Policy Updates Medical Policy & Clinical GuidelinesCommercialApril 10, 2025

Medical Policies and Clinical Guidelines updates, May 2025

The following Medical Polices and Clinical Guidelines were reviewed for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Utilization Management Guidelines, go to https://anthem.com > Providers > select your state > Provider Resources > Policies, Guidelines & Manuals.

To help determine if preapproval is needed, go to https://anthem.com > Providers > select your state > Claims > Prior Authorization. You can also call the preapproval 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.

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‑98

Parenteral Antibiotics for the Treatment of Lyme Disease

  • Moved content from MED.00013 to new clinical UM guideline with the same title
  • NV&NMN changed to NMN as a result of MP to CUMG transition
  • Moved CPT® codes 96365, 96366, 96367, 96368, 96372 and HCPCS codes for antibiotics from MED.00013

August 1, 2025

*CG‑SURG‑123

Autologous Fat Grafting and Injectable Soft Tissue Fillers

  • Moved content related to autologous fat grafting and injectable soft tissue filters from MED.00132 to new clinical UM guideline
  • Moved codes 15771, 15772, 15773, 15774, 11950, 11951, 11952, 11954, 31574, C1878, G0429, L8607, Q2026, Q2028, and NOC 17999, L8699 from MED.00132

August 1, 2025

*CG‑SURG‑125

Canaloplasty

  • Moved content for canaloplasty from SURG.00095 to new clinical UM guideline
  • NV&NMN changed to NMN as a result of MP to CUMG transition
  • Revised MN statement to remove mild to moderate stage

August 1, 2025

*DME.00053

Home Video‑Assisted Robotic Rehabilitation Systems

  • Home video‑assisted robotic rehabilitation systems are considered INV&NMN for all indications
  • Existing HCPCS code E0739 (code effective 4/1/2024) for Motus hand/Motus foot considered INV&NMN

August 1, 2025

*MED.00151

Gene Therapy for Aromatic L‑Amino Acid Decarboxylase Deficiency

  • Gene therapy for aromatic l‑amino acid decarboxylase deficiency using eladocagene exuparvovec‑tneq is considered INV&NMN for all indications
  • Existing ICD‑10‑PCS code XW0Q316 for KEBILIDI considered INV&NMN; NOC CPT and HCPCS codes 64999, C9399, J3490, J3590 when specified as KEBILIDI considered INV&MN

August 1, 2025

*MED.00152

Outpatient Intravenous Insulin Therapy

  • Outpatient intravenous insulin therapy is considered INV&NMN as a treatment for all indications, including diabetes
  • Existing HCPCS code G9147 is considered INV&NMN

August 1, 2025

*SURG.00165

Histotripsy

  • Histotripsy is considered INV&NMN for all indications
  • Existing CPT category III codes 0686T (moved from CG‑SURG‑78), 0888T, NOC code 55899 specified as histotripsy, and associated ICD‑10‑PCS codes are considered INV&NMN

August 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‑ANC‑03

Acupuncture

  • Revised descriptors for 97811, 97814 effective 1/1/2025

January 1, 2025

CG‑MED‑64

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins

  • Revised descriptor for 93656 effective 1/1/2025

January 1, 2025

CG‑MED‑91

Remote Therapeutic and Physiologic Monitoring Services

  • Revised descriptors for 98975, 98976, 98977, 98978 effective 1/1/2025

January 1, 2025

*CG‑SURG‑61

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

  • Added new CPT codes 60660, 60661 effective 1/1/2025 for radiofrequency ablation thyroid considered NMN (was included in NOC 60699)

January 1, 2025

CG‑SURG‑120

Vagus Nerve Stimulation

  • Added new CPT Category III codes 0908T, 0909T, 0910T, 0911T, 0912T effective 1/1/2025 for a stimulator (not yet FDA approved) for rheumatoid arthritis considered NMN

January 1, 2025

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

  • Added new CPT PLA code 0525U effective 1/1/2025 for 3D Predict Ovarian test considered NMN; removed 0564T deleted as of 1/1/2025

January 1, 2025

LAB.00015

Detection of Circulating Tumor Cells

  • Clarified CPT codes 86152, 86153 considered INV&NMN only for blood specimen; other specimens (eg, CSF) not addressed

February 1, 2025

LAB.00026

Pathology Systems and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions

  • Added MN criteria for ArteraAI Prostate cancer risk stratification test
  • Revised INV&NMN statement to remove prostate cancer
  • CPT PLA code 0376U will be considered MN when criteria are met (was INV&NMN)

February 1, 2025

*LAB.00028

Blood‑based Biomarker Tests for Multiple Sclerosis

  • Added new CPT code 83884 effective 1/1/2025 for neurofilament light chain considered INV&NMN

January 1, 2025

*LAB.00035

Multi‑biomarker Disease Activity Blood Tests for Rheumatoid Arthritis

  • Added new CPT PLA code 0521U effective 1/1/2025 for rheumatoid arthritis panel considered INV&NMN

January 1, 2025

*LAB.00040

Serum Biomarker Tests for Risk of Preeclampsia

  • Added new CPT PLA code 0524U effective 1/1/2025 for sFlt‑1/PlGF test considered INV&NMN

January 1, 2025

LAB.00042

Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy

  • Added CPT NOC code 81599 replacing PLA code 0456U for PrismRA deleted as of 1/1/2025

January 1, 2025

*LAB.00046

Testing for Biochemical Markers for Alzheimer's Disease

  • Revised formatting and content of MN statement
  • Added new CPT codes 82233, 82234, 84393, 84394 for Abeta and pTau considered MN when criteria are met and new CPT code 83884 for neurofilament light chain considered INV&NMN all effective 1/1/2025, removed PLA code 0346U deleted as of 1/1/2025

January 1, 2025

*MED.00057

MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications

  • Revised INV&NMN to include examples bilateral staged focused ultrasound thalamotomy or pallidotomy, BPH and uterine fibroids
  • Added new CPT code 61715 effective 1/1/2025 for intracranial MRgFUS considered MN when criteria are met replacing 0398T deleted as of 1/1/2025

January 1, 2025

MED.00132

Autologous Adipose‑derived Regenerative Cell Therapy. Previously titled: Adipose‑derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

  • Revised title, Revised Position Statement
  • Revised scope of document to address autologous adipose‑derived regenerative cell therapy
  • Moved content related to autologous fat grafting and injectable soft tissue fillers to new document CG‑SURG‑123
  • Removed codes 15771‑15774, 11950‑11952, 11954; 31574; C1878; G0429; L8607; Q2026; Q2028 17999; L8699 now addressed in CG‑SURG‑123

February 1, 2025

*MED.00135

Gene Therapy for Hemophilia

  • Added new HCPCS code J1414 effective 1/1/2025 for Beqvez considered MN when criteria are met replacing C9172 deleted as of 1/1/2025

January 1, 2025

MED.00137

Eye Movement Analysis Using Non‑spatial Calibration for the Diagnosis of Concussion

  • Revised descriptor for 0615T effective 1/1/2025

January 1, 2025

MED.00140

Gene Therapy for Beta Thalassemia

  • Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590

January 1, 2025

MED.00146

Gene Therapy for Sickle Cell Disease

  • Added new HCPCS code J3392 effective 1/1/2025 for Casgevy considered MN when criteria are met, replacing NOC codes C9399, J3490, J3590

January 1, 2025

*SURG.00011

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

  • Added new 1/1/2025 CPT and HCPCS codes 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, C8002 for skin cell suspension considered MN when criteria are met, and new HCPCS codes Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353 for products considered INV&NMN

January 1, 2025

*SURG.00135

Renal Sympathetic Nerve Ablation

  • Added new HCPCS codes C1735, C1736 effective 1/1/2025 for renal denervation catheters considered INV&NMN

January 1, 2025

*SURG.00155

Cryoneurolysis

  • Added new HCPCS codes C9808, C9809 effective 1/1/2025 for cryoICE and Iovera devices considered INV&NMN

January 1, 2025

SURG.00156

Implanted Artificial Iris Devices

  • Added new CPT code 66683 effective 1/1/2025 for iris prosthesis implantation considered INV&NMN, replacing category III codes 0616T‑0618T deleted as of 1/1/2025

January 1, 2025

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

  • Added new HCPCS code C9807 effective 1/1/2025 for the Sprint device considered INV&NMN

January 1, 2025

*SURG.00162

Implantable Shock Absorber for Treatment of Knee Osteoarthritis

  • Added new HCPCS code C8003 effective 1/1/2025 for implantation MISHA knee system considered INV&NMN

January 1, 2025

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

  • Added ICD‑10‑CM diagnosis code C49.3 as MN when criteria are met

January 1, 2025

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-080572-25

PUBLICATIONS: May 2025 Provider Newsletter