Policy Updates Medical Policy & Clinical GuidelinesCommercialAugust 1, 2019

Medical Policy and Clinical Guideline Updates -- August 2019*

The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on June 6, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

Below are new medical policies or clinical guidelines

 

NOTE *Precertification required

Title

Information

Effective Date

*GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

• The use of bronchial gene expression classification for the diagnostic evaluation of lung cancer in individuals with pulmonary lesions is considered Investigational and Not Medically Necessary (INV&NMN)

-No specific code for bronchial gene expression classifiers such as Percepta by Veracyte; listed 81479 NOC

11/1/19

SURG.00153 Cardiac Contractility Modulation Therapy

·        The use of cardiac contractility modulation therapy is considered Investigational and Not Medically Necessary (INV&NMN) for all indications, including but not limited to heart failure.

·        Existing codes 0408T-0418T and associated ICD-10-PCS codes will be denied Investigational and Not Medically Necessary (Inv&NMN) for all diagnoses

11/1/19

*MED.00129 Gene Therapy for Spinal Muscular Atrophy

• A one-time infusion of onasemnogene abeparvovec-xioi (Zolgensma®) is considered Medically Necessary (MN) in individuals with spinal muscular atrophy (SMA) type 1 when all of the  criteria are met

• Onasemnogene abeparvovec-xioi is considered Investigational and Not Medically Necessary (INV&NMN) when criteria are not met, including for repeat infusions, and for all other indications

6/13/19

 

 

These current Clinical Guidelines and/or Medical policies were reviewed and updates were approved.

 

NOTE *Precertification required

Title

Change

Effective date

*CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

• Content moved from GENE.00021

• Investigational and Not Medically Necessary (INV&NMN) changed to Not Medically Necessary (NMN) as a result of Medical Policy to Clinical UM Guideline transition

• No other change to clinical indications

9/4/19

CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus

• Content moved from SURG.00106

• Revised Medically Necessary (MN) indications to include IMC

• Added cryoablation to Medically Necessary (MN) criteria

• Investigational and Not Medically Necessary (INV&NMN) changed to Not Medically Necessary (NMN) as a result of Medical Policy to Clinical UM guideline transition

9/4/19

*DME.00037 Cooling Devices and Combined Cooling/Heating Devices

• Added devices that combine cooling and vibration to the Investigational and Not Medically Necessary (INV&NMN) statement

-No specific code for vibration devices; added to E1399 NOC

11/1/19

LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests

• Added Mediator Release Test to Investigational and Not Medically Necessary (INV&NMN) statement

11/1/19

LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer

• Clarified Investigational and Not Medically Necessary (INV&NMN) statement to include 4Kscore and AR-V7

-No specific code for AR-V7 protein biomarker testing, listed 81479 NOC

11/1/19

*OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis

• Clarified Medical Necessity position statement criteria 2 through 4

• Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered Investigational and Not Medically Necessary (INV&NMN) for all indications

11/1/19

SURG.00011 Allogeneic, Xenographic, Synthetic, and Composite Products for Wound Healing and Soft Tissue Grafting

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

-Codes 65778, 65779, 65780, V2790 for ocular amniotic membrane application will be allowed for appropriate diagnosis codes

11/1/19

SURG.00045 Extracorporeal Shock Wave Therapy

 

Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions

• Added erectile dysfunction, Peyronie’s disease and wound repair to the Investigational and Not Medically Necessary (INV&NMN) statement

• Revised title

-Added existing codes 0512T, 0513T for wounds and 55899 NOC for male genital ESWT; will deny as Investigational and Not Medically Necessary (Inv&NMN)

11/1/19

SURG.00121 Transcatheter Heart Valve Procedures

• Added Investigational and Not Medically Necessary (INV&NMN) statement to address use of transcatheter tricuspid valve repair or replacement for all indications

-Added CPT codes 0544T, 0545T effective 07/01/19 for mitral and tricuspid valve procedures  Investigational and Not Medically Necessary (Inv&NMN)

11/1/19

 

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

 

PUBLICATIONS: August 2019 Anthem Provider News - Wisconsin