Coverage Guidelines effective November 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 November 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 June 6, 2019. 

 

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 HealthKeepers, Inc. products with the exception of Anthem HealthKeepers Plus (Medicaid), the Anthem CCC Plus plan, 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 below.

 

The guidelines address in this edition of Provider News are:

 

• Cooling Devices and Combined Cooling/Heating Devices (DME.00037)

 

• Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer (GENE.00051)

 

• Selected Blood, Serum and Cellular Allergy and Toxicity Tests (LAB.00027)

 

• Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer (LAB.00033)

 

• Gene Therapy for Spinal Muscular Atrophy (MED.00129)

 

• Microprocessor Controlled Lower Limb Prosthesis (OR-PR.00003)

 

• Extracorporeal Shock Wave Therapy (SURG.00045)

 

• Transcatheter Heart Valve Procedures (SURG.00121)

• Cardiac Contractility Modulation Therapy (SURG.00153)