Having reliable internet access is an important part of life. The internet helps us find information and connect with people, including finding and connecting with healthcare providers via virtual visits. However, not everyone can afford it. We share a health vision with our care provider partners that means real change for consumers. Making the internet more accessible is one way we can improve the whole health of our communities.

The Affordable Connectivity Program can help.

What is the Affordable Connectivity Program?

The Affordable Connectivity Program is a government program that helps families who may need assistance pay for internet access. Qualified households can receive:

• Up to a $30/month discount on internet service.
• Up to a $75/month discount on internet service if they live on certain Tribal lands.
• Up to a $100 one-time discount on a laptop, desktop, or tablet bought through a participating internet provider.

Who is eligible for the program?

A household is eligible for the Affordable Connectivity Program if:

• The household income is 200% or less than the Federal Poverty Guidelines.
• Someone in the household (including a child or dependent):

• Participates in certain government assistance programs such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, Social Security Income (SSI), the Free and Reduced-Price School Lunch Program or School Breakfast Program, or others.
• Participates in certain Tribal assistance programs, such as Head Start, Tribal Temporary Assistance for Needy Families (TANF), or others.
• Received a Federal Pell Grant during the current award year.
• Already receives a Lifeline benefit (another government program providing discounts on internet and phone service).

How do my patients apply?

Your eligible patients can apply for the Affordable Connectivity Program online or by mail. They can also ask their current internet provider if they participate in the program. Please direct your patients to learn more at AffordableConnectivity.gov.

As we communicated in July, August, and September, the Provider Data Management (PDM) application on Availity Essentials* is now the only intake application to verify and initiate care provider demographic change requests, including submitting roster uploads, for all professional and facility care providers.** Previous intake channels are now retired as of October 1, 2023. 

If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

Training is available:

• PDM application specific trainings:
  • Learn about and attend one of our training opportunities by visiting here.
  • View the Availity PDM quick start guide here.

Note: An Availity account is required to access these training options. If not registered yet, see below for registration details.

• Roster Automation Standard Template and Roster Automation Rules of Engagement specific training:
  • Listen to our recorded webinar here.

Choice and flexibility to select the option that works best for you

Request data updates via either of the following options:

• Standard PDM experience
• Submitting a spreadsheet via a roster upload

Benefits to our care providers using Availity PDM

The Availity PDM application will ensure the following:

• Consistently updated data
• Decreased turnaround time for updates 
• Compliance with federal and/or state mandates
• Improved data quality through standardization
• Increased provider directory accuracy

Want to submit a roster using Availity PDM?

Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation:***

1. Utilize the Roster Automation Standard Template:
   • For your convenience, there is a standard roster Excel document. Find it online here.
2. Follow the Roster Automation Rules of Engagement:
   • A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
   • More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). 
3. Upload your completed roster via the Availity PDM application.

Availity PDM compatibility check for roster submissions

Availity PDM has been enhanced to incorporate a roster compatibility check. Providers can see if the roster was successfully submitted:

• If there is an error to the roster, providers will see an error rejection message with detailed reason for the rejection.
• Errors will need to be corrected. Then, the roster should be re-uploaded. Status will show as successfully submitted once corrected and re-submitted. 
• After successful submission of the roster, all accepted elements of the roster will be processed and only errors/rejections will fall out.
• Any elements that fall out will require manual intervention.

How to access the Availity PDM application

Log onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. 

Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, please ensure you have registered all TINs associated with your Availity account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (282-4548).

** Exclusions:

• Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health. 
• Any specific state mandates or requirements for provider demographic updates.

*** If any roster data updates require credentialing, your submission will be routed appropriately for further action.

Note: The following requested adds, changes, or terminations will be routed to the Provider Contracting team for validation and impact to provider contracts and network adequacy:

• Change tax ID
• Change organization name
• Add a network to agreement
• Change provider specialty
• Terminate entire agreement

Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name.

Beginning in the second quarter of 2024 or later, an additional sorting option will be available for our Medicare Advantage members to search by provider performance called Personalized Match Phase 1. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Providers with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name:

• You may review a copy of the Personalized Match Phase 1 methodology that has been posted on Availity* – our secure Web-based provider tool – using the following navigation:   Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Phase 1 Methodology.pdf.
• If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
• If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.

Anthem has expanded the scope of Personalized Match Phase 1 to include selected specialty providers and will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

Background:

We continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Provider performance can vary widely in relation to efficiency, quality, and member experience. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables.

Beginning January 1, 2023, we added a new sorting option on the FindCare tool for members to leverage when they are searching for a primary care provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers are listed in order of their total score, though no individual scores appear within the tool or be visible to Medicare covered patients. The Personalized Match Phase 1 algorithm is based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options are still available on FindCare for our members.

Personalized Match Phase 1 highlights:

• We strive to make healthcare simpler, more affordable, and more accessible, and one of the ways to help achieve that goal is to ensure that consumers are connected with care providers who have strong track records delivering quality care.
• Beginning on November 10, 2023, we will upgrade the online FindCare tool for Medicare members with a new sorting option called Personalized Match Phase 1, to match consumers with providers who perform well in efficiency and quality metrics within a certain geographical distance.
• The new sorting option, known as Personalized Match Phase 1, will be the default for consumers who search for Medicare non-primary specialty care providers in FindCare.
• We currently offer Personalized Match to Commercial consumer members. Personalized Match seeks to match consumers with documented health conditions with provider ranked based on cost effectively managing quality care. For example, if a consumer who has been given a diagnosis of diabetes conducts a search, they will be matched with providers whose patients are more likely to cost effectively manage similar patients with diabetes (for example, consistently receive recommended A1c tests A consumer who is a 60-year-old male would receive different Personalized Match provider rank order than a consumer who is a 30-year-old female). The goal is to move to this full Personalized Match solution in Medicare in the future. Personalized Match Phase 1 only analyzes providers’ quality and efficiency performance regardless of member characteristics for generating the sort order.
• You may review a copy of the new sorting methodology which has been posted on Availity.*
• If you have general questions regarding this new sorting option, please submit an inquiry via the web on Availity.
• If you would like information about your scoring used for this sorting option or if you would like to request reconsideration of your score, you may do so by submitting an inquiry via the web on Availity.
• This change is part of a greater effort to help improve access to high quality, affordable healthcare, which is essential to our customers.

FAQ

Why are we reimagining the strategy for evaluating non-primary specialty care providers?

There is variability in provider performance (efficiency, quality, experience), and we want to ensure all members receive high-quality care that leads to improved patient outcomes. The strategy aligns with the future direction of our specialty provider care strategy. This phase of the Medicare FindCare improvement utilizes measures related to appropriate practice (for example, overuse and underuse measures). We utilize a vendor, Motive Medical, to generate an overall Appropriate Practice Score at the NPI level, based on all CMS Fee-for-Service members.

How will I know my inquiry went through successfully once I submit?

An email will be sent to the inquirer acknowledging receipt of inquiry within two business days.

What is the turnaround time from when I submit my question to receiving an answer?

The goal is to have all questions answered within two business days. If further clarification is needed, or if detailed research is required, that time frame will be extended.

How will I receive my response?

An email will be sent with the required information back to the email address provided during the initial inquiry request.

How do I submit an inquiry?

Inquiries can be made at Availity site. There are three dropdown options for inquiry types. These are: 1) General Program Inquires, 2) Request a Copy of Your Provider Performance Scorecard, and 3) Provider Performance Scorecard Inquiries. An open text field is available to describe the nature of the inquiry in more detail.

What type of inquiries can I submit?

Any questions relating to Personalized Match Phase 1 that is not answered in this FAQ or by the Methodology document.

Do providers have any recourse if they feel their Provider Performance Scorecard is inaccurate?

If a provider disagrees with their Provider Performance Scorecard results, the provider can submit an inquiry at Availity site detailing their reasoning. We will determine the best course of action as needed, but potential outcomes could be a provider consultation, reanalysis, and potentially a rescoring of provider performance to be reflected in Personalized Match Phase 1 and the Provider Performance Scorecard.

What provider specialties are included in Personalized Match Phase 1?

For 2023, selected non-primary specialty care providers are included. We plan to potentially incorporate other provider specialties in future provider performance evaluations.

What measures are included in quality scoring and why were they included?

The quality measures selected for Personalized Match Phase 1 include underuse and overuse measures, within the appropriate practice domain. Measures vary by specialty and are available on request.

How are measures weighted?

Motive Medical considers three factors in weighting the importance of each measure as it impacts the overall NPI Appropriate Practice Score (APS):

• Measure volume (for example, the number of instances a provider is eligible for measurement)
• Cost differential (for example, the difference in cost between the inappropriate service chosen versus the cost of the appropriate alternative), and
• Patient harm (for example, measures weigh more heavily if they have a stronger negative impact on the patient).

What measurement year and source are used in quality scoring?

Motive Medical’s Fall 2022 Refresh was used for quality scoring with varying claim periods by measure including dates from January 1, 2019, to December 31, 2021.

What are the inclusion criteria for quality scoring?

A non-primary specialist care provider must have at least three appropriateness measures with at least ten members in each measure (a few measures require 20 members) for the APS score to be calculated. If the provider does not meet this threshold, the APS score is not available.

The APS score can be described in the following steps:

• Within each specialty, calculate the mean Motive Medical APS score to be used as the national-specialty benchmark.
• For each non-primary care specialty provider, calculate an APS Observed to Expected (O/E) ratio, comparing the provider to the benchmark for the same specialty:
  • Provider’s APS / national-specialty benchmark.
• The quality score is the provider’s APS O/E percentile ranking at the national-specialty level.

What factors go into your efficiency target?

The factors going into our efficiency target are the episodes of the members are assigned to provider specialty who has the highest cost within the episode for Surgery and Evaluation costs. The observed cost of an episode is the sum of provider’s total allowed costs. The expected or peer benchmark cost of an episode is the average cost of treating the same condition or procedure with the same severity level for all specialists in the same line of business, specialty and geographic area multiplied by number of provider’s volume. For ETGs the measure is at the condition level (diabetes, asthma) and for PEGs it’s the procedure level (knee replacement, lumbar fusions):

• Observed cost: Total provider cost
• Expected cost: Specialty average cost for same case mix * physician volume
• Efficiency index = observed / expected 

How is your efficiency target set?

Efficiency scores from the condition ETG and PEG procedure (observed/expected ratio scores) are blended into one final efficiency score by weighing the percentage of all the dollars that are tied to procedures vs conditions. This ensures that the efficiency scores for proceduralists (surgeons) are based more heavily on the procedure episodes. This is the final blended efficiency score for the provider:

• A minimum of 20 episodes that have benchmarks are required to calculate a condition efficiency or procedure efficiency score for the provider.
• A 90% statistical confidence interval is computed around the provider’s final blended efficiency score to account for the level of statistical uncertainty around the point estimation. For example, a provider with a final blended efficiency score of 0.97 might have the following confidence interval: Upper confidence level (UCL) of 1.03, Lower Confidence level (LCL) of 0.91.  

Cost ratings are then assigned to providers and provider groups using confidence intervals, as shown below. The provider group cost ratings are used for TIN Designation while individual provider cost ratings are used for the Provider composite score.

 For high-cost cases, how do you normalize which can occur across different groups?

We exclude outlier episodes from the scoring, low cost and high-cost episodes are flagged by the software at Condition/Procedure, Severity, and Line of business level.

Provider specialties with quality measures:

We know one of the reasons you call us for claims status is because all the information you need isn’t always available.  We want to change that by making Availity Essentials’* claims status enhancements available for Anthem member inquiries. In November, enjoy the benefits of expanded search options, filters, and downloadable reports from the same Claims Status application you are using for other payers on Availity.com.

Claims Status application enhancements include:

• Improved search options (by patient account number and claim number).
• Customizable fields with sort options and exportable results.
• Details screen that includes interest and payment information.
• Remit Viewer (Electronic Remittance Advice — 835). 
• Simplified layout that includes less scrolling and screens.

Enhancements will be rolled out, maximizing the effectiveness of the application. These updates are also available for claims submitted through clearinghouses or care providers using API transmissions.

The new claim status enhancements are in addition to the benefits you already enjoy:

• Submit documentation directly to your claim
• File a claim dispute 
• Verify eligibility and benefits
• Send a secure message or chat with us directly from the application
• Chat with Payer available in all markets

Training and support

Learn how to optimize your experience using the Claims Status application on Availity.com by attending live or recorded webinar sessions. Visit the learning microsite here and register for training today.

We know one of the reasons you call us for claims status is because all the information you need isn’t always available. We want to change that by making Availity Essentials’* claims status enhancements available for Anthem member inquiries. In November, enjoy the benefits of expanded search options, filters, and downloadable reports from the same Claims Status application you are using for other payers on Availity.com.

Claims Status application enhancements include:

• Improved search options (by patient account number and claim number).
• Customizable fields with sort options and exportable results.
• Details screen that includes interest and payment information.
• Remit Viewer (Electronic Remittance Advice — 835). 
• Simplified layout that includes less scrolling and screens.

Enhancements will be rolled out, maximizing the effectiveness of the application. These updates are also available for claims submitted through clearinghouses or care providers using API transmissions.

The new claim status enhancements are in addition to the benefits you already enjoy:

• Submit documentation directly to your claim
• File a claim dispute 
• Verify eligibility and benefits
• Send a secure message or chat with us directly from the application
• Chat with Payer available in all markets

Training and support

Learn how to optimize your experience using the Claims Status application on Availity.com by attending live or recorded webinar sessions. Visit the learning microsite here and register for training today.

Enhancing claims status results is one of the ways Anthem is collaborating for success. For questions or additional information, reach out to your Provider Relations Account Management Representative or use Chat with Payer.

This forum has moved from the original date of September 27, 2023 to October 19, 2023

Register today for the youth mental health forum hosted by Anthem and Motivo* for Anthem providers on October 19, 2023.

Thursday, October 19, 2023
3:30 to 5 p.m. Eastern time

This important event will address the critical need to engage young people in leading their mental health. By deepening the discussion on youth mental health, we can do our part to foster a culture of understanding and support for youth and young adults. Authentic conversations lead to reducing implicit bias and 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 and young leaders as we explore the challenges experienced by today’s youth, amplify the experiences and ideas of young people, and equip attendees with practical tools and innovative approaches to create meaningful change.

Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, increase inclusion, advance equity in healthcare.

Please register for this event by visiting this link. 

As a contracted provider for Special Needs Plan (SNP) from Anthem Blue Cross and Blue Shield (Anthem), you are required to participate in an annual training on Model of Care for Anthem. This training includes a detailed overview of SNPs and program information — highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination.

Training for SNP product for Anthem is self-paced and available at availity.com.*

The training must be completed by December 31, 2023.

How to access the Custom Learning Center on the Availity website:

1. Log in to Availity website at availity.com.
   • At the top of Availity website, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents: https://apps.availity.com/availity/Demos/Registration/index.htm for complete registration instructions.

Overview

We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. 

Engagement Hub objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
• Offer care providers a convenient way to earn CME credits at a time that works best for them. 
• Each session in this series is approved for one American Academy of Family Physicians credit:
  • Browse the listing of free CME webinars.
  • Open the CME webinars in Google Chrome

Effective December 30, 2023, Anthem Blue Cross and Blue Shield (Anthem) will transition the Clinical Criteria for site of care reviews to the following Carelon Medical Benefits Management* (Caralon) site of care guidelines to perform medical necessity and clinical appropriateness reviews for the requested site of care for certain procedures.

Note: These reviews do not apply to procedures performed on an emergent basis.

Carelon Medical Benefits Management also manages the musculoskeletal level of care review using The Carelon Musculoskeletal Appropriate Use Criteria: Level of Care for Musculoskeletal Surgery and Procedures guideline.  

Members included in the program

The new review criteria apply to all Anthem members currently participating in the above mentioned Carelon Medical Benefits Management programs. To determine if prior authorization by Carelon Medical Benefits Management is required for a member, contact the Provider Services phone number on the back of the member’s ID card. 

The following members are excluded: Medicare Advantage (individual and group),

Medicare, Medicare supplement, and the Federal Employee Program^® (FEP).

Prior authorization requirements

Prior authorization requirements remain the same. For services scheduled to begin on or after December 29, 2023, care providers must contact Carelon Medical Benefits Management to obtain prior authorization. Requested services received on or after December 29, 2023, will be reviewed with the new Clinical Criteria.

Care providers may submit prior authorization requests to Carelon Medical Benefits Management at providerportal.com. Initiating a request and entering all the requested clinical information will provide an immediate determination 24/7.

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

Special note:

All services addressed in the Coverage Guidelines below require prior authorization except for the following plans:

• Anthem HealthKeepers Plus
• Medicare Advantage
• Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program^® or FEP^®).

Prior authorization requests can be submitted for Anthem PPO products.

Anthem Blue Cross and Blue Shield (Anthem) in Virginia and our affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective January 1, 2024. 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). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on August 10, 2023.

The guidelines addressed in this edition of Provider News are:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices 
• LAB.00011 Selected Protein Biomarker Algorithmic Assays
• MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation (Omidubicel)
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring   
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
• TRANS.00041 Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection 
• CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices 
• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside of Liver 

Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities (ANC.00009)

This coverage guideline addresses a variety of surgical procedures that may be considered medically necessary, cosmetic, or reconstructive in nature. 

The position regarding lipectomy or liposuction for lymphedema and lipedema has been revised. 

Lipectomy or liposuction is considered medically necessary in individuals with documented lymphedema (primary or secondary, for example, related to surgical mastectomy) when all of the following criteria are met (A through E):

A. Signs and symptoms have not responded to at least three consecutive months of optimal medical management, including one or more of the following:

1. Compression garments; or
2. Manual lymph drainage; or
3. Complex/complete decongestive therapy (CDT); 

and

B. There is documented significant functional impairment (for example, difficulty ambulating or performing activities of daily living) or medical complication, such as recurrent cellulitis as a result of lymphedema for each anatomical region being considered for treatment; and

C. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and

D. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and 

E. Photographic documentation is consistent with the diagnosis of lymphedema in the affected extremities, including limb asymmetry.

Lipectomy or liposuction is considered medically necessary in individuals with lipedema when all of the following criteria are met (A through F):

A. A diagnosis of lipedema has been documented, including all of the following:

1. Bilateral, symmetrical, disproportionate fatty tissue hypertrophy on the limbs sparing the hands and feet; and
2. Negative Stemmer sign; and
3. Marked tendency to bruise or form hematomas; and
4. Stable limb circumference with weight reduction or caloric restriction (if applicable); and
5. Pain on pressure and touch; 

and

B. Signs and symptoms have not responded to at least three consecutive months of optimal medical management, including both of the following:

1. Compression garments; and
2. Manual lymphatic drainage; 

and

C. There is documented significant functional impairment (for example, difficulty ambulating or performing activities of daily living) as a result of lipedema for each anatomical region being considered for treatment; and

D. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and

E. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and

F. Photographic documentation is consistent with the diagnosis of lipedema in the affected extremities, including limb symmetry.

Correction of lymphedema (for example, related to surgical mastectomy) or lipedema using lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal.

Lipectomy or liposuction is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met or when the medically necessary criteria in this section are not met, including for treatment of obesity in the absence of a documented diagnosis of lymphedema or lipedema.

The CPT^® and HCPCS codes associated with this revised coverage guideline are 15832, 15833, 15834, 15835, 15836, 15837, 15839, 15877, 15878, 15879, 21740, 21742, 21743, 54360, 54440, 55899, 56800, 56805, 56810, 57291, 57292, 57335, and 58999. 

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices (DME.00011)

This coverage guideline addresses certain types of electrical stimulation devices. 

It has been revised to include electrical stimulation wound treatment device, electromagnetic wound treatment device and pulsed electromagnetic field stimulation (PENFS).

Electrical stimulation wound treatment device, electromagnetic wound treatment device, and pulsed electromagnetic field stimulation (PENFS) are considered investigational and not medically necessary for all indications. 

The CPT and HCPCS codes associated with this revised coverage guideline are 64999, 0278T, 0720T, 0766T, 0767T, 0768T, 0769T, 0783T, A4596, E0761, E0762, E0769, E1399, K1002, K1023, S8130, S8131, and S8930. 

Selected Protein Biomarker Algorithmic Assays (LAB.00011)

This coverage guideline addresses the use of selected protein biomarker algorithmic assays, which involve the qualitative and/or quantitative analysis of protein constituents in a biological sample that are reported as a predictive, diagnostic, or prognostic algorithmic result. Protein biomarker algorithmic assays are under investigation in certain tumors and for other applications such as predicting the likelihood of preterm delivery in pregnancy. 

It has been revised to include the IMMray® PanCan-d test to be considered investigational and not medically necessary for all indications. 

The CPT codes associated with this revised coverage guideline are 81538, 81599, 0080U, 0092U, 0174U, 0247U, 0249U, 0342U, and 0360U. 

Cellular Therapy Products for Allogeneic Stem Cell Transplantation (MED.00147)

This new coverage guideline addresses stem cell therapy products such as omidubicel (Omisirge^®, Gamida Cell, Ltd. Boston, MA) for hematologic malignancies (blood cancers) which are amenable to stem cell transplantation. Omidubicel is the first U. S. Food and Drug Administration (FDA) approved stem cell therapy product for allogeneic stem cell transplantation.

Use of ex-vivo expansion of cord blood stem cell products (for example, omidubicel) is considered medically necessary for individuals when the following criteria are met:

1. 12 years of age or older; and
2. Is a candidate for myeloablative allogeneic hematopoietic stem cell transplantation to treat a hematologic malignancy; and 
3. The appropriate stem cell transplant criteria are met; and 
4. Is eligible and planned for umbilical cord blood transplantation following myeloablative conditioning; and
5. Use is intended to reduce the time to neutrophil recovery and the incidence of infection; and

Use of ex-vivo expansion of cord blood stem cell products (for example, omidubicel) is considered investigational and 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 38999, C9399, J3490, and J3590. 

Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring (SURG.00129)   

This coverage guideline addresses surgical treatments for obstructive sleep apnea (OSA). 

It has been revised to include the definition of failed CPAP treatment. Failed CPAP treatment is demonstrated by an AHI greater than 15 when using PAP therapy for greater than 4 hours each night on at least 70% of nights.

The CPT and HCPCS codes associated with this revised coverage guideline are 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 41512, 41530, 42145, 42299, 64582, C1767, C1778, C1787, C9727, S2080, D7940, D7941, D7943, D7944, D7945, D7946, D7947, L8680, L8681, L8688. 

Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia (SURG.00144)

This coverage guideline addresses occipital nerve blocks (or blockade) and sphenopalatine ganglion nerve blocks as a therapy for treatment of headache syndromes.

The scope has been revised to include sphenopalatine ganglion nerve blocks. 

Sphenopalatine ganglion nerve block therapy is considered investigational and not medically necessary for all indications including, but not limited to, the treatment of migraines and non -migraine headaches. 

The CPT codes associated with this revised coverage guideline are 64405, 64450, and 64505.

Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection (TRANS.00041)

This new coverage guideline addresses histological analysis using microarray gene expression profiling (for example, Molecular Microscope^® Diagnostic System MMDx^®, Kashi Clinical Laboratories, Portland, or) as a complement to conventional biopsy processing when assessing for allograft injury or rejection in kidney transplant recipients. 

Histological analysis using microarray gene expression profiling is considered investigational and not medically necessary for detection of allograft injury or rejection in kidney transplant recipients and for all indications.

The CPT code associated with this new coverage guideline is 0088U. 

Myoelectric Upper Extremity Prosthetic Devices (CG-OR-PR-05)

This Clinical UM Guideline addresses the use of myoelectric prosthetic devices for individuals with an amputation or absence of a portion of an upper extremity at any level from the hand, including partial-hand, to the shoulder. 

It has been revised to include criteria for the repair and replacement of myoelectric upper extremity prosthetic devices. 

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered medically necessary when either A or B below are met:

A. Needed for normal wear or accidental damage; or

B. The changes in the individual’s condition warrant additional or different equipment, based on clinical documentation.

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered not medically necessary when the criteria above have not been met.

Enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices have also been added to the scope. 

Enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices (for example, Life Under Kinetic Evolution [LUKE] Arm) are considered not medically necessary for all indications.

The HCPCS codes associated with this revised clinical UM Guideline are L6026, L6925, L6935, L6945, L6955, L6965, L6975, L6611, L6677, L6715, L6880, L6881, L6882, L7007, L7008, L7009, L7045, L7180. L7181, L7190, L7191, L7510, L7520, and L7499.

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside of Liver (CG-SURG-61)

This Clinical UM Guideline focuses on the use of cryosurgical (also known as cryosurgery or cryoablation), radiofrequency, microwave, or laser ablation as a treatment of:

• Primary or secondary malignancies outside the liver; and
• Benign tumors outside the liver.

Microwave ablation has been added to the scope of this revised Clinical UM Guideline and is considered medically necessary when the medical necessity criteria are met. 

Focal cryosurgical ablation of prostate tumors is also addressed and is considered not medically necessary. 

The CPT and HCPCS codes associated with this revised Clinical UM Guideline are 19105, 19499, 20982, 20983, 32994, 32998, 48999, 50250, 50542, 50592, 50593, 53850, 55873, 60699, 61736, 61737, 0581T, 0673T, and C9751. 

These coverage guidelines are 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 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 emergency room (ER)/Urgent Care and authorized services.

To request precertification, 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 use disorder precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Effective for dates of service on and after October 1, 2023, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

Please note, inclusion of a national drug code 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 any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

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

New Reimbursement Policy 

Genetic Tests: Once per Lifetime
(Policy G-23002, effective 01/01/2024)

Beginning with dates of service on or after January 1, 2024, HealthKeepers, Inc. will implement a new reimbursement policy titled Genetic Tests: Once per Lifetime. This policy identifies specific genetic tests allowed once in an Anthem HealthKeepers Plus member’s lifetime. During the member’s lifetime, the germline genotype will not change. However, the interpretation of the gene sequence may change due to recategorization of variants or other factors. Repeat sequencing is not required for future interpretation of germline genotype or re-analysis of previously sequenced data. 

The Related Coding section includes a Once per Lifetime Genetic Test coding list, which describes the genetic procedures that are limited to once per lifetime sequencing. Reinterpretation of the original results are not separately reimbursable. 

For additional information, please review the Genetic Tests: Once per Lifetime reimbursement policy at https://providers.anthem.com/va.

New Reimbursement Policy

Genetic Tests: Once per Lifetime
(Policy G-23002, effective 01/01/2024)

Beginning with dates of service on or after January 1, 2024, Anthem Blue Cross and Blue Shield (Anthem) will implement a new reimbursement policy titled Genetic Tests: Once per Lifetime. This policy identifies specific genetic tests allowed once in a member’s lifetime. During the member’s lifetime, the germline genotype will not change. However, the interpretation of the gene sequence may change due to recategorization of variants, or other factors. Repeat sequencing is not required for future interpretation of germline genotype, or re-analysis of previously sequenced data.

The Related Coding section includes a Once per Lifetime Genetic Test coding list, which describes the genetic procedures that are limited to once per lifetime sequencing. Reinterpretation of the original results are not separately reimbursable.

For additional information, please review the Genetic Tests: Once per Lifetime reimbursement policy at https://www.anthem.com/medicareprovider.

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.*

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 request prior authorization review for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Effective for dates of service on and after January 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

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

Step therapy updates

Courtesy notice — Effective for dates of service on and after October 1, 2023, updated step therapy criteria for iron agents found in the clinical criteria document for CC-0182 will be implemented. The preferred product list is being expanded to include Infed. Please refer to the clinical criteria document for details.

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

Quantity limit updates

Effective for dates of service on and after January 1, 2024, 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.

The previous effective date was previously listed in error as October 1, 2023, this correct effective date is December 1, 2023.

Effective for dates of service on and after December 1, 2023, 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.

Effective for dates of service on and after January 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.

Effective October 1, 2023, the following medication codes will require prior authorization.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the following Clinical Criteria:

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 Anthem HealthKeepers Plus Provider Services at 800-901-0020.

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