Medical policies and clinical utilization management guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria 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 members of 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-SURG-112 — Carpal Tunnel Decompression Surgery
  • Outlines the Medically Necessary and Not Medically Necessary criteria for carpal tunnel decompression surgery
• *CG-SURG-113 — Tonsillectomy with or without Adenoidectomy for Adults
  • Outlines the Medically Necessary and Not Medically Necessary criteria
• *DME.00043 — Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
  • The use of a neuromuscular electrical training device is considered Investigational & Not Medically Necessary for the treatment of obstructive sleep apnea or snoring
• *GENE.00058 — TruGraf Blood Gene Expression Test for Transplant Monitoring
  • TruGraf blood gene expression test is considered Investigational & Not Medically Necessary for monitoring immunosuppression in transplant recipients and for all other indications
• *LAB.00040 — Serum Biomarker Tests for Risk of Preeclampsia
  • Serum biomarker tests to diagnosis, screen for, or assess risk of preeclampsia are considered Investigational & Not Medically Necessary
• *LAB.00042 — Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
  • Molecular signature testing to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy is considered Investigational & Not Medically Necessary for all uses, including but not limited to guiding treatment for rheumatoid arthritis
• *OR-PR.00007 — Microprocessor Controlled Knee-Ankle-Foot Orthosis
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of a microprocessor controlled knee-ankle-foot orthosis
• *SURG.00032 — Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
  • Added Medically Necessary statement for transcatheter closure of left atrial appendage (LAA) for individuals with non-valvular atrial fibrillation for the prevention of stroke when criteria are met
  • Revised Investigational & Not Medically Necessary statement for transcatheter closure of left atrial appendage when the criteria are not met
• *SURG.00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous, or Transcervical Image Guided Techniques
  • Added Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation
  • Added Not Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation when criteria in Medically Necessary statement are not met
  • Removed laparoscopic radiofrequency ablation from Investigational & Not Medically Necessary statement
  • Removed Investigational & Not Medically Necessary statement on radiofrequency ablation using a transcervical approach

 

Medical Policies

On August 12, 2021, 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 December 8, 2021.

 

 

Publish date	Medical Policy	Medical Policy title	New or revised
10/6/2021	*DME.00043	Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring	New
10/6/2021	*GENE.00058	TruGraf Blood Gene Expression Test for Transplant Monitoring	New
10/6/2021	*LAB.00040	Serum Biomarker Tests for Risk of Preeclampsia	New
10/6/2021	*LAB.00042	Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy	New
10/6/2021	*OR-PR.00007	Microprocessor Controlled Knee-Ankle-Foot Orthosis	New
8/19/2021	*SURG.00032	Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention	Revised
8/19/2021	*SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	Revised
8/19/2021	SURG.00119	Endobronchial Valve Devices	Revised
8/19/2021	SURG.00121	Transcatheter Heart Valve Procedures	Revised

Clinical UM Guidelines

On August 12, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for members on September 23, 2021. These guidelines take effect December 8, 2021.

  

Publish date	Clinical UM Guideline	Clinical UM Guideline title	New or revised
10/6/2021	*CG-SURG-112	Carpal Tunnel Decompression Surgery	New
10/6/2021	*CG-SURG-113	Tonsillectomy with or without Adenoidectomy for Adults	New
10/6/2021	CG-DME-44	Electric Tumor Treatment Field (TTF)	Revised
8/19/2021	CG-GENE-22	Gene Expression Profiling for Managing Breast Cancer Treatment	Revised
8/19/2021	CG-MED-55	Site of Care: Advanced Radiologic Imaging	Revised
8/19/2021	CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids	Revised

 

AWI-NU-0329-21