Medicare AdvantageApril 24, 2025
Medical Policies and Clinical Utilization Management Guidelines update
Effective May 25, 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.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit the Medical Policies & 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 May 25, 2025.
Publish date | Medical Policy number | Medical Policy title | Status |
1/30/2025 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised |
1/30/2025 | DME.00053 | Home Video-Assisted Robotic Rehabilitation Systems | New |
1/30/2025 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions | Revised |
1/30/2025 | LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | Revised |
1/30/2025 | MED.00151 | Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency | New |
1/30/2025 | MED.00152 | Outpatient Intravenous Insulin Therapy | New |
1/30/2025 | SURG.00165 | Histotripsy | New |
1/30/2025 | TRANS.00029 | Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | Revised |
1/30/2025 | TRANS.00033 | Heart Transplantation | 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 May 25, 2025.
Publish date | Clinical UM Guideline number | Clinical UM Guideline title | Status |
1/30/2025 | CG-DME-06 | Compression Devices for Lymphedema | Revised |
1/30/2025 | CG-MED-98 | Parenteral Antibiotics for the Treatment of Lyme Disease | Conversion New |
1/30/2025 | CG-OR-PR-04 | Cranial Remodeling Bands and Helmets (Cranial Orthoses) | Revised |
1/30/2025 | CG-RAD-26 | Maternity Ultrasound in the Outpatient Setting | Conversion New |
1/30/2025 | CG-SURG-123 | Autologous Fat Grafting and Injectable Soft Tissue Fillers | Conversion New |
1/30/2025 | CG-SURG-124 | Viscocanalostomy | Conversion New |
1/30/2025 | CG-SURG-125 | Canaloplasty | Conversion New |
1/30/2025 | CG-THER-RAD-07 | Intravascular Coronary and Non-Coronary Brachytherapy | 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-082359-25-CPN81285
PUBLICATIONS: May 2025 Provider Newsletter
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