Medicare AdvantageMarch 11, 2025
Medical Policies and Clinical Utilization Management Guidelines update
Effective April 12, 2025
The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.
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To view a guideline, visit the Medical Policy and Clinical UM Guidelines website.
Medical Policies
The Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 12, 2025.
Publish date | Medical Policy number | Medical Policy title | New or revised |
October 1, 2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised |
October 1, 2024 | DME.00052 | Brain Computer Interface Rehabilitation Devices | New |
October 1, 2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | Revised |
October 1, 2024 | LAB.00051 | Per‑ and Polyfluoroalkyl Substances PFAS Testing | New |
October 1, 2024 | MED.00150 | Hepzato Kit™ (melphalan hepatic delivery system) | New |
October 1, 2024 | SURG.00032 | Patent Foramen Ovale and Left Atrial Appendage Closure Devices | Revised |
October 1, 2024 | TRANS.00023 | Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias | Revised |
Clinical UM Guidelines
The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect April 12, 2025.
Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised |
October 1, 2024 | CG‑LAB-33 | Carcinoembryonic Antigen Testing | New |
October 1, 2024 | CG‑LAB-35 | Cancer Antigen 19‑9 Testing | New |
October 1, 2024 | CG‑MED-39 | Bone Mineral Density Testing Measurement | Revised |
October 1, 2024 | CG‑SURG-01 | Colonoscopy | Revised |
October 1, 2024 | CG‑SURG-122 | Lingual Frenotomy for Ankyloglossia‑Related Feeding Difficulties | New |
October 1, 2024 | CG‑SURG-57 | Diagnostic Nasal Endoscopy | Revised |
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-CR-075680-24-CPN74692
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