The following new and revised medical policies were endorsed at the July 26, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com/providers, then scroll down and select "Find Resources for Ohio", then from the Wisconsin Provider Home Page, select Medical Policies and Clinical UM Guidelines.

 

These medical policies were converted to clinical guidelines and became effective on September 20, 2018.

 

New Clinical Guideline

Content Moved From Clinical Guideline and/or Medical Policy

CG-DME-45 Ultrasound Bone Growth Stimulation

Content moved from DME.00027

No change to position statement → clinical indications

CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

Content moved from MED.00005

No change to position statement → clinical indications

CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

Content moved from MED.00051

No change to position statement → clinical indications

CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

Content moved from MED.00107

No change to position statement → clinical indications

CG-MED-76 Magnetic Source Imaging and Magnetoencephalography

Content moved from RAD.00019

No change to position statement → clinical indications

CG-MED-77 SPECT/CT Fusion Imaging

Content moved from RAD.00042

No change to position statement → clinical indications

CG-REHAB-11 Cognitive Rehabilitation

Content moved from MED.00081

Removed "Note" in Clinical Indications referring to

CG-REHAB-09 Acute Inpatient Rehabilitation

CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants

Content moved from SURG.00014

No change to position statement → clinical indications

CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids

Content moved from SURG.00020

No change to position statement → clinical indications

CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery

Content moved from SURG.00049

No change to position statement → clinical indications

CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

Content moved from SURG.00074

Revised title - Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring

No change to position statement → clinical indications

CG-SURG-88 Mastectomy for Gynecomastia

Content moved from SURG.00085

No change to position statement → clinical indications

CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

Content moved from SURG.00090

No change to position statement → clinical indications

CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

Content moved from TRANS.00018

No change to position statement → clinical indications

 

These medical policies were converted to clinical guidelines and will become effective on October 31, 2018

 

New Clinical Guideline

Content Moved From Clinical Guideline and/or Medical Policy

CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Content moved from SURG.00024

No change to position statement → clinical indications

CG-SURG-85 Hip Resurfacing

Content moved from SURG.00051

No change to position statement → clinical indications

CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

Content moved from SURG.00054

No change to position statement → clinical indications

 

This new medical policy will be implemented on January 1, 2019

 

New Medical Policy

Content

GENE.00049 Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)

MPTAC approved this new medical policy which reflects the following:

The use of a circulating tumor DNA (ctDNA) test for the diagnosis or treatment of cancer is considered investigational and not medically necessary (INV&NMN) for all indications

 

This medical policy has been revised and will be effective January 1, 2019

 

New Medical Policy

Content

ANC.00007 Cosmetic and Reconstructive Services: Skin Related

MPTAC approved revision of policy which reflects the following: 

• Added microneedling (also known as percutaneous collagen induction therapy or skin needling) as COS&NMN for all indications

 

This medical policy is archived effective September 1, 2018

 

GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance



Featured In:
October 2018 Anthem Wisconsin Provider Newsletter