Material Adverse Change (MAC)

The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 11, 2022.


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.


These medical policies to not apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®). To view medical policies and utilization management guidelines applicable to FEP members, please visit > Policies & Guidelines.


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

* Denotes prior authorization required.




Effective date

*MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy

·         Addresses the recent U.S. FDA-approved gene therapy product, elivaldogene autotemcel (Skysona®)


*MED.00129 Gene Therapy for Spinal Muscular Atrophy

·         Revised MN criterion to no more than 3 copies of SMN2


CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

·         Added thiopurine methyltransferase (TPMT) to scope of document and Clinical Indications MN section

·         Existing CPT® code 81335 will be reviewed for MN criteria


CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment

·         Added MN statement on decisions on extending adjuvant hormone therapy beyond 5 years in individuals with 1-3 positive lymph nodes


*DME.00044 Robotic Arm Assistive Devices


Previously titled: Wheelchair Mounted Robotic Arm

·         Revised title

·         Rescoped the Position Statement to also address robotic feeding assistive device

·         No specific code for robotic assistive feeding device, E1399 NOC already listed; considered INV&NMN


*MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

·         Added MN criteria for essential tremor

·         CPT Category III code 0398T for intracranial MRgFUS will be reviewed for MN criteria for diagnosis G25.0 (was considered INV&NMN)


SURG.00079 Nasal Valve Repair

Previously titled: Nasal Valve Suspension

·         Revised title

·         Revised the Position Statement

·         Expanded scope of document to address an absorbable nasal implant and low-dose radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction

·         Content related to the absorbable nasal implant (Latera) moved from CG-SURG-87 to this document

·         Added CPT code 30468 for absorbable nasal implant (Latera), considered INV&NMN (was addressed in CG-SURG-87); no specific code for RF remodeling considered INV&NMN, CPT 30999 NOC already listed


SURG.00119 Endobronchial Valve Devices

·         Added a note in the Position Statement addressing individuals unable to perform a 6‑Minute Walk Distance test

·         Updated hierarchy formatting in Position Statement


*SURG.00121 Transcatheter Heart Valve Procedures

·         Clarified TAVR MN Clinical Indications

·         Added MN statement for transcatheter Mitral Edge-to-Edge Repair/transcatheter mitral valve repair using an FDA approved device when criteria met

·         Added NMN statement for transcatheter mitral edge-to-edge repair/TMVr for the treatment of primary or secondary (functional) MR when the criteria above are not met

·         Revised INV/NMN statement TMVr to address transcatheter mitral edge-to-edge repair for all “other” indications

·         CPT codes 33418, 33419 specific to MitraClip mitral valve procedure will be reviewed for MN criteria (were INV&NMN), and added associated ICD-10-PCS code (other mitral valve codes still considered INV&NMN)


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

·         Added MN criteria for hypoglossal nerve stimulation as a treatment of OSA in individuals with Down syndrome

·         Removed examples from the NMN indications

·         Hypoglossal nerve stimulation codes will be reviewed for MN criteria for diagnosis codes Q90.0-Q90.9


*CG-GENE-13 Genetic Testing for Inherited Diseases

·         Interim update to add genes PIK3CA and CDKL5 to the table of genes in the Discussion section; added existing CPT code 81309 and genes to Tier 2 codes 81405, 81406 (MN criteria)


*SURG.00150 Leadless Pacemaker

·         Moving from Post Service Review to Prior Authorization



Below are clinical guidelines and/or medical policies that will be moving from Post Service Review to Prior Authorization effective February 1, 2023.




Effective date


Skin Nerve Fiber Density Testing



Selected Blood, Serum and Cellular Allergy and Toxicity Tests



Navigational Bronchoscopy



Fetal Surgery for Prenatally Diagnosed Malformations



Photocoagulation of Macular Drusen



Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System



High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus



Internal Rib Fixation Systems




Featured In:
November 2022 Anthem Provider News - Wisconsin