Policy Updates Medical Policy & Clinical GuidelinesCommercialJune 25, 2025

Medical Policies and Clinical Guidelines updates — August 2025

The following Anthem Blue Cross and Blue Shield Medical Policies and Clinical Guidelines have been reviewed for care providers in Indiana, Kentucky, Missouri, Ohio, and Wisconsin. These updates will ensure the best ongoing care for our members.

Below are the new Medical Policies and/or Clinical Guidelines that have been approved.

* Denotes prior authorization required

Policy/Guideline

Information

Effective date

*CG-MED-99

Intradialytic Parenteral Nutrition

  • Intradialytic parenteral nutrition is considered NMN for all indications

11/1/2025

*CG-MED-100

Surface Electrical Stimulation Devices for Headache and Migraine

  • Moved content related to remote electrical neuromodulation (REN) and supraorbital transcutaneous neurostimulation from DME.00011 to new clinical UM guideline
  • Moved remote electrical neuromodulation (REN) from INV& NMN to MN with criteria
  • Moved content related to vagus nerve stimulation for migraines from CG-SURG-120 to new clinical UM guideline

11/1/2025

*CG-SURG-126

Tibial Nerve Stimulation

  • Moved content for tibial nerve stimulation from CG-SURG-95 to new clinical UM guideline
  • Added NMN for transcutaneous tibial nerve stimulation

11/1/2025

*CG-SURG-127

Canaloplasty

  • Moved MN and NMN criteria for breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications from SURG.00011 to new clinical UM guideline
  • Added NuShield and Oasis Ultra Tri-Layer Wound Matrix as MN for diabetic foot ulcers
  • Added Oasis Ultra Tri-Layer Wound Matrix as MN for chronic wounds
  • Removed limit of “not more than [52] weeks” from DFU and non-healing wound criteria
  • Revised ocular indications to be agnostic to specific product, as long as it is amnion-derived

11/1/2025

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

*CG-SURG-119

Treatment of Varicose Veins (Lower Extremities)

  • Revised the Clinical Indications to reflect current nomenclature for AASV/ASV
  • Added NMN statement regarding VenoValve device

4/16/2025

*LAB.00045

Selected Tests for the Evaluation and Management of Infertility

  • Removed information regarding endometrial receptivity testing from the Position Statement
  • Removed CPT PLA code 0253U, criteria for this service has been transitioned to Carelon Medical Benefits Management Genetic Testing guidelines

9/1/2025

*SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously Titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

  • Revised title and scope
  • Moved content related to breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications to new clinical UM guideline CG-SURG-127
  • Added new products to INV&NMN statement

4/1/2025

*SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis

  • Revised Position Statement to remove age criterion for POEM and requirement for no previous open surgery
  • Added MN criteria for the TIF and G-POEM procedures

4/1/2025

*SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

  • Added new MN statement for ReActiv8 Implantable Neurostimulation System
  • Revised INV&NMN statement

5/1/2025

For additional information:

  • To view Medical Policies and Utilization Management Guidelines, go to https://anthem.com/provider > 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 https://anthem.com/provider> 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.

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare), and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-086393-25