The following Anthem Blue Cross and Blue Shield medical polices will require prior authorization for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

NOTE *Precertification required

 

Title

Information

Effective Date

* GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

• Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered Investigational and not medically necessary (INV&NMN) for all indications.

CPT PLA code 0203U (effective 10/01/2020) will be considered INV&NMN; also listed NOC codes 81479, 81599 considered NMN when specified as this test.

5/1/2021

* SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

• Implantable peripheral nerve stimulation devices are considered INV&NMN for all indications including, but not limited to, treatment of acute and chronic pain

• Moved content addressing implantable devices (temporarily or permanently implanted) from DME.00011 to this new policy with no change in criteria.

Existing nonspecific codes 64555, 64575, 64590, C1767, C1778, C1787, L8679, L8680, L8683 for neurostimulator implantation and devices will be reviewed and considered INV&NMN for description of PNS systems for pain

5/1/2021

* CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

5/1/2021

 

976-0221-PN-IN.OH.WI



Featured In:
February 2021 Anthem Provider News - Wisconsin