The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Note:

  • Effective November 1, 2018, MCG Heath Care Guidelines will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).
  • Effective November 1, 2018, AIM Specialty Health Proton Beam Therapy will be used for clinical reviews.

 

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

 

To search for specific drug policies or guidelines, visit http://www.anthem.com/cptsearch_shared.html.

 

Medical Policies updates: May 2018

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Medicaid (Anthem). 

Publish date Medical Policy number Medical Policy title New or revised
6/6/2018 DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®) New
6/6/2018 DRUG.00046 Ipilimumab (Yervoy®) Revised
5/10/2018 DRUG.00047 Brentuximab Vedotin (Adcetris®) Revised
5/10/2018 DRUG.00053 Carfilzomib (Kyprolis®) Revised
6/6/2018 DRUG.00071 Pembrolizumab (Keytruda®) Revised
6/6/2018 DRUG.00075 Nivolumab (Opdivo®) Revised
5/10/2018 DRUG.00076 Blinatumomab (Blincyto®) Revised
6/6/2018 DRUG.00111 Monoclonal Antibodies to Interleukin-23 Revised
5/10/2018 SURG.00026 Deep Brain, Cortical and Cerebellar Stimulation Revised

Clinical UM Guidelines updates: May 2018

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.


Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/6/2018

CG-LAB-12 

Testing for Oral and Esophageal Cancer

New

6/6/2018

CG-MED-71

Wound Care in the Home Setting

New

6/28/2018

CG-DME-44

Electric Tumor Treatment Field (TTF)

New

6/28/2018

CG-DRUG-67

Cetuximab (Erbitux®)

New

6/28/2018

CG-DRUG-94

Rituximab (Rituxan®) for Nononcologic Indications

New

6/28/2018

CG-DRUG-95

Belatacept (Nulojix®)

New

6/28/2018

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

New

6/28/2018

CG-DRUG-97

Rilonacept (Arcalyst®)

New

6/28/2018

CG-DRUG-98

Bendamustine Hydrochloride

New

6/28/2018

CG-DRUG-99

Elotuzumab (Empliciti™)

New

6/28/2018

CG-DRUG-100

Interferon gamma-1b (Actimmune®)

New

6/28/2018

CG-DRUG-101

Ixabepilone (Ixempra®)

New

6/28/2018

CG-DRUG-102

Olaratumab (Lartruvo™)

New

6/28/2018

CG-MED-72

Hyperthermia for Cancer Therapy

New

6/28/2018

CG-SURG-76

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

New

6/28/2018

CG-SURG-77

Refractive Surgery

New

6/28/2018

CG-SURG-78

Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

New

6/28/2018

CG-SURG-79

Implantable Infusion Pumps

New

6/28/2018

CG-SURG-80

Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors

New

5/10/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

6/6/2018

CG-DRUG-60

Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications

Revised

6/6/2018

CG-DRUG-62

Fulvestrant (FASLODEX®)

Revised

6/6/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised



Featured In:
October 2018 Anthem Wisconsin Provider Newsletter