*Material Adverse Change (MAC)

 

The following Anthem Blue Cross and Blue Shield medical policies and clinical guidelines were reviewed on February 17, 2022.

 

To view medical policies and utilization management guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.

 

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also 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 fepblue.org > Policies & Guidelines. 

 

 

Below are the new medical policies and/or clinical guidelines that have been approved.

* Denotes prior authorization required

Policy/ Guideline

Information

Effective date

*LAB.00043

Immune Biomarker Tests for Cancer

• Oncologic immune biomarker tests are considered investigational (INV)and not medically necessary (NMN) for all indications

 

Listed CPT PLA code 0261U effective 10/01/2021, considered INV and NMN

9/1/2022

*LAB.00044

Saliva-based Testing to Determine Drug-Metabolizer Status

• Saliva-based testing to determine drug-metabolizer status is considered INV and NMN for all indications

 

No specific code for tests of CYP450 enzymes for drug-metabolizer status using a saliva specimen, considered INV and NMN; listed 84999 NOC

9/1/2022

*LAB.00045

Selected Tests for the Evaluation and Management of Infertility

• The following tests or procedures are considered INV and NMN for diagnosing or managing infertility:
- Endometrial receptivity analysis;
- Sperm-capacitation test;
- Sperm deoxyribonucleic acid (DNA) fragmentation test;
- Sperm penetration assay; and
- Uterine natural killer (uNK) cells test

 

Listed existing CPT codes  89329, 89330, 0253U, 0255U 86357 considered INV and NMN for infertility; no specific code for sperm DNA fragmentation, 89398 NOC

9/1/2022

*LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered INV and NMN as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered INV and NMN
• Moved content related to biomarker testing for Alzheimer’s disease (AD) from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document

 

Listed codes 83520, 84999 NOC, 0206U, 0207U for biochemical marker testing for Alzheimer’s disease, previously addressed in GENE.00003 considered INV and NMN

9/1/2022

*RAD.00067

Quantitative Ultrasound for Tissue Characterization

• Quantitative ultrasound for tissue characterization is considered INV and NMN for all indications

 

Listed CPT Category III codes 0689T, 0690T effective 1/1/2022 for quantitative US for tissue characterization, considered INV and NMN

9/1/2022

*SURG.00160

Implanted Port Delivery Systems to Treat Ocular Disease

• The use of a port delivery system to treat ocular disease is considered INV and NMN for all indications

 

Listed existing codes 67027, 67028 considered INV and NMN when described as implantation and refill of a port delivery system; no specific code for SUSVIMO product,  C9399, J3490, J3590 NOC codes

9/1/2022

*TRANS.00038

Thymus Tissue Transplantation

• Outlines the medical necessity (MN) and INV

 

No specific code for thymus tissue transplantation, listed 27599, L8699 NOC codes considered medically necessary when criteria met

9/1/2022

 

Below are the current clinical guidelines and/or medical policies we reviewed and updates were approved.

* Denotes prior authorization required

Policy/Guideline

Information

Effective date

*SURG.00154

Microsurgical Procedures for the Prevention or Treatment of Lymphedema

 

Previously titled: Microsurgical Procedures for the Treatment of Lymphedema

• Revised title

• Revised Position Statement to include the prevention of lymphedema

 

Added existing CPT codes 15756, 49906 considered INV and NMN when specified as tissue transfer for lymphedema; no specific codes for lymph node procedures

9/1/2022

 

Below is the clinical guideline we reviewed and will be adopted for prior authorization.

* Denotes prior authorization required

Policy/Guideline

Information

Effective date

*CG-DME-46

Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

• All Claims containing a request for pneumatic compression devices

• All extremities are included already in our Pneumatic Compression Devices initiative

9/1/2022

 

2648-0622-PN-CNT

 



Featured In:
June 2022 Anthem Provider News - Wisconsin