Coverage Guidelines update (effective October 1, 2023)

Special note:
The services addressed in the coverage guidelines presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus, Medallion. Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program^® or FEP^®). A pre-determination can be requested for our Anthem PPO products.

Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective October 1, 2023. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus members, Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the FEP^®). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 11, 2023.

The guidelines addressed in this edition of Provider News are:

• MED.00004 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions
• SURG.00121 Transcatheter Heart Valve Procedures
• SURG.00161 Nanoparticle-Mediated Thermal Ablation 

Noninvasive Imaging Technologies for the Evaluation of Skin Lesions (MED.00004)

This coverage guideline addresses the use of photographic, optical, video, and other imaging technologies for the evaluation of skin lesions.

It has been revised to consider the following technologies as investigational and not medically necessary for the evaluation of skin lesions: 

1. Confocal scanning laser microscopy
2. Electrical impedance spectroscopy 
3. Elastic scattering spectroscopy
4. Molecular fluorescent imaging
5. Multi-spectral image analysis
6. Multiphoton laser scanning microscopy 
7. Optical coherence tomography 
8. Photoacoustic microscopy
9. Quantitative infrared imaging
10. Raman spectroscopy
11. Ultrasonography 
12. Visual image analysis

The CPT^® codes associated with this revised coverage guideline are 96904, 96931, 96932, 96933, 96934, 96935, 96936, 96999, 0658T, 0700T, and 0701T. 

Transcatheter Heart Valve Procedures (SURG.00121)

This coverage guideline addresses the transcatheter (percutaneous or catheter-based) approach for aortic or pulmonary heart valve replacement, transcatheter edge-to-edge repair (also referred to as transcatheter mitral valve repair using leaflet repair or percutaneous annuloplasty), and transcatheter tricuspid valve repair or replacement. 

It has been revised to consider TAVR cerebral protection devices (Sentinel^™ Cerebral Protection System) investigational and not medically necessary for all indications. 

The CPT codes associated with this revised coverage guideline are 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33999, 33418, 33419, 33477, 0345T, 0483T, 0484T, 0544T, 0545T, 0569T, 0570T, and 0646T.

Nanoparticle-Mediated Thermal Ablation (SURG.00161)

This new coverage guideline addresses the use of nanoparticle-medicated thermal ablation to treat solid tumors. In this treatment, nanoparticles are instilled into tumor tissue and then exposed to an energy source. Nanoparticle vibration induced by the energy source increases temperature to ablate the targeted tissue. Nanoparticle-mediated thermal ablation is purported to achieve homogeneous heat distribution in tumor tissue while protecting surrounding healthy tissue. 

Nanoparticle-mediated thermal ablation is considered investigational and not medically necessary for all indications.

The CPT codes associated with this new coverage guideline are 0738T, 0739T, 55899, and 64999. 

These coverage guidelines are available for review on our website at anthem.com.