/2020

*THER-RAD.00012

Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

New

2/5/2020

*GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

New

4/15/2020

*DME.00041

Low Intensity Therapeutic Ultrasound for the Treatment of Pain

New

4/15/2020

*GENE.00053

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

New

4/15/2020

*GENE.00054

Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer

New

4/15/2020

*SURG.00154

Microsurgical Procedures for the Treatment of Lymphedema

New

2/27/2020

*SURG.00155

Cryoneurolysis for Treatment of Peripheral Nerve Pain

New

5/21/2020

DME.00009

Vacuum Assisted Wound Therapy in the Outpatient Setting

Revised

7/8/2020

*DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Revised

5/21/2020

DME.00034

Standing Frames

Revised

7/8/2020

*MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

Revised

5/21/2020

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

Revised

5/21/2020

SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

Revised

 


Clinical UM Guidelines

 

On November 7, 2019, February 20, 2020 and May 14, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were adopted by the medical operations committee for Anthem HealthKeepers Plus members on November 28, 2019, April 23, 2020 and May 25, 2020.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

4/15/2020

*CG-ANC-08

Mobile Device-Based Health Management Applications

New

7/1/2020

*CG-SURG-107

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

New

4/15/2020

*CG-SURG-108

Stereotactic Radiofrequency Pallidotomy

New

7/8/2020

*CG-DME-46

Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

Revised

7/8/2020

*CG-DME-47

Noninvasive Home Ventilator Therapy for Respiratory Failure

Revised

7/8/2020

*CG-GENE-02

Analysis of RAS Status

Revised

5/21/2020

CG-MED-44

Holter Monitors

Revised

7/8/2020

*CG-MED-64

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

Revised

7/8/2020

*CG-MED-68

Therapeutic Apheresis

Revised

5/21/2020

CG-MED-74

Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

Revised

5/21/2020

CG-MED-77

SPECT/CT Fusion Imaging

Revised

5/21/2020

CG-SURG-27

Gender Reassignment Surgery

Revised

5/21/2020

CG-SURG-98

Prostate Biopsy using MRI Fusion Techniques

Revised

 

AVA-NU-0276-20

PUBLICATIONS: September 2020 Anthem Provider News - Virginia