The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 13, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

Determine if prior authorization is needed for an Anthem member by going to > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.


To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit > Policies & Guidelines.


Below are the new medical policies that have been approved.




Effective date

GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

• The use of gene expression profiling to assist in the diagnosis or management of idiopathic pulmonary fibrosis is considered investigational and not medically necessary (INV&NMN) in all situations


LAB.00041 Machine Learning Derived Probability Score for Rapid Kidney Function Decline

• Use of a machine learning derived probability score (e.g., KidneyIntelX) to predict rapid kidney function decline in chronic kidney disease is considered INV&NMN for all indications
• Existing CPT PLA code 0105U will be considered INV&NMN


MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

• Eye movement analysis using non-spatial calibration is considered INV&NMN for the diagnosis of concussion
• Existing CPT Category III code 0615T will be considered INV&NMN



Home Parenteral Nutrition

• Outlines the MN and NMN criteria for initial and continuing use of home parenteral nutrition

-Existing codes B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, S9364, S9365, S9366, S9367, S9368 for parenteral nutrition will be reviewed for MN criteria



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


Note:  *Prior authorization required



Effective date

*CG-SURG-27 Gender Affirming Surgery


Previously titled: Gender Reassignment Surgery


• Revised title

• Replaced the word 'reassignment' with the word 'affirming' in title and throughout document

• Alphabetized procedures in MN statements

• Revised gender dysphoria criteria in all MN statements

• Added “or intolerance” to hormone therapy related criteria

• Clarified hair removal MN statement

• Moved bilateral mastectomy and nipple reconstruction from MN to REC section

• Added breast augmentation and breast reduction to REC section and reframed procedures as "gender affirming chest procedures"

• Moved gender affirming facial surgical procedures from cosmetic and not medically necessary (COS&NMN) to REC section

• Moved voice modification surgery from COS&NMN to reconstructive (REC) section

• Removed voice therapy from scope of document

• Clarified the NMN and the COS&NMN statements to reflect changes listed above

• Revised the Further Considerations statement to include all gender affirming chest procedures
• Added CPT codes for urethroplasty (pelvic surgery); added facial reconstructive procedures including rhinoplasty, fat grafting, collagen injections, liposuction, and NOC code for thyroid cartilage chondroplasty; added NOC code for voice modification surgery; added liposuction and fat grafting as chest procedures


MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

• Added electrical impedance spectroscopy for the evaluation of skin lesions as INV&NMN
• Added CPT category III code 0658T effective 07/01/2021 for electrical impedance spectroscopy; considered INV&NMN


*OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis

• Revised medical necessity (MN) criteria for microprocessor controlled lower limb prosthesis

• Added microprocessor controlled foot or ankle systems as MN when criteria are met

• Clarified INV&NMN statement addressing microprocessor controlled foot-ankle prosthesis

• HCPCS code L5973 for microprocessor controlled ankle-foot system will be reviewed for MN criteria (was INV&NMN)


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

• Added hypoglossal nerve stimulation as MN when criteria are met

• Revised NMN and INV&NMN statements 

• CPT category III codes 0466T, 0467T, 0468T for hypoglossal nerve stimulators and related nonspecific codes 64568, C1767, C1778, C1787, L8680, L8681, L8688 will be reviewed for MN criteria for obstructive sleep apnea (OSA) diagnoses (were INV&NMN)


SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy

• Added the use of perirectal spacers during prostate radiotherapy as MN when criteria are met

• Revised INV&NMN statement

• CPT code 55874 will be reviewed for MN criteria for prostate cancer diagnoses (was INV&NMN)


*TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

• Added a single autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation as MN for the treatment of relapsing-remitting multiple sclerosis when criteria are met.

• Added a single autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplant as INV&NMN for the treatment of multiple sclerosis when the MN criteria are not met, including for primary progressive or secondary progressive forms of multiple sclerosis

• Added a repeat autologous (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplant as INV&NMN for the treatment of relapsing-remitting multiple sclerosis.

• Added an allogeneic (ablative or non-myeloablative [mini-transplant]) hematopoietic stem cell transplantation, or planned tandem as INV&NMN for the treatment of multiple sclerosis.

• Revised INV&NMN statement for all other autoimmune diseases

• CPT codes 38206, 38232, 38241 and related non-specific CPT and ICD-10-PCS codes for autologous HSCT will be reviewed for diagnosis G35 multiple sclerosis for MN criteria (were INV&NMN)



Standing Frames

• Content moved from DME.00034

• No change to Clinical Indications



Featured In:
July 2021 Anthem Provider News - Wisconsin