Policy Updates Medical Policy & Clinical GuidelinesCommercialNovember 30, 2018

Medical Polices and Clinical Guidelines Updates - December 2018

The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on September 13, 2018 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

Below is a new Medical Policy effective March 1, 2019:

 

New Medical Policy

Effective March 1, 2019

MED.00125 Biofeedback and Neurofeedback

• Outlines the MN and INV&NMN indications for biofeedback and neurofeedback.

 

Existing CPT codes 90875, 90876, 90901, 90911 will be reviewed for MN (medical necessity) criteria; HCPCS device code E0746 considered INV&NMN (Investigational and Not Medically necessary)

 

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

 

Below are Medical Policy updates effective March 1, 2019:

*requires precertification

 

Medical Policy Updates

Effective March 1, 2019

CG-ADMIN-02 Clinically Equivalent Cost Effective Services – Targeted Immune Modulators

• Added cost effective agent language for Cimzia to the Clinically Equivalent Cost Effective Services (CECE) for Crohn’s Disease or Ulcerative Colitis section

• Added off-label indications for Remicade in immune checkpoint inhibitor-related toxicities to Table section

• Added off-label indications for Actemra in chronic antibody mediated rejection (cAMR) in renal transplantation to Table section

*CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring

 

Revised title

• Revision to the ambulatory EEG MN statement to include with or without video monitoring

• Revision to NMN statement of ambulatory EEG by adding “Antiepileptic drug treatment withdrawal or modification in individuals because the risk of seizure precipitation would require immediate medical intervention”

• Revision to the MN statement for attended EEG video monitoring in a healthcare facility by adding “withdrawal”

LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

Revised title

• Expanded scope of policy to address all monoclonal antibody drugs

• Revised position statement to state:

   "The measurement of serum concentrations of either of the following is considered investigational and not medically necessary under all circumstances:

     A. Monoclonal antibody drugs, including but not limited to tumor necrosis factor antagonist drugs; or

     B. Antibodies to monoclonal antibody drugs, including but not limited to tumor necrosis factor antagonist drugs

SURG.00011 Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting

• Added several products to the INV&NMN section.

Added existing codes 65778, 65779, 65780, V2790 for ocular indications, considered INV&NMN (investigational and not medically necessary)

*SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

 

• Added iStent inject Trabecular Micro-Bypass System as MN when criteria met

• Revised INV&NMN to include iStent inject Trabecular Micro-Bypass System for all indications not listed as MN

• Revised MN and INV&NMN statements as a result of manufacturer's voluntary removal of the CyPass System from the market

CPT Category III code 0474T (CyPass) changed to INV&NMN

 

Below are Coding updates effective March 1, 2019:

 

Coding Updates

Effective March 1, 2019

GENE.00016 Gene Expression Profiling for Colorectal Cancer

Added CPT code 0069U expression profiling test considered INV&NMN

GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Added CPT codes 0070U-0076U for CYP2D6 testing replacing 0028U (MN criteria); added pain panel 0078U considered INV&NMN

LAB.00029 Rupture of Membranes (ROM) Testing in Pregnancy

Added CPT code 0066U considered INV&NMN

MED.00111  Added HCPCS code C9750 considered INV&NMN

Added HCPCS code C9750 considered INV&NMN

PUBLICATIONS: December 2018 Anthem Wisconsin Provider Newsletter