The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on January 24, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

The current Clinical Guidelines and/or Medical Policies listed below were reviewed and updates were approved.

 

*Precertification required

 


Title


Change

Effective date

CG-SURG-94 Keratoprosthesis

• Content moved from SURG.00115

3/21/19

*CG-SURG-95  Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

• Content moved from SURG.00117

• Previous title: Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention

 

3/21/19

MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

• Added bioengineered autologous skin-derived products (for example, SkinTE) as Investigational and not medically necessary for all indications.

• Existing HCPCS code Q4200 for Skin TE will be considered Investigational & Not Medically Necessary

7/1/19

MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

• Added nasal nitric oxide as Investigational & Not medically necessary in the diagnosis and monitoring of asthma and other respiratory disorders

7/1/19

*SURG.00037 Treatment of Varicose Veins (Lower Extremities)

• Replaced "non-surgical management" with "conservative therapy" in the MN criteria

• Added sclerotherapy used in conjunction with a balloon catheter (for example, KAVS procedure) as INV&NMN

• Existing CPT Category III code 0524T will be considered as Investigational & Not Medically Necessary

7/1/19

TRANS.00035 Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

• Previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications

• Expanded the document's scope to address non-FDA approved uses of mesenchymal stem cell therapy

• Revised Position Statement: “Mesenchymal stem cell therapy is considered Investigational & Not medically necessary for the treatment of joint and ligament disorders caused by injury or degeneration as well as autoimmune, inflammatory and degenerative diseases”

7/1/19

 

The new Medical Policy below will become effective 7/1/19

 


Title


Change

Effective date

Lab.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus

• Multiplex autoantigen microarray testing to screen for, diagnose, or manage systemic lupus erythematous is considered Investigational & Not Medically Necessary

• Existing PLA code 0062U will be considered Investigational & Not Medically Necessary

7/1/19

 



Featured In:
April 2019 Anthem Provider Newsletter - Wisconsin