CommercialSeptember 1, 2022
Medical policy and clinical guideline updates – September 2022*
*Material Adverse Change (MAC)
The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on May 12, 2022.
To view Medical Policies and Utilization Management Guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.
To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.
To view Medical Policies and Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP®]), please visit fepblue.org > Policies & Guidelines.
New policies
Below are the new medical policies and/or clinical guidelines that have been approved.
* Denotes prior authorization required.
|
Policy/guideline |
Information |
Effective date |
|
*DME.00046 Intermittent Abdominal Pressure Ventilation Devices |
Intermittent abdominal pressure ventilation devices are considered investigational and not medically necessary (INV & NMN) for all indications
Listed existing HCPCS code K1021 (code effective 10/1/2021) for exsufflation belt; considered INV & NMN |
12/1/2022 |
|
DME.00047 Rehabilitative Devices with Remote Monitoring |
The use of rehabilitative devices with remote monitoring or adjustment capabilities (for example, ROMTech PortableConnect® and ROMTech AccuAngle®) is considered INV & NMN for all indications
No specific code for this type of device, considered INV & NMN; listed E1399 NOC |
12/1/2022 |
|
DME.00048 Virtual Reality Assisted Therapy Systems |
Use of virtual reality systems (for example, EaseVRx, SootheVR, and RelieVR) for screening, diagnosis, or treatment of a health condition is considered INV & NMN for all indications
No specific code for this type of device, considered INV & NMN; listed E1399 NOC |
12/1/2022 |
|
*GENE.00059 Hybrid Personalized Molecular Residual Disease Testing for Cancer |
Oncologic hybrid personalized molecular residual disease (MRD) tests are considered INV & NMN for all indications
No specific code currently for this test, considered INV & NMN; listed 81479 NOC |
12/1/2022 |
|
* LAB.00048 Pain Management Biomarker Analysis |
The functional pain biomarker urine test panel is considered INV & NMN for chronic pain management and for all other indications
Listed existing CPT® PLA code 0117U specific to this test; considered INV & NMN |
12/1/2022 |
|
MED.00139 |
Electrical impedance scanning for cancer detection is considered INV & NMN for all indications
No specific code for this type of scanning, considered INV & NMN; listed 99199 NOC |
12/1/2022 |
|
TRANS.00039 Portable Normothermic Organ Perfusion Systems |
Outlines the MN and INV & NMN criteria for Portable Normothermic Organ Perfusion Systems
No specific transplant-related CPT codes for this technology; listed 32999 NOC lung and 47399 NOC liver having MN criteria, listed 33999 heart and 53899 kidney considered INV & NMN |
12/1/2022 |
Updated policies
Below are the current clinical guidelines and/or medical policies we reviewed, and updates were approved.
* Denotes prior authorization required.
|
Policy/guideline |
Information |
Effective date |
|
CG-MED-90 Chelation Therapy |
Moved content of MED.00127 Chelation Therapy to new clinical UM guideline document with the same title
HCPCS codes J0470, J0600, J0895, J3520, M0300, S9355 for chelation therapy now addressed in this document; considered NMN if criteria not met |
7/6/2022 |
|
*GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma
Previously titled: Gene Expression Profiling of Melanomas |
· Revised title · Expanded Scope and Position Statement to include cutaneous squamous cell carcinoma · Added existing CPT PLA code 0315U for GEP for squamous cell carcinoma; considered INV & NMN |
12/1/2022 |
|
*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting |
Revised INV & NMN statement to NMN for products with MN indications
Updated to consider NMN where indicated; added HCPCS codes Q4259, Q4260, Q4261 effective 7/1/2022 for products considered INV & NMN |
7/1/2022 |
|
*SURG.00097 Scoliosis Surgery |
Added MN criteria for vertebral body tethering CPT Category III codes 0656T, 0657T, and associated ICD-10-PCS codes for tethering considered MN when criteria are met (were considered INV & NMN) |
7/6/2022 |
|
*MED.00132 |
Added CPT Category III codes 0717T, 0718T, effective 7/1/2022 for autologous ADRC therapy for rotator cuff tear; considered INV & NMN |
7/1/2022 |
|
DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices |
Added CPT Category III code 0720T effective 7/1/2022 for PENFS device (e.g., IB-Stim); considered INV & NMN |
7/1/2022 |
|
*GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting |
Added CPT PLA code 0323U effective 7/1/2022, for metagenomic NGS assay; considered INV & NMN |
7/1/2022 |
|
LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests |
Added existing CPT code 83520, considered INV & NMN for food allergy diagnoses |
7/6/2022 |
|
*CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management |
For CPT PLA code 0229U (Colvera test) descriptor revision only effective 7/1/2022 |
7/1/2022 |
|
*CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing |
Added CPT PLA code 0327U effective 7/1/2022, for Vasistera test; considered MN based on diagnosis |
7/1/2022 |
|
*GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) |
Added CPT PLA code 0326U effective 7/1/2022, for Guardant360 panel; considered INV & NMN |
7/1/2022 |
|
*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling |
Added CPT PLA code 0329U for Oncomap test having MN criteria, and CPT PLA code 0331U for genome mapping test considered INV & NMN; both codes effective 7/1/2022 |
7/1/2022 |
|
*GENE.00056 Gene Expression Profiling for Bladder Cancer |
For CPT code 0016M (Decipher Bladder TURBT) descriptor revision only effective 7/1/2022 |
7/1/2022 |
|
LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays |
Added CPT PLA codes 0324U, 0325U effective 7/1/2022, for ovarian tumor drug response panels, considered NMN |
7/1/2022 |
|
LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease |
For CPT PLA code 0166U (Liverfast test) descriptor revision only effective 7/1/2022 |
7/1/2022 |
PUBLICATIONS: September 2022 Anthem Provider News - Wisconsin
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