Beginning in June 2022, Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. will implement new processes for providers to validate the information we have in our online provider directories.

Individual providers

Anthem is partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.

Facilities and groups

Anthem is also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information and provide updates as needed.

If you have questions, please contact Provider Services.

2781-0622-PN-VA

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Please review your demographic information in our online Find Care tool to ensure members and fellow providers can reach you.

Submit your updates by using our online Provider Maintenance Form. Update options include:

• Add/change an address location
• Name change
• Taxpayer identification number (TIN) changes
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.

Thank you for doing your part to help keep our online provider directories up to date.

2681-0622-PN-VA

One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.

Measure up

Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Anthem Blue Cross and Blue Shield members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:

• Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
• Eye exam (retinal) performed
• Evaluation for kidney disease
• BP control (< 140/90 mm Hg)

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

2765-0622-PN-VA

Register today for the Exploring the Intersection of Race and Disability forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on June 22, 2022.

Anthem is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias are critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.    

Wednesday, June 22, 2022

4 p.m. to 5:30 p.m. ET

Please register for this event by June 22, 2022

REGISTER TODAY

* Motivo is an independent company providing a virtual forum on behalf of Anthem.

VABCBS-COMM-000597-22-CPN501

In our efforts to improve the health of humanity, Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. have made a long-term commitment to reducing morbidity and mortality associated with substance use disorder (SUD). In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, Anthem has been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).

Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise in deaths from overdose that the nation has experienced with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”).  Anthem’s internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.

What can we do to address this?

First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, which is an organization that Anthem has historically supported.

Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.

Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.  

As previously communicated in the May 2022 edition of Anthem Provider News, effective August 1, 2022, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will transition medical necessity review of physical, occupational, and speech therapy services to AIM Specialty Health_® (AIM) – a separate company.

The new Rehabilitation program reviews certain treatment plans against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine.  Anthem in Virginia will be utilizing the AIM Outpatient Rehabilitative and Habilitative Services clinical guidelines. Any qualified providers acting within the scope of their license who intend to provide therapy services are required to obtain a prior authorization from AIM. 

Note: Chiropractors performing therapy services are not required to obtain a prior authorization from AIM due to the current American Specialty Health (ASH) chiropractor utilization management program.

For therapy services that are scheduled to begin on or after August 1, 2022, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:

• Physical therapy
• Occupational therapy
• Speech therapy

For more information:

AIM provider website helps you learn more about the program and provides access to useful information and tools such as order entry checklists, clinical guidelines, and FAQs.  To learn more about AIM, please visit www.aimspecialtyhealth.com.

To help you prepare for this program, Anthem in Virginia and AIM are hosting a series of live webinar sessions and Q & A only webinar sessions that are designed for providers and office staff who will be requesting prior authorization. Please register to attend at least one training opportunity. Facilities are highly encouraged to attend an AIM training opportunity. AIM solution specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

How to submit a request for review

Starting July 18, 2022, providers can begin submitting requests for review or verify order numbers using one of the following methods:

Online

The AIM ProviderPortal_SM is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to https://aimspecialtyhealth.com/providerportal/. Registration opens July 18, 2022.

By Phone

Call AIM Specialty Health toll free at 866-789-0158, Monday through Friday between 8 a.m. and 5 p.m. ET.

Anthem and HealthKeepers, Inc. value your participation in our networks, as well as the services you provide. We look forward to working with you to help improve the health of our members.

2778-0622-PN-VA

Effective September 1, 2022, AIM Specialty Health_® (AIM), a separate company, will expand the AIM Musculoskeletal Program to perform medical necessity review of the requested site of service for certain spine, joint and interventional pain procedures for Anthem Blue Cross and Blue Shield’s (Anthem) fully insured members, as outlined below. 

AIM will continue to manage the AIM Musculoskeletal program and level of care review. The AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review.  Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care).  AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on the Anthem provider portal Coverage Guidelines & Clinical UM Guidelines page.  Please note, this does not apply to procedures performed on an emergent basis.

A subset of the AIM Musculoskeletal Program codes will be reviewed for site of care.  A complete list of CPT codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization for the AIM Musculoskeletal Program applies for an Anthem member on or after September 1, 2022, contact the Anthem Provider Services phone number on the back of the member’s ID card.    AIM will also have a file from Anthem of the membership for whom the program applies and will not provide prior authorization for members for whom the program does not apply.  NOTE:  If providers attempt to use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient musculoskeletal case, ICR will produce a message referring the provider to AIM. (ICR cannot accept prior authorization requests for services administered by AIM.)

Members included in the new program

All fully insured members currently participating in the AIM Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal Program to add to their members’ benefit packages as of September 1, 2022.  Members enrolled in the following are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, Medicare Advantage Group Retiree Solutions (MA GRS), and the Federal Employee Program® (FEP®). 

Pre-service review requirements

For services scheduled to begin on or after September 1, 2022, providers must contact AIM to obtain prior authorization.  Ordering and servicing providers may begin contacting AIM on August 15, 2022.

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 Web Portal at availity.com.

• Call the AIM Contact Center toll-free number at 866-789-0158, Monday–Friday, 8 a.m. to 5 p.m. ET.

Initiating a request on AIM’s ProviderPortal_SM and entering all the requested clinical questions will allow you to receive an immediate determination.  If the request is approved, you will receive the order ID, number of visits and valid time frame. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

AIM Musculoskeletal training webinars

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  Go to the AIM Musculoskeletal microsite to register for an upcoming webinar.  If you have previously registered for other services managed by AIM, there is no need to register again.

We value your participation in our network and look forward to working with you to help improve the health of our members.

Effective October 1, 2022, AIM Specialty Health_® (AIM), a separate company, will enhance the AIM Musculoskeletal program by adding a Monitored Anesthesia Care (MAC) for Interventional Pain component to perform medical necessity review of monitored anesthesia, or conscious sedation, when performing certain interventional pain procedures for Anthem Blue Cross and Blue Shield’s (Anthem) fully insured members, as further outlined below. 

Prior authorization will now be required for the clinical appropriateness of monitored anesthesia services when pain management clinician requests in conjunction with interventional pain codes.  It is the obligation of the requesting provider to have available the health plan’s determination for the Anesthesiologist on the day of the procedure. AIM will use the following Anthem Clinical UM Guideline: CG-Med-78: Anesthesia Services for Interventional Pain Management Procedures. The clinical criteria to be used for these reviews can be found on the Coverage Guidelines & Clinical UM Guidelines page on anthem.com.   Clinical site of care may also be applicable if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center (ASC). AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

If you have a member in a current course of treatment for pain management where we approved without reviewing the monitored anesthesia care, please identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.

At this time, the codes to be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940.  A complete list of CPT codes requiring prior authorization for the AIM Monitored Anesthesia Care for Interventional Pain program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after October 1, 2022, providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information.  AIM will recognize out of scope membership and will not require prior authorization for such members.      If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient Musculoskeletal procedure, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)

Members included in the new program

All fully insured members currently participating in the AIM Musculoskeletal program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal program to add to their members’ benefit package as of October 1, 2022.

Pre-service review requirements

For interventional pain procedures that are scheduled to begin on or after October 1, 2022, all providers must contact AIM to obtain prior authorization. The following groups are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®). 

For services provided on or after October 1, 2022, ordering and servicing providers may begin contacting AIM on September 17 for review.  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 Web Portal at availity.com.

• Call the AIM Contact Center toll-free number at 866-789-0158, Monday–Friday, 8 a.m. to 5 p.m. ET.

Initiating a request on AIM’s ProviderPortal_SM and entering all the requested clinical questions will allow you to receive an immediate determination.  The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

AIM Musculoskeletal training webinars

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  Go to the AIM Musculoskeletal microsite to register for an upcoming webinar.  If you have previously registered for other services managed by AIM, there is no need to register again.

We value your participation in our networks and look forward to working with you to help improve the health of our members.

Please continue to read news and updates at anthem.com/provider/medicare-advantage for the latest Medicare Advantage information, including:

• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines

• New specialty pharmacy medical step therapy requirements

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

• Updates to AIM Specialty Health Musculoskeletal Clinical Appropriateness Guidelines

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 members of your practice and office staff.

To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines.

Notes/updates:

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

• *CG-LAB-20 — Thyroid Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
  • Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
  • Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
  • The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
    • Endometrial receptivity analysis
    • Sperm-capacitation test
    • Sperm deoxyribonucleic acid (DNA) fragmentation test
    • Sperm penetration assay
    • Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.

• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
  • Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
  • Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
  • The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
  • Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

Medical Policies

On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2022.

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect June 4, 2022.

On November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 would like 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 members of your practice and office staff.

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.

Applicable to the following states:

California, Colorado, Connecticut, Georgia, Kentucky, Maine, Missouri, Nevada, New Hampshire, New Mexico, Ohio, Virginia, Washington, and Wisconsin.

For services beginning on September 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS.* Through this program, myNEXUS clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.

Providers are encouraged to request authorization using NexLync. Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 833-311-2986.

Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com or email Provider_Network@myNEXUScare.com.

If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622.

Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.

* myNEXUS is an independent company providing post-acute benefits management services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0331-22

Effective for dates of service on and after September 11, 2022, 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 spine

• Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs

Imaging of the extremities

• Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture.
• Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks.
• Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty.
• Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty.

Vascular imaging

• Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios.
• Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines.
• Chronic stroke/TIA – New indication; modality approach by circulation presentation.
• Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
• Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis.
• Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
• Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
• Upper or lower extremity peripheral arterial disease (PAD):
  • Suspected PAD without physiologic testing (including exercise testing) not indicated
  • New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)

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

• Access AIM’s ProviderPortal_℠ directly at https://www.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 Portal* at https://www.availity.com
• Call the AIM Contact Center toll-free number Monday through Friday from 7 a.m. to 7 p.m. CT:
  • Virginia: 888-240-5058

For 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.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

This communication applies to the Medicare Advantage program from Anthem Blue Cross and Blue Shield (Anthem).

Evaluation and management services for COVID testing — professional

Effective with dates of service on or after September 1, 2022, Anthem will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT^® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.

Prior to payment, Anthem will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Anthem will reimburse using CPT code 99211.

Professional providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.

If you have questions on this program, contact your Provider Experience representative.

Please continue to check our website https://providers.anthem.com/virginia-provider/home for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are the topics we’re addressing in this edition:

• Transcranial magnetic stimulation provider communication

• Prior authorization update for select durable medical equipment (DME) items

• MES and DMAS enrollment requirement

• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines

• Prior authorization updates for medications billed under the medical benefit

• Precertification requirement notice

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

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 members of your practice and office staff.

To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/search.

Notes/updates:

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

• *CG-LAB-20 — Thyroid Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
  • Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
  • Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
  • The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
    • Endometrial receptivity analysis
    • Sperm-capacitation test
    • Sperm deoxyribonucleic acid (DNA) fragmentation test
    • Sperm penetration assay
    • Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.

• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
  • Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
  • Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
  • The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
  • Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

Effective June 4, 2022, HealthKeepers, Inc. will begin using the AIM Specialty Health^®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Musculoskeletal guidelines:
  • Spine surgery
  • Joint surgery
  • Small joint surgery
  • Sacroiliac joint fusion
• Rehabilitative services:
  • Occupational therapy
  • Physical therapy
  • Speech therapy

Medical Policies

On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to HealthKeepers, Inc. These guidelines take effect June 4, 2022.

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect June 4, 2022.

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

¹ AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc.

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

On November 19, 2021, January 4, 2022, and February 25, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the Anthem HealthKeepers Plus 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 would like 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 members of your practice and office staff.

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.

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

AVA-NU-0574-22

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

Effective for dates of service on and after September 11, 2022, 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 spine

• Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs

Imaging of the extremities

• Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
• Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
• Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
• Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty

Vascular imaging

• Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
• Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
• Chronic stroke/TIA – New indication; modality approach by circulation presentation
• Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
• Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
• Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
• Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
• Upper or lower extremity peripheral arterial disease (PAD):
  • Suspected PAD without physiologic testing (including exercise testing) not indicated
  • New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)

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

• Access AIM’s ProviderPortal_℠ directly at https://www.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 Portal* at https://www.availity.com
• Call the AIM Contact Center toll-free number: 800-714-0040 Monday through Friday from 8 a.m. to 8 p.m. PT

For 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.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc. Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0568-22

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

Evaluation and management services for COVID testing – professional
 

Effective with dates of service on or after September 1, 2022, HealthKeepers, Inc. will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT^® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.

Prior to payment, HealthKeepers, Inc. will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, HealthKeepers, Inc. will reimburse using CPT code 99211.

Professional providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

AVA-NU-0576-22