Based on feedback from our care provider partners, we understand the majority prefer not to receive paper letters. We want to make our interactions easy through digital channels and ensure you receive authorization case notifications timely. Since notifications about authorization decisions are available today through Availity Essentials, we will soon eliminate sending paper notifications.

You now have 24/7 access to authorization case information in one location through Availity Essentials. The digital authorization case status notifications are available under the Authorizations and Referrals* application once you have logged in to Availity Essentials and selected Patient Registration. By eliminating the redundancy of receiving both a digital and paper letter, you’ll see fewer errors associated with manual processes in handling the paper letters while reducing cost and our carbon footprint.

* Note: Your Availity Essentials administrator must assign you the role of Authorization & Referral Inquiry or request to access this application.

Care providers will be able to choose different options to receive authorization decision notifications via the Provider Preference Center under Availity Payer Spaces. Look for details on the Provider Preference Center options and ways to access authorization case status in an upcoming communication.

This change applies to Commercial products only. We will implement digital-only authorization case status notifications for Medicaid and Medicare products later this year.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Summary: On December 11, 2023, and January 5, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for HealthKeepers, Inc. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by HealthKeepers, Inc. only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

The following guideline was among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 15, 2024. Revisions have been made to the coding, which may result in services previously considered medically necessary to now be considered not medically necessary for DOS on or after July 1, 2024.

These guidelines impact all the products from Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., except for Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc., Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

The services addressed in the guideline presented in this document will require authorization for all our products offered by HealthKeepers, Inc., except for Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc., Medicare Advantage, and FEP. A predetermination can be requested for our Anthem PPO products.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective July 1, 2024. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus, Medallion offered by HealthKeepers, Inc.; 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. These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 15, 2024.

The guidelines addressed in this edition of Provider News are:

• LAB.00039 Combined Pathogen Identification and Drug Resistance Testing
• OR-PR.00008 Osseointegrated Limb Prosthesis
• SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00135 Renal Sympathetic Nerve Ablation
• SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis

Combined Pathogen Identification and Drug Resistance Testing (LAB.00039)

This revised coverage guideline addresses combined pathogen identification and drug resistance testing, including pooled antibiotic sensitivity testing (P-AST). This type of test involves a combination of Multiplex Polymerase Chain Reaction (M-PCR) assay for the identification pathogens in a biological sample with genotyping for antibiotic resistance genes. This type of testing has been proposed for the treatment of recurrent, persistent, and complicated urinary tract infections (UTI) and other conditions that have been refractory to conventional pharmacotherapy.

Combined pathogen identification and drug resistance testing is considered investigational and not medically necessary in the outpatient setting for all indications.

The CPT^® codes associated with this revised coverage guideline are 87999, 0141U, 0142U, 0321U, 0369U, 0370U, 0372U, 0373U, and 0374U.

Osseointegrated Limb Prosthesis (OR-PR.00008)

This new coverage guideline addresses the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss.

Osseointegrated limb prostheses are considered medically necessary for individuals with transfemoral, transtibial, transhumeral, or forearm amputations when all of the criteria set forth in (A) and (B) below have been met:

A. Selection criteria:

• Individual is skeletally mature
• Has normal skeletal anatomy
• Is between 18 years old and 70 years old
• Does not have diabetes
• Does not have peripheral vascular disease
• Does not have metabolic bone disease (for example, osteoporosis with T score ≤ -2.5)

B. Documentation and performance criteria:

• Cannot tolerate or use a conventional socket-type prosthesis (for example, there is documentation of problems that prohibit functional prosthetic use, including but not limited to: frequent or recurrent skin infections, ulcerations, severe pain, frequent physiological changes in residual limb, pistoning not corrected with adjustments of prosthetic sockets, inadequate limb length or musculature, or excessive and uncontrolled perspiration)
• Has a multidisciplinary treatment team comprised of, at minimum, a surgeon, a physiatrist, and a prosthetist who attest that the individual
• Understands the use and risks of the osseointegrated prosthetic system
• Is likely to be able to comply with the system’s requirements

Osseointegrated limb prostheses are considered not medically necessary when the criteria above are not met, and for all other indications.

The CPT and HCPCS codes associated with this new coverage guideline are 24999, 27599, L5991, L7499, and L8699.

Percutaneous Vertebral Disc and Vertebral Endplate Procedures (SURG.00052)

This revised coverage guideline addresses several minimally invasive surgical procedures designed to destroy nociceptive nerve fibers with or without structural changes to the intervertebral discs.

The medically necessary criteria for Intraosseous basivertebral nerve ablation (BVNA) have been expanded to include:

• Magnetic resonance imaging (MRI)-demonstrated Modic Type 1 or 2 changes in at least one vertebral endplate, at one or more levels from L3 to S1, including one of the following:
  • Fibrovascular bone marrow changes are present (hypointense MRI signal for Modic Type 1)
  • Fatty bone marrow changes are present (hyperintense MRI signal for Modic Type 2)
• There is no previous history of lumbar spine surgery
• There is no previous history of BVNA at the planned level of treatment
• No evidence on imaging (MRI, flexion/extension radiographs, CT) of other causes of low back pain (including, but not limited to: lumbar stenosis, degenerative scoliosis, spondylolisthesis, segmental instability, facet arthropathy, and disc disease)
• No evidence of lumbar radiculopathy or radicular pain
• No evidence of metabolic bone disease (for example, osteoporosis with T score ≤ -2.5)

BVNA is considered not medically necessary when the medically necessary criteria are not met.

The CPT codes associated with this revised coverage guideline are 22526, 22527, 22899, 64628, and 64629.

Renal Sympathetic Nerve Ablation (SURG.00135)

This revised coverage guideline addresses ablation (for example, radiofrequency ablation [RFA] or high-intensity focused ultrasound [HIFU]) of the renal sympathetic nerves).

The scope has been expanded to include HIFU.

High-intensity focused ultrasound of the renal sympathetic nerves is considered investigational and not medically necessary for all indications.

The CPT codes associated with this revised coverage guideline are 0338T and 0339T.

Implantable Shock Absorber for Treatment of Knee Osteoarthritis (SURG.00162)

This new coverage guideline addresses the use of an implantable shock absorber device (for example, MISHA^™ Knee System [Moximed, Inc., Fremont, CA]) for the treatment of osteoarthritis of the knee.

Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered investigational and not medically necessary.

The CPT and HCPCS codes associated with this new coverage guideline are 27599, A4649, and C1734.

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

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised 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.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider and select Change State and pick appropriate state. Then Providers > Policies, Guidelines & Manuals.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities;
• Previously titled: Cosmetic and Reconstructive Services of the Trunk and Groin:
  • Revised title to include “Extremities"
  • Revised Position Statement regarding lipectomy or liposuction for lymphedema and lipedema
• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices:
  • Reformatted bullet points to letters
  • Added lines to Investigational & Not Medically Necessary statement on electrical stimulation wound treatment device, electromagnetic wound treatment devices and pulsed electromagnetic field stimulation
• LAB.00011 - Selected Protein Biomarker Algorithmic Assays:
  • Reformatted bullet points to letters
  • Added IMMray® PanCan-d test to the Investigational & Not Medically Necessary statement
• LAB.00028 - Blood-based Biomarker Tests for Multiple Sclerosis, Previously titled: Serum Biomarker Tests for Multiple Sclerosis:
  • Revised title
  • Expanded scope of document from serum to blood-based biomarker testing for multiple sclerosis (MS)
  • Revised Position Statement to indicate blood-based biomarker tests for multiple sclerosis are considered Investigational & Not Medically Necessary for all uses
• MED.00140 - Lentiviral Gene Therapy for Beta Thalassemia and Sickle Cell Disease; Previously Titled: Gene Therapy for Beta Thalassemia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement on lovotibeglogene autotemcel
• MED.00144 - Gene Therapy for Duchenne Muscular Dystrophy:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the infusion of Delandistrogene moxeparvovec-rokl (ELEVIDYS)
• MED.00147 - Cellular Therapy Products for Allogeneic Stem Cell Transplantation:
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for the use of ex-vivo expansion of cord blood stem cell products
• SURG.00129 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures:
  • Removed the criteria examples for failed CPAP treatment
  • Added definition for failed CPAP treatment
• SURG.00144 - Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia; Previously titled: Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia:
  • Revised title
  • Added Investigational & Not Medically Necessary statement for sphenopalatine ganglion nerve blocks
• TRANS.00041 - Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection:
  • Histological analysis using microarray gene expression profiling is considered Investigational & Not Medically Necessary for detection of allograft injury or rejection in kidney transplant recipients
• CG-MED-39 - Bone Mineral Density Testing Measurement:
  • Added phrase “using Dual-X-Ray Absorptiometry” to bullets I and III of Medically Necessary criteria and to bullets I and IV of Not Medically Necessary criteria
  • Added Not Medically Necessary position statement for bone strength and fracture risk assessment using imaging scans other than DXA
• CG-MED-95 - Transanal Irrigation:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for transanal irrigation
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices:
  • Revised formatting of Medically Necessary section
  • Added Repair and Replacement criteria to Clinical Indications section
  • Added new Not Medically Necessary statement regarding enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices
  • Added new Medically Necessary and Not Medically Necessary criteria for device repair and replacement.
• CG-SURG-61 - Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver; Previously titled: Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver:
  • Revised title
  • Added microwave ablation to the Clinical Indications
  • Added cryoablation and microwave ablation to the Medically Necessary indications for NSCLC and malignant tumors that have metastasized to the lung
  • Added Not Medically Necessary statements regarding focal cryoablation of the prostate and microwave ablation for all other indications
  • Revised Medically Necessary indication for cryoablation of the prostate to whole gland cryoablation of the prostate
  • Reordered clinical indications to be based on clinical condition rather than ablative technique

Medical Policies

On August 10, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 5, 2024.

Clinical UM Guidelines

On August 10, 2023, 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 September 28, 2023. These guidelines take effect April 5, 2024.

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility

The ordering or rendering provider of service is responsible for completing the prior authorization process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for

non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out of network benefit is available with the exception of ER/urgent care and authorized services.

To request precertification with the Virginia Plan

Access Availity Essentials (Availity.com).

For maternity, medical, surgical precertification, call the number listed on the back of the member’s ID card.

For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

As communicated in the March 2024, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Oncology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on March 18, 2024, for dates of service April 1, 2024, and after.

Members included in the new program

All fully insured, self-funded (ASO), HealthLink, and national members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of April 1, 2024. A separate notice will be published for Medicare Advantage, Medicare, and MA GRS.

Members of the following products are excluded: Medicaid, Medicare supplement, and Federal Employee Program^® (FEP^®).

Pre-service review requirements

For procedures that are scheduled to begin on or after April 1, 2024, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the services including but not limited to the following non-emergency modalities. Please refer to the clinical guidelines on the microsite resource pages for complete code lists.

Please note: The procedure list has been updated since the original notification. All codes will only be reviewed for medical necessity for the requested service and not for site of care at this time. Vascular procedures will not require prior authorization for National and Commercial members currently participating in the Carelon Medical Benefits Management Cardiology program.

To determine if prior authorization is needed for a member on or after April 1, 2024, contact the Provider Services phone number on the back of the member’s ID card for benefit information.  Providers using the Interactive Care Reviewer (ICR) tool on Availity Essentials to pre-certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com/ to register.

For more information

Go to https://providers.carelonmedicalbenefitsmanagement.com/genetictesting, https://providers.carelonmedicalbenefitsmanagement.com/cardiology/, https://providers.carelonmedicalbenefitsmanagement.com/radiology/, https://providers.carelonmedicalbenefitsmanagement.com/musculoskeletal/, https://providers.carelonmedicalbenefitsmanagement.com/surgicalprocedures/; for resources to help your practice get started with the Radiology, Expanded Cardiology, Genetic Testing, Musculoskeletal, Surgical, and Radiation Oncology programs. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs, or you can call your local Network Relations representative.

With your help, we can continually build towards a future of shared success.

Effective for dates of service on and after July 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.:

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com:
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access the Availity website at Availity.com.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective July 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements.

Effective since December 1, 2023, Consumer Directed Service Facilitators are no longer required to submit prior authorizations for routine visit billing code 99509. There is a benefit limit of 1 unit/visit per month with a maximum of 10 units/visits per year.

Providers with questions about this billing guidance may reach out via email to VALTSSPR@Anthem.com or contact their regional provider relationship management representative.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

Effective for dates of service on and after July 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

The formulary changes listed in the table below apply to all FAMIS and Anthem HealthKeepers Plus members. These changes were reviewed and approved at the fourth-quarter 2023 meeting of our Pharmacy and Therapeutics Committee.

Effective May 1, 2024, formulary changes, non-formulary changes, and prior authorization requirements will apply. Remember to read the footnotes at the end of the table.

* This change will be implemented once the medication is on the market.

** This change will be implemented ASAP.

What action do I need to take?

Please review these changes and work with your Anthem HealthKeepers Plus patients to transition them to formulary alternatives. If you determine that formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date.

What if I need assistance?

We recognize the unique aspects of patients’ cases. If your patients cannot be converted to a formulary alternative, call our Pharmacy department at 800-901-0020 and follow the voice prompts for pharmacy prior authorization. You can find the searchable formulary on our provider website at providers.anthem.com/va under Eligibility & Pharmacy > Pharmacy Information.

If you have any questions about this communication, call our Provider Services team at 800-901-0020.

Effective May 1, 2024, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 800-901-0020.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.