Guideline UpdatesHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 12, 2024

Lab testing reminder

Background

In February 2022, updates to Clinical Utilization Management (UM) Guidelines were published with an August 1, 2022, effective date. These updates included changes to clinical coding edits for the lab test indicated below.

Update

The updated guidelines state that only medically necessary lab testing will be covered. Effective March 1, 2024, coverage for these labs will be denied unless medically necessary:

Clinical UM Guideline number/title

Clinical indications for medical necessity

MCD ENT — CG-Lab-29: Gamma Glutamyl Transferase Testing

GGT testing using blood is considered medically necessary for any of the following indications:

  1. To differentiate between sources of elevated alkaline phosphatase activity; or
  2. To evaluate liver function, injury, or disease in individuals with at least one of the following:
    1. Known or suspected hepatobiliary disease; or
    2. Alcohol use disorder; or
    3. Substance use disorder; or
    4. Therapy with medication that has potentially toxic effects on the liver; or
    5. Exposure to hepatotoxins; or
    6. Infections that may cause liver injury (for example, viral hepatitis, amoebiasis, tuberculosis, and similar infections); or
    7. Pancreatic disease; or
    8. Gastrointestinal disease; or
    9. Liver transplantation; or
    10. Primary or secondary malignant neoplasms; or
    11. Diseases or conditions known to have liver involvement (for example, diabetes mellitus, sarcoidosis, amyloidosis, disorders of iron and mineral metabolism, lupus, hypertension, heart failure).

Clinical UM Guideline number/title

Clinical indications for medical necessity

MCD ENT-CG — Lab-30: Outpatient Laboratory-based Blood Glucose Testing

Blood glucose testing is considered medically necessary for individuals who meet any of the following criteria (A through Q):

  1. Signs or symptoms of either of the following:
    1. Hypoglycemia; or
    2. Hyperglycemia; or
  2. Overweight or obesity* of any age; or
  3. From a population with a high prevalence of diabetes mellitus**; or
  4. Impaired fasting glucose has been found on other testing; or
  5. Pregnant and considered to be at high risk for type 2 diabetes mellitus; or
  6. Prior testing at least 3 months previously showed abnormal blood glucose results; or
  7. Insulin resistance syndrome; or
  8. Carbohydrate intolerance; or
  9. Hypoglycemia disorders, such as nesidioblastosis or insulinoma; or
  10. Catabolic or malnutrition states; or
  11. Tuberculosis; or
  12. Unexplained chronic or recurrent infection; or
  13. Alcohol use disorder; or
  14. Coronary artery disease; or
  15. Unexplained skin conditions (including pruritis, local skin infections, ulceration, and gangrene without an established cause); or
  16. Chronic glucocorticoid therapy; or
  17. To evaluate glycemic status for individuals with established diabetes mellitus, prediabetes, or a history of gestational diabetes when done no more often than the following test frequencies:
    1. Up to once yearly for individuals with prediabetes; or
    2. Up to two times per year for individuals with diabetes mellitus who are meeting treatment goals; or
    3. Within the first year postpartum and then up to once yearly for individuals who have had gestational diabetes.

Notes:
* ADA, ACOG, and USPSTF recommendations about individuals who have overweight or obesity

and
** Populations with high prevalence of diabetes mellitus

What if I have questions?

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HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: February 2024 Provider Newsletter