We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year.

Stay tuned for more updates.

The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is:

• We’ll receive the documents needed faster than through the mail.
• Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
• Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
• More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.

However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays:

1. Valid claim number
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges

For a clinical appeal, ensure these elements are included:

1. Valid claim number
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix) and billed charges
   or

4. Member name, member date of birth, and correct dates of service
   or

5. Member name, member date of birth, authorization, or reference number

This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission.

The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission.

To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation.

For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal.

If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation.

For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow.

Effective for dates of service on and after April 1, 2023, the following code updates will apply to the AIM Specialty Health_®* Percutaneous Coronary Intervention Clinical Appropriateness Guidelines.

Percutaneous coronary intervention:

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

• Access AIM’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 AIM via the Availity Essentials at availity.com 

If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline

• Imaging of the Brain:
  • Meningioma — Added more frequent surveillance for WHO grade II/III
  • Bell’s palsy — Limited the use of CT to scenarios where MRI cannot be performed
  • Seizure disorder — Added indication for advanced imaging in pediatric patients with nondiagnostic electroencephalogram (EEG)
• Imaging of the Head and Neck:
  • Perioperative imaging — Added indication for imaging prior to facial feminization surgery
• Imaging of the Chest:
  • Perioperative imaging — Added indication for imaging prior to lung volume reduction procedures
  • Imaging abnormalities — Added indication for evaluation of suspected tracheal or bronchial pathology
• Imaging of the Abdomen/Pelvis:
  • Uterine leiomyomata — Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
  • Pancreatic indications — Added indication for pancreatic duct dilatation
  • Pancreatic mass — Added allowance for more frequent follow up of lesions with suspicious features or in high-risk patients
  • Pancreatitis — Removed allowance for MRI following nondiagnostic CT
  • Pelvic floor disorders — Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
  • Abdominal/pelvic pain, undifferentiated — Removed indication for MRI following nondiagnostic CT
• Oncologic Imaging:
  • National Comprehensive Cancer Network annual alignments for breast cancer screening and the following: Cervical, Head and Neck, Histiocytic Neoplasms, Lymphoma (Non-Hodgkin and Leukemia), Multiple Myeloma, Thoracic, and Thyroid cancers
  • Prostate Cancer:
    • Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds (and removal of low-risk disease waiver from conventional imaging footnote).
    • Addition of 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:

• Access AIM’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 AIM via Availity* Essentials at availity.com.

 For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines at http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.

Note: AIM will join the Carelon* family of companies and change its name to Carelon Medical Benefits Management, Inc. on March 1, 2023.

MULTI-BCBS-CRCM-012947-22-CPN11942

Special note:
The services addressed in the Clinical Guideline presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus. Other exceptions are 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.

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. will implement the following Clinical Guideline effective May 1, 2023. This guideline impacts all our products with the exception of Anthem HealthKeepers Plus; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

The guideline addressed in this edition of Provider News is:

• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (CG-SURG-106)

This Clinical UM Guideline addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including but not limited to venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

Venous angioplasty with or without stent placement or venous stenting alone is considered medically necessary for treatment of the following conditions:

1. Venous thoracic outlet syndrome; or
2. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome); or
3. Superior vena cava syndrome; or
4. Iliac vein compression syndrome (for example, May-Thurner Syndrome);or
5. Pulmonary vein stenosis; or
6. Congenital heart disease, including but not limited to:
   1. Stenosis or hypoplasia of a pulmonary artery in a child; or
   2. Symptomatic stenosis/occlusion of superior or inferior vena cava;or
   3. Venous narrowing due to repair of sinus venosus atrial septal defect (ASD); or
   4. Venous obstruction of an atrial baffle following Mustard or Senning repair of transposition of the great arteries.

 Venous angioplasty with or without stent placement or venous stenting alone is considered not medically necessary for the treatment of all other conditions not listed above, including but not limited to:

1. Multiple sclerosis; or
2. Chronically occluded iliac veins; or
3. Idiopathic intracranial hypertension (pseudotumor cerebri); or
4. Ilio-femoral venous thrombosis; or
5. Nutcracker syndrome.

This guideline is available for review on our website at anthem.com.

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 precertification process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification 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.

Requesting precertification with the Virginia plan 

To obtain precertification, providers can access Availity Essentials* at www.availity.com or call the Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

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 precertification process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification 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.

Requesting precertification with the Virginia plan 

To obtain precertification, providers can access Availity Essentials* at www.availity.com or call the Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

Special note:
The services addressed in all the Clinical Guidelines presented in this document will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus members. Other exceptions are 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.

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. will implement the following new and revised Clinical Guidelines effective May 1, 2023. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus members, Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

The guidelines addressed in this edition of Provider News are:

• CG-MED-92 Foot Care Services.
• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.

Foot Care Services (CG-MED-92)

This new Clinical UM Guideline addresses the following foot care services: cutting or removal of corns or calluses, trimming, cutting, clipping, or debriding of nails (including mycotic nails), and cleaning and soaking of the feet.

Foot care services including cutting or removal of corns or calluses, or trimming, cutting, clipping, or debriding of nails are considered medically necessary when the following criteria are met:

• The individual has a systemic condition resulting in circulatory insufficiency or desensitization of the lower extremity, including but not limited to one or moreof the conditions listed below:
  • Arteriosclerosis; or
  • Chronic thrombophlebitis; or
  • Diabetes mellitus; or
  • Peripheral vascular disease; or
  • Peripheral neuropathy; or
  • Raynaud’s disease; and
• The individual is at risk of impeded healing that could potentially jeopardize life of limb (for example, evidence of sensory loss or prior ulceration or amputation, Charcot foot, history of angioplasty or vascular surgery, retinopathy, renal disease, or current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication)); and
• Performance of foot care services by a nonprofessional person would put the individual at risk; and
• Foot care services are not provided more frequently than once every two months (unless documentation demonstrates clinical appropriateness).

Debridement of mycotic nails, no more than once every two months (unless documentation demonstrates clinical appropriateness), in the absence of a systemic condition above, is considered medically necessary when the following criteria are met:

• For ambulatory individuals, pain results in difficulty walking and/or abnormality of gait in conventional walking footwear; or
• In non-ambulatory individuals, there is pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Foot care services, including cutting or removal of corns or calluses, or trimming, cutting, clipping, or debriding of nails (including mycotic nails) are considered not medically necessary when the criteria above are not met and for all other indications.

Cleaning and soaking of the feet are considered not medically necessary for all indications.

The CPT^® and HCPCS codes associated with this new Clinical UM Guideline are 11055, 11056, 11057, 11719,11720, 11721, 11730, 11732, 11750, 11765, 97022, G0127, G0247, and S0390.

Venous Angioplasty with or without Stent Placement or Venous Stenting Alone (CG-SURG-106)

This Clinical UM Guideline addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including but not limited to venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

Venous angioplasty with or without stent placement or venous stenting alone is considered medically necessary for treatment of the following conditions:

• Venous thoracic outlet syndrome; or
• Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome); or
• Superior vena cava syndrome; or
• Iliac vein compression syndrome (for example, May-Thurner syndrome);or
• Pulmonary vein stenosis; or
• Congenital heart disease, including but not limited to:
  • Stenosis or hypoplasia of a pulmonary artery in a child; or
  • Symptomatic stenosis/occlusion of superior or inferior vena cava;or
  • Venous narrowing due to repair of sinus venosus atrial septal defect (ASD); or
  • Venous obstruction of an atrial baffle following Mustard or Senning repair of transposition of the great arteries.

Venous angioplasty with or without stent placement or venous stenting alone is considered not medically necessary for the treatment of all other conditions not listed above, including but not limited to:

• Multiple sclerosis; or
• Chronically occluded iliac veins; or
• Idiopathic intracranial hypertension (pseudotumor cerebri); or
• Ilio-femoral venous thrombosis; or
• Nutcracker syndrome.

The CPT codes associated with this Clinical UM Guideline are 37238, 37239, 37248, 37249, 61630, and 61635.

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

To view the 2023 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program^® (FEP), go to www.fepblue.org > select Tools & Resources > Brochure & Resources. Here, you will find the Service Benefit plan brochure, benefit plan summaries, and Quick Reference Guides on information for year 2023. If you have questions, please contact FEP Customer Service at:

CO – 800-852-5957

CT – 800-438-5356

GA – 800-282-2473

IN – 800-382-5520

KY – 800-456-3967

ME – 800-722-0203

MO – 800-392-8043

NV – 800-727-4060

NH – 800-852-3316

NY – 800-522-5566

OH – 800-451-7602

VA – 800-552-6989

WI – 800-242-9635

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_®* (AIM), a separate company. For Anthem along with our affiliate HealthKeepers, Inc. prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require pre-service clinical review by AIM, a separate company. This would apply to members with Preferred Provider Organization (PPO), Healthkeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code. The health plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.

Reminder: Clinical Criteria name change

In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.

Prior authorization updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

* Oncology use is managed by AIM.

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

 Step therapy updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. 

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.

* Oncology use is managed by AIM.

Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.

Quantity limit updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Effective for dates of service on and after May 1, 2023, the following Clinical Criteria were developed and might result in services that were previously covered but may now be found to be not medically necessary.

For Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require prior authorization by AIM Specialty Health_® (AIM),* a separate company. This applies to consumers with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH) plans.

 Access the Clinical Criteria document information: