State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsSeptember 30, 2019

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed and/or revised by HealthKeepers, Inc. to support clinical coding edits. Note, several policies and 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 view a guideline, visit https://www11.anthem.com/search.html.

 

Notes/updates:

 

  • CG-DME-44 — Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.

 

  • CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.

 

  • CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.

 

  • CG-SURG-30 — Tonsillectomy for Children with or without Adenoidectomy was revised to:

 

Spell out number of episodes of throat infections in MN criteria (A1, A2, A3).

Clarify criterion addressing parapharyngeal abscess (B4) to say two or more.

Add “asthma” as potential condition improved by tonsillectomy in MN criteria (C1b).

 

  • The following AIM Specialty Health® updates took effect on September 28, 2019:  


Advanced Imaging:


Imaging of the Brain
Imaging of the Extremities
Imaging of the Spine

 


Medical Policies

 

On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem HealthKeepers Plus members.

 

Publish date

Medical Policy number

Medical Policy title

New or revised

4/24/2019

MED.00127

Chelation Therapy

New

4/24/2019

GENE.00050

Gene Expression Profiling for Coronary Artery Disease

New

4/24/2019

MED.00128

Insulin Potentiation Therapy

New

4/24/2019

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

New

3/28/2019

DRUG.00088

Atezolizumab (Tecentriq®)

Revised

3/28/2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

4/24/2019

GENE.00045

Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

Revised

4/24/2019

GENE.00010

Genotype Testing for Genetic Polymorphisms to Determine

Drug-Metabolizer Status

Revised

4/24/2019

SURG.00139

Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

Revised

4/24/2019

GENE.00012

Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

Revised

4/24/2019

SURG.00121

Transcatheter Heart Valve Procedures

Revised

 

 

Clinical UM Guidelines

 

On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were adopted by the medical operations committee for members on May 7, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

3/28/2019

CG-ANC-07

Inpatient Interfacility Transfers

Revised

3/28/2019

CG-DRUG-50

Paclitaxel, protein-bound (Abraxane®)

Revised

3/28/2019

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

Revised

3/28/2019

CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

Revised

4/24/2019

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

4/24/2019

CG-DRUG-68

Bevacizumab (Avastin®) for

Non-Ophthalmologic Indications

Revised

4/24/2019

CG-GENE-01

Janus Kinase 2, CALR, and MPL Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays

Revised

4/24/2019

CG-GENE-05

Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)

Revised

4/24/2019

CG-MED-82

Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

New

4/24/2019

CG-MED-83

Level of Care: Specialty Pharmaceuticals

New

4/24/2019

CG-SURG-30

Tonsillectomy for Children with or without Adenoidectomy

Revised

5/9/2019

CG-DRUG-113

Inotuzumab ozogamicin (Besponsa®)

New

5/9/2019

CG-GENE-06

Preimplantation Genetic Diagnosis Testing

New

5/9/2019

CG-GENE-07

BCR-ABL Mutation Analysis

New

5/9/2019

CG-GENE-08

Genetic Testing for PTEN Hamartoma Tumor Syndrome

New

5/9/2019

CG-GENE-09

Genetic Testing for CHARGE Syndrome

New

5/9/2019

CG-MED-81

High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

New

5/9/2019

CG-SURG-98

Prostate Multiparametric Magnetic Resonance Imaging

New

5/9/2019

CG-SURG-99

Panniculectomy and Abdominoplasty

New

6/24/2019

CG-SURG-97

Cardioverter Defibrillators

New

 

PUBLICATIONS: October 2019 Anthem Provider News - Virginia