The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit the Medical Policies & Clinical UM Guidelines website.

Medical Policies

The Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to HealthKeepers, Inc. These medical policies take effect May 1, 2025.

Clinical UM Guidelines

The MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. These guidelines were adopted by the medical operations committee for Anthem HealthKeepers Plus members. These guidelines take effect May 1, 2025.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit the Medical Policies & Clinical UM Guidelines website.

Medical Policies
The medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect May 25, 2025.

Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect May 25, 2025.

Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Chromosomal microarray analysis:

• Added neonatal death to the list of indications considered medically necessary.
• Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.

Whole Exome Sequencing (WES) and Whole Genome Sequencing:

• Clarified and restructured the criteria for improved readability.
• Added Medically Necessary criteria for Prenatal and PostNatal testing
• Added Not Medically Necessary statement for early neonatal death
• Added note that WES may include comparator testing.

Pharmacogenomic testing:

• Deleted typo (“one” before “genotyping”) in first sentence
• Added “considered medically necessary for genotyping” to title of Table 1
• Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
• Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
• Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
• Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics

Predictive and prognostic polygenic testing:

• Updated Description/Scope and Rationale and added References

Musculoskeletal

Interventional pain management:

• Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
• Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
• Exclusions:
• Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
• Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.
• Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
• Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:
• Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
• Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.
• Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:
• Specified nonsurgical low back pain as an exclusion.

As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management using the following:

• Access the Carelon Medical Benefits Management provider portal directly at 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.

For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com.

Special note: The services addressed in the coverage guidelines presented in this document will require authorization for all our products offered by Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. except for services offered to 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 will implement the following new and revised Coverage Guidelines effective August 1, 2025. These guidelines impact all our products except for Anthem HealthKeepers Plus, Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 20, 2025.

The guidelines addressed in this edition of Provider News are:

• CG‑SURG‑119: Treatment of Varicose Veins (Lower Extremities)
• CG‑SURG‑123: Autologous Fat Grafting and Injectable Soft Tissue Fillers
• SURG.00011: Products for Wound Healing and Soft Tissue Grafting: Investigational (previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting)
• SURG.00155: Cryosurgery of Peripheral Nerves (previously titled: Cryoneurolysis)

Treatment of Varicose Veins (Lower Extremities) (CG‑SURG‑119)

This clinical guideline addresses various modalities for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV), anterior accessory great saphenous vein (AAGSV)/anterior saphenous vein (ASV), or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins.

Revisions include addition of the VenoValve device which is considered not medically necessary for the treatment of chronic venous insufficiency in the lower extremities.

The CPT® and HCPCS codes associated with this revised clinical guideline are: 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37799, 36473, 36474, 36482, 36483, 0524T, 37241, 36468, 96999, and S2202.

Autologous Fat Grafting and Injectable Soft Tissue Fillers (CG‑SURG‑123)

This guideline addresses autologous fat grafting (autologous fat transfer) and injectable soft tissue fillers.

The revision to this guideline includes the addition of code D9914.

Other CPT and HCPCS codes associated with this guideline are: 11950‑11954, 17999, 31574, C1878, G0429, L8607, L8699, Q2026, and Q2028.

Products for Wound Healing and Soft Tissue Grafting: Investigational (previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting) (SURG.00011)

This guideline addresses the use of soft tissue (for example, skin, ligament, cartilage) substitutes in wound healing and surgical procedures. It now addresses products that are considered investigational and not medically necessary for all uses. The product list has been updated, and products with medical necessity criteria have been moved to CG‑SURG‑127.

The CPT codes associated with this guideline are: 31574, 46707, 0627T, 0628T, 0629T, 0630T, 15150, 15151, 15152, 15155, 15156, 15157, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777, 29999, 17999, 65778, 65779, 65780, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278, A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2017, A2018, A2019, A2020, A2021, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2029, C1763, C9352, C9353, C9354, C9355, C9356, C9361, C9364, C9399, C9796, G0428, Q4100, Q4103, Q4108, Q4111, Q4112, Q4113, Q4114, Q4117, Q4118, Q4123, Q4125, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4152, Q4153, Q4155, Q4156, Q4157, Q4159, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4183, Q4184, Q4185, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4284, Q4285, Q4286, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367.

Cryosurgery of Peripheral Nerves (Previously Titled: Cryoneurolysis) (SURG.00155)

This guideline addresses cryosurgical techniques for peripheral nerves that create a temporary nerve block through application of extreme cold to the selected site for treatment. These techniques are known as cryoneurolysis, cryoanalgesia, and cryoablation of peripheral nerves.

Revisions include coding additions and a change to the position statement that cryosurgical techniques (for example, cryoneurolysis and cryoablation) of peripheral nerves are considered investigational and not medically necessary for all indications.

The CPT and HCPCS codes associated with this coverage guideline are: 0440T, 0441T, 0442T, 64999, C9808, C9809.

These coverage guidelines are available for review on our website at https://anthem.com/provider.

Effective June 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization by HealthKeepers, Inc. for Medicaid 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/prior authorization rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by phone by calling Provider Services with additional information which may include medical records.

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

• J9248 — Injection, melphalan (Hepzato), 1 mg
• L5841 — Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control

To request precertification/prior authorization, you may use one of the following methods:

• Web: Once logged in to Availity Essentials at https://Availity.com.
• Fax: 800-964-3627
• Phone: 800-901-0020

Not all PA requirements are listed here. Detailed precertification/prior authorization requirements are available to providers on https://providers.anthem.com/virginia-provider/resources/prior-authorization-requirements or for contracted providers by accessing https://Availity.com. Providers may also call Provider Services at 800‑901‑0020 for assistance with PA requirements.

Effective for dates of service on or after June 1, 2025, the following medication codes will require preapproval.

Including a national drug code (NDC) on your medical claim is necessary for claims processing.

For more information, click on the Clinical Criteria links in the table below or visit Clinical Criteria and enter the code in the search window.

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

What if I need assistance?

If you have any questions, contact your local provider relationship management representative or Provider Services at 800‑901‑0020.

Effective June 1, 2025, the following Medicare Part B medication from the current Clinical Criteria Guidelines will be included in our medical step therapy preapproval review process. Step therapy review will apply upon preapproval initiation in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving the medication listed below.

Visit our Clinical Criteria page to search for specific criteria.

Effective for dates of service on and after August 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our preapproval review process.

Federal and state law, state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over preapproval rules and must be considered first when determining coverage. Claims that do not comply with these new requirements may not be approved.