The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on November 5, 2020 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.


Below are new medical policies and/or clinical guidelines.


NOTE *Precertification required




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.


LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

• Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered INV&NMN for screening, diagnosis or management of irritable bowel syndrome, and for all other indications.


CPT PLA codes 0164U (effective 04/01/2020) and 0176U (effective 07/01/2020) will be considered INV&NMN.


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



The current clinical guidelines and/or medical policies below were reviewed and updates were approved.


NOTE *Precertification required




Effective date

*CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing

• Content moved from GENE.00026

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Re-formatted clinical indications


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

• Revised scope to only include non-implantable devices

• Reformatted Position Statement section to a single bulleted list of INV&NMN devices

• Added “non-implantable” to bullet point on percutaneous neuromodulation therapy

• Added percutaneous electrical nerve field stimulation (PENFS) as INV&NMN for all indications including, but not limited to, functional abdominal pain associated with irritable bowel syndrome

• Moved content addressing implantable devices (temporarily or permanently implanted) to SURG.00158


*SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele


Previous title: Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

• Revised title

• Expanded scope to include percutaneous testicular vein embolization for varicocele

• Added embolization of the testicular (spermatic) veins as INV&NMN as a treatment of testicular varicocele.


Added ICD-10-PCS codes for testicular vein embolization and ICD-10-CM code for varicocele




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January 2021 Anthem Provider News - Wisconsin