State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsOctober 1, 2018

Medical Policies and Clinical Utilization Management Guidelines update

Medical Policies update

On January 25, 2018, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem HealthKeepers Plus members. These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

Please note:

Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Publish date	*Medical Policy* number	*Medical Policy* title	New or revised
2/28/2018	DRUG.00116	Vestronidase alfa (Mepsevii™)	New
2/28/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
2/28/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
2/28/2018	DRUG.00077	Monoclonal Antibodies to Interleukin-17A	Revised
2/1/2018	DRUG.00080	Monoclonal Antibodies for the Treatment of Eosinophilic Conditions	Revised
2/28/2018	DRUG.00082	Daratumumab (DARZALEX™)	Revised
2/28/2018	DRUG.00099	Cerliponase Alfa (Brineura™)	Revised
2/28/2018	GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	Revised
2/1/2018	GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	Revised
2/28/2018	GENE.00035	Genetic Testing for TP53 Mutations	Revised
2/28/2018	MED.00100	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	Revised
2/1/2018	SURG.00011	Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
2/1/2018	SURG.00098	Mechanical Embolectomy for Treatment of Acute Stroke	Revised
2/28/2018	SURG.00145	Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)	Revised

Clinical Utilization Management Guidelines update

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines to Anthem HealthKeepers Plus members. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

Please note:

Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Publish date	*Clinical UM Guideline* number	*Clinical UM Guideline* title	New or revised
5/1/2018	CG-DME-42	Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices	New
5/1/2018	CG-DME-43	High-Frequency Chest Compression Devices for Airway Clearance	New
5/1/2018	CG-DRUG-82	Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension	New
5/1/2018	CG-DRUG-83	Growth Hormone	New
5/1/2018	CG-DRUG-84	Belimumab (Benlysta®)	New
5/1/2018	CG-DRUG-85	Tesamorelin (Egrifta®)	New
5/1/2018	CG-DRUG-86	Ocriplasmin (Jetrea®) Intravitreal Injection Treatment	New
5/1/2018	CG-DRUG-87	Vedolizumab (Entyvio®)	New
5/1/2018	CG-DRUG-88	Dupilumab (Dupixent®)	New
5/1/2018	CG-SURG-70	Gastric Electrical Stimulation	New
5/1/2018	CG-SURG-71	Reduction Mammaplasty	New
5/1/2018	CG-SURG-72	Endothelial Keratoplasty	New
7/1/2018	CG-THER-RAD-03	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy	New
7/1/2018	CG-THER-RAD-04	Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors	New
5/1/2018	CG-DRUG-29	Hyaluronan Injections	Revised
2/28/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
2/28/2018	CG-DRUG-59	Testosterone Injectable	Revised
2/28/2018	CG-DRUG-73	Denosumab (Prolia®, Xgeva®)	Revised
2/28/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised
2/28/2018	CG-MED-39	Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry	Revised
2/28/2018	CG-MED-53	Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing	Revised
2/28/2018	CG-SURG-33	Lumbar Fusion and Lumbar Total Disc Arthroplasty	Revised

Coverage Guidelines and Clinical Utilization Management Guidelines update

The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed or revised to support clinical coding edits. Note, several guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

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

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

Coverage Guidelines

On March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

Publish date	*Coverage Guidelines* number	*Coverage Guidelines* title	New or revised
3/29/2018	MED.00120	Voretigene neparvovec-rzyl (Luxturna™)	New
4/25/2018	SURG.00151	Balloon Dilation of Eustachian Tube	New
4/25/2018	DME.00009	Vacuum-Assisted Wound Therapy in the Outpatient Setting	Revised
3/29/2018	GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	Revised
4/25/2018	RAD.00029	CT Colonography (Virtual Colonoscopy) for Colorectal Cancer	Revised
4/25/2018	SURG.00033	Cardioverter Defibrillators	Revised
4/25/2018	SURG.00098	Mechanical Embolectomy for Treatment of Acute Stroke	Revised
4/25/2018	SURG.00121	Transcatheter Heart Valve Procedures	Revised

Clinical UM Guidelines

On March 22, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

Publish date	*Clinical UM Guideline* number	*Clinical UM Guideline* title	New or revised
6/28/2018	CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome	New
6/22/2018	CG-DRUG-89	Implantable and Extended-Release Buprenorphine-Containing Products	New
6/28/2018	CG-DRUG-90	Intravitreal Treatment for Retinal Vascular Conditions	New
6/28/2018	CG-DRUG-91	Intravitreal Corticosteroid Implants	New
6/28/2018	CG-DRUG-92	Alpha-1 Proteinase Inhibitor Therapy	New
6/28/2018	CG-DRUG-93	Sarilumab (Kevzara®)	New
6/28/2018	CG-LAB-13	Skin Nerve Fiber Density Testing	New
6/28/2018	CG-MED-69	Inhaled Nitric Oxide	New
6/28/2018	CG-MED-70	Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule	New
6/28/2018	CG-SURG-73	Balloon Sinus Ostial Dilation	New
6/28/2018	CG-SURG-74	Total Ankle Replacement	New
6/28/2018	CG-SURG-75	Transanal Endoscopic Microsurgical Excision of Rectal Lesions	New
6/28/2018	CG-THER-RAD-07	Intravascular Brachytherapy (Coronary and Noncoronary)	New
4/25/2018	CG-SURG-31	Treatment of Keloids and Scar Revision	Revised
4/25/2018	CG-SURG-49	Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities	Revised

Coverage Guidelines

Note:

Effective November 1, 2018, MCG Health Care Guidelines® will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).

Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

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

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

Publish date	*Coverage Guidelines* number	*Coverage Guidelines* title	New or revised
6/6/2018	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)	New
6/6/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
5/10/2018	DRUG.00047	Brentuximab Vedotin (Adcetris®)	Revised
5/10/2018	DRUG.00053	Carfilzomib (Kyprolis®)	Revised
6/6/2018	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
6/6/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
5/10/2018	DRUG.00076	Blinatumomab (Blincyto®)	Revised
6/6/2018	DRUG.00111	Monoclonal Antibodies to Interleukin-23	Revised
5/10/2018	SURG.00026	Deep Brain, Cortical and Cerebellar Stimulation	Revised

Clinical Utilization Management (UM) Guidelines

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

Publish date	*Clinical UM Guideline* number	*Clinical UM Guideline* title	New or revised
6/6/2018	CG-LAB-12	Testing for Oral and Esophageal Cancer	New
6/6/2018	CG-MED-71	Wound Care in the Home Setting	New
6/28/2018	CG-DME-44	Electric Tumor Treatment Field (TTF)	New
6/28/2018	CG-DRUG-67	Cetuximab (Erbitux®)	New
6/28/2018	CG-DRUG-94	Rituximab (Rituxan®) for Nononcologic Indications	New
6/28/2018	CG-DRUG-95	Belatacept (Nulojix®)	New
6/28/2018	CG-DRUG-96	Ado-trastuzumab emtansine (Kadcyla®)	New
6/28/2018	CG-DRUG-97	Rilonacept (Arcalyst®)	New
6/28/2018	CG-DRUG-98	Bendamustine Hydrochloride	New
6/28/2018	CG-DRUG-99	Elotuzumab (Empliciti™)	New
6/28/2018	CG-DRUG-100	Interferon gamma-1b (Actimmune®)	New
6/28/2018	CG-DRUG-101	Ixabepilone (Ixempra®)	New
6/28/2018	CG-DRUG-102	Olaratumab (Lartruvo™)	New
6/28/2018	CG-MED-72	Hyperthermia for Cancer Therapy	New
6/28/2018	CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty	New
6/28/2018	CG-SURG-77	Refractive Surgery	New
6/28/2018	CG-SURG-78	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies	New
6/28/2018	CG-SURG-79	Implantable Infusion Pumps	New
6/28/2018	CG-SURG-80	Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors	New
5/10/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
6/6/2018	CG-DRUG-60	Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications	Revised
6/6/2018	CG-DRUG-62	Fulvestrant (FASLODEX®)	Revised
6/6/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised

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Medical Policies and Clinical Utilization Management Guidelines update

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