Anthem Blue Cross and Blue Shield | Medicare AdvantageSeptember 30, 2019
Medical Policies and Clinical Utilization Management Guidelines update
Category: Medicare
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit the provider website at www.anthem.com/medicareprovider.
Notes/updates
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:
- * DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
- * LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
- * LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
- * OR-PR.00003:
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Clarified medically necessary position statement criteria 2 through 4 |
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Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications |
- * SURG.00011:
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Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera |
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Added new products to investigational and not medically necessary statement |
- * SURG.00045:
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Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement |
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Revised title |
- * SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications
- The following AIM Specialty Health® updates were approved on June 6, 2019:
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Advanced imaging:
Imaging of the heart Oncologic imaging Vascular imaging |
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Proton beam therapy |
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Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new) |
Medical Policies
On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).
|
Publish date |
Medical Policy # |
Medical Policy title |
New or revised |
|
June 13, 2019 |
MED.00129 |
Gene Therapy for Spinal Muscular Atrophy |
New |
|
June 13, 2019 |
GENE.00029 |
Genetic Testing for Breast and/or Ovarian Cancer Syndrome |
Revised |
|
June 13, 2019 |
* SURG.00011 |
Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting |
Revised |
|
June 13, 2019 |
SURG.00023 |
Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures |
Revised |
|
June 13, 2019 |
SURG.00028 |
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions |
Revised |
|
June 27, 2019 |
GENE.00025 |
Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors |
Revised |
|
June 27, 2019 |
DRUG.00046 |
Ipilimumab (Yervoy®) |
Revised |
|
June 27, 2019 |
DRUG.00053 |
Carfilzomib (Kyprolis®) |
Revised |
|
June 27, 2019 |
DRUG.00062 |
Obinutuzumab (Gazyva®) |
Revised |
|
June 27, 2019 |
DRUG.00067 |
Ramucirumab (Cyramza®) |
Revised |
|
June 27, 2019 |
DRUG.00071 |
Pembrolizumab (Keytruda®) |
Revised |
|
June 27, 2019 |
DRUG.00075 |
Nivolumab (Opdivo®) |
Revised |
|
June 27, 2019 |
DRUG.00107 |
Avelumab (Bavencio®) |
Revised |
|
June 27, 2019 |
GENE.00044 |
Analysis of PIK3CA Status in Tumor Cells |
Revised |
|
June 27, 2019 |
* SURG.00121 |
Transcatheter Heart Valve Procedures |
Revised |
|
June 27, 2019 |
GENE.00001 |
Genetic Testing for Cancer Susceptibility |
Revised |
|
June 27, 2019 |
GENE.00043 |
Genetic Testing of an Individual’s Genome for Inherited Diseases |
Revised |
|
June 27, 2019 |
LAB.00011 |
Analysis of Proteomic Patterns |
Revised |
|
June 27, 2019 |
LAB.00015 |
Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer |
Revised |
|
July 10, 2019 |
GENE.00051 |
Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer |
New |
|
July 10, 2019 |
SURG.00153 |
Cardiac Contractility Modulation Therapy |
New |
|
July 10, 2019 |
* DME.00037 |
Cooling Devices and Combined Cooling/Heating Devices |
Revised |
|
July 10, 2019 |
DME.00038 |
Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices |
Revised |
|
July 10, 2019 |
GENE.00011 |
Gene Expression Profiling for Managing Breast Cancer Treatment |
Revised |
|
July 10, 2019 |
* LAB.00027 |
Selected Blood, Serum and Cellular Allergy and Toxicity Tests |
Revised |
|
July 10, 2019 |
* LAB.00033 |
Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer |
Revised |
|
July 10, 2019 |
MED.00109 |
Corneal Collagen Cross-Linking |
Revised |
|
July 10, 2019 |
* OR-PR.00003 |
Microprocessor Controlled Lower Limb Prosthesis |
Revised |
|
July 10, 2019 |
SURG.00005 |
Partial Left Ventriculectomy |
Revised |
|
July 10, 2019 |
* SURG.00045 |
Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions |
Revised |
|
July 10, 2019 |
SURG.00120 |
Internal Rib Fixation Systems |
Revised |
|
September 4, 2019 |
GENE.00010 |
Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status |
Revised |
Clinical UM Guidelines
On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.
|
Publish date |
Clinical UM Guideline # |
Clinical UM Guideline title |
New or revised |
|
June 27, 2019 |
CG-SURG-97 |
Cardioverter Defibrillators |
New |
|
June 27, 2019 |
CG-DRUG-98 |
Bendamustine Hydrochloride |
Revised |
|
June 27, 2019 |
CG-LAB-09 |
Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain |
Revised |
|
June 27, 2019 |
CG-LAB-14 |
Respiratory Viral Panel Testing in the Outpatient Setting |
Revised |
|
July 10, 2019 |
CG-SURG-100 |
Laser Trabeculoplasty and Laser Peripheral Iridotomy |
New |
|
July 10, 2019 |
CG-ADMIN-01 |
Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists |
Revised |
|
July 10, 2019 |
CG-ANC-06 |
Ambulance Services: Ground; Non-Emergent |
Revised |
|
July 10, 2019 |
CG-DME-03 |
Neuromuscular Stimulation in the Treatment of Muscle Atrophy |
Revised |
|
July 10, 2019 |
CG-DME-07 |
Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) |
Revised |
|
July 10, 2019 |
CG-DME-08 |
Infant Home Apnea Monitors |
Revised |
|
July 10, 2019 |
CG-DME-39 |
Dynamic Low-Load Prolonged-Duration Stretch Devices |
Revised |
|
July 10, 2019 |
CG-DME-42 |
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices |
Revised |
|
July 10, 2019 |
CG-DME-45 |
Ultrasound Bone Growth Stimulation |
Revised |
|
July 10, 2019 |
CG-MED-41 |
Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting |
Revised |
|
July 10, 2019 |
CG-MED-49 |
Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders |
Revised |
|
July 10, 2019 |
CG-MED-57 |
Cardiac Stress Testing with Electrocardiogram |
Revised |
|
July 10, 2019 |
CG-MED-59 |
Upper Gastrointestinal Endoscopy in Adults |
Revised |
|
July 10, 2019 |
CG-SURG-11 |
Surgical Treatment for Dupuytren's Contracture |
Revised |
|
July 10, 2019 |
CG-SURG-17 |
Trigger Point Injections |
Revised |
|
July 10, 2019 |
CG-SURG-35 |
Intracytoplasmic Sperm Injection (ICSI) |
Revised |
|
July 10, 2019 |
CG-SURG-49 |
Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities |
Revised |
|
July 10, 2019 |
CG-SURG-81 |
Cochlear Implants and Auditory Brainstem Implants |
Revised |
|
July 10, 2019 |
CG-SURG-85 |
Hip Resurfacing |
Revised |
|
July 10, 2019 |
CG-SURG-93 |
Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction |
Revised |
|
September 4, 2019 |
CG-GENE-11 |
Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status |
New |
|
September 4, 2019 |
CG-GENE-10 |
Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies |
New |
|
September 4, 2019 |
CG-SURG-101 |
Ablative Techniques as a Treatment for Barrett’s Esophagus |
New |
|
September 4, 2019 |
CG-SURG-102 |
Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy |
New |
503273MUPENMUB
PUBLICATIONS: October 2019 Anthem Provider News - Virginia
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