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-SURG-112 — Carpal Tunnel Decompression Surgery
    • Outlines the Medically Necessary and Not Medically Necessary criteria for carpal tunnel decompression surgery
  • *CG-SURG-113 — Tonsillectomy with or without Adenoidectomy for Adults
    • Outlines the Medically Necessary and Not Medically Necessary criteria
  • *DME.00043 — Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
    • The use of a neuromuscular electrical training device is considered Investigational & Not Medically Necessary for the treatment of obstructive sleep apnea or snoring
  • *GENE.00058 — TruGraf Blood Gene Expression Test for Transplant Monitoring
    • TruGraf blood gene expression test is considered Investigational & Not Medically Necessary for monitoring immunosuppression in transplant recipients and for all other indications
  • *LAB.00040 — Serum Biomarker Tests for Risk of Preeclampsia
    • Serum biomarker tests to diagnosis, screen for, or assess risk of preeclampsia are considered Investigational & Not Medically Necessary
  • *LAB.00042 — Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
    • Molecular signature testing to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy is considered Investigational & Not Medically Necessary for all uses, including but not limited to guiding treatment for rheumatoid arthritis
  • *OR-PR.00007 — Microprocessor Controlled Knee-Ankle-Foot Orthosis
    • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of a microprocessor controlled knee-ankle-foot orthosis
  • *SURG.00032 — Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
    • Added Medically Necessary statement for transcatheter closure of left atrial appendage (LAA) for individuals with non-valvular atrial fibrillation for the prevention of stroke when criteria are met
    • Revised Investigational & Not Medically Necessary statement for transcatheter closure of left atrial appendage when the criteria are not met
  • *SURG.00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous, or Transcervical Image Guided Techniques
    • Added Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation
    • Added Not Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation when criteria in Medically Necessary statement are not met
    • Removed laparoscopic radiofrequency ablation from Investigational & Not Medically Necessary statement
    • Removed Investigational & Not Medically Necessary statement on radiofrequency ablation using a transcervical approach

 

Medical Policies

On August 12, 2021, 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 December 8, 2021.

 

 

Publish date

Medical Policy

Medical Policy title

New or revised

10/6/2021

*DME.00043

Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

New

10/6/2021

*GENE.00058

TruGraf Blood Gene Expression Test for Transplant Monitoring

New

10/6/2021

*LAB.00040

Serum Biomarker Tests for Risk of Preeclampsia

New

10/6/2021

*LAB.00042

Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy

New

10/6/2021

*OR-PR.00007

Microprocessor Controlled Knee-Ankle-Foot Orthosis

New

8/19/2021

*SURG.00032

Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention

Revised

8/19/2021

*SURG.00077

Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques

Revised

8/19/2021

SURG.00119

Endobronchial Valve Devices

Revised

8/19/2021

SURG.00121

Transcatheter Heart Valve Procedures

Revised



Clinical UM Guidelines

On August 12, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for members on September 23, 2021. These guidelines take effect December 8, 2021.

  

Publish date

Clinical UM Guideline

Clinical UM Guideline title

New or revised

10/6/2021

*CG-SURG-112

Carpal Tunnel Decompression Surgery

New

10/6/2021

*CG-SURG-113

Tonsillectomy with or without Adenoidectomy for Adults

New

10/6/2021

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

8/19/2021

CG-GENE-22

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

8/19/2021

CG-MED-55

Site of Care: Advanced Radiologic Imaging

Revised

8/19/2021

CG-SURG-82

Bone-Anchored and Bone Conduction Hearing Aids

Revised

 

AWI-NU-0329-21



Featured In:
December 2021 Anthem Provider News - Wisconsin