Coverage Guidelines effective January 1, 2019

Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and revised coverage guidelines effective January 1, 2019.  These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).  Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on July 26, 2018. 

 

SPECIAL NOTES:

 

The services addressed in these coverage guidelines in this section and in the attachment under “Article Attachments” on the right will require authorization for all of our products offered by HealthKeepers, Inc. with the exception of Anthem HealthKeepers Plus (Medicaid) and the Commonwealth Coordinated Care Plus (Anthem CCC Plus).  Other exceptions are Medicare Advantage and the Federal Employee Program.

A pre-determination can be requested for our PPO products.

 

Services related to specialty pharmacy drugs (non-cancer related) require a medical necessity review, which includes site of care criteria, as outlined in the applicable coverage or clinical UM guideline listed.

The following guidelines are addressed in this October 2018 edition (see also attachment under "Article Attachments" on the right):

 

• Cosmetic and Reconstructive Services: Skin Related (ANC.00007)

 

• Chelation Therapy (DRUG.00003)

 

• Ibalizumab-uiyk (TrogarzoTM) (DRUG.00096)

 

• Epidermal Growth Factor Receptor (EGFR) Testing (GENE.00006)

 

• Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) (GENE.00049)

 

• Neuromuscular Stimulation in the Treatment of Muscle Atrophy (CG-DME-03)

 

• Diagnostic Infertility Surgery (CG-SURG-34)