Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies (MP) and Clinical Utilization Management (UM) Guidelines (CUMG) below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/search/

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• CG-DME-31 - Powered Wheeled Mobility Devices
  • Added Not Medically Necessary statement for powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs or uneven terrain (for example, the iBOT Personal Mobility Device) for all indications
• CG-LAB-24 - Outpatient Urine Culture
  • Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient urine culture testing for bacteria
• CG-LAB-25 - Outpatient Glycated Hemoglobin and Protein Testing
  • Outlines the Medically Necessary and Not Medically Necessary criteria for outpatient glycated hemoglobin (HbA1c) and total glycated serum proteins (GSPs) testing
• CG-MED-92 - Foot Care Services
  • Outlines the Medically Necessary and Not Medically Necessary criteria for foot care services
• CG-MED-93 - Navigational Bronchoscopy
  • Moved content from MED.00099 Navigational Bronchoscopy to a new clinical UM guideline document with the same title
  • Added Medically Necessary criteria for navigational bronchoscopy
  • Revised Investigational & Not Medically Necessary statement to Not Medically Necessary when criteria not met
• CG-SURG-115 - Mechanical Embolectomy for Treatment of Stroke
  • Moved content from SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke to new clinical UM guideline document with a similar title
  • Investigational & Not Medically Necessary changed to Not Medically Necessary as a result of MP to CUMG transition
• CG-SURG-116 - Surgical Treatment of Hyperhidrosis
  • Moved content from CG-MED-63 Treatment of Hyperhidrosis to new clinical UM guideline document
  • Change of category and addition of surgical to title
  • Moved content related to iontophoresis to CG-MED-28 Iontophoresis
• GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
  • Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document
  • Added chromosome conformation signatures to scope of document and Investigational & Not Medically Necessary statement
• MED.00130 - Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring; Previously titled: Surface Electromyography Devices for Seizure Monitoring
  • Revised title
  • Revised Position Statement by adding electrodermal activity sensor devices
• MED.00135 - Gene Therapy for Hemophilia
  • Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for a one-time infusion of etranacogene dezaparvovec-drlb for select individuals with hemophilia B
• MED.00143 - Ingestible Devices for the Treatment of Constipation
  • Outlines the Investigational & Not Medically Necessary criteria for ingestible devices for the treatment of constipation
• SURG.00097 - Scoliosis Surgery
  • Added magnetically controlled growing rods to scope of document in Investigational & Not Medically Necessary statement

Medical Policies

On November 10, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 18, 2023.

Clinical UM Guidelines

On November 10, 2022, MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicaid members on December 15, 2022. These guidelines take effect June 18, 2023.