Below are new medical policies or clinical guidelines

NOTE *Precertification required

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

NOTE *Precertification required

^{* 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.}

• Revised Clinical Indications for admission and added examples for:
  • o Aggressive hydration needs that cannot be managed in an infusion center
  • o Prolonged marrow suppression
• Added Regimens that cannot be managed as an outpatient with examples

Click here to view the summary of MCG 23RD edition customizations.

For questions, please contact the provider service number on the back of the member's ID card.

^{* 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.}

Oncologic Imaging Guideline contains updates to the following:

• Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary / cancers not otherwise specified,
• Added new sections on hepatobiliary cancer and suspected metastases
• Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
• Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”

Vascular Imaging Guideline contains updates to the following:

• Brain, Head and Neck: Aneurysm - intracranial,  Aneurysm - extracranial, Arteriovenous malformation (AVM) and fistula (AVF), Fibromuscular dysplasia, Hemorrhage - intracranial, Stenosis or occlusion -  extracranial, Stenosis or occlusion -  intracranial, stroke and Venous thrombosis or compression -  intracranial
• Chest: Acute aortic syndrome, Aortic aneurysm, Pulmonary artery hypertension
• Abdomen and Pelvis: Acute aortic syndrome, Aneurysm of the abdominal aorta or iliac arteries, Hematoma/hemorrhage within the abdomen or unexplained hypotension, Renal artery stenosis (RAS)/Renovascular hypertension, Venous thrombosis or compression – intracranial, Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
• Upper Extremity: Peripheral arterial disease, Venous thrombosis or occlusion
• Lower Extremity: Added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
• Added arterial ultrasound guideline content
• Aligned peripheral arterial ultrasound with advanced vascular imaging criteria

Imaging of the Heart Guideline contains updates to the following:

• Blood Pool Imaging: Changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
• Cardiac CT: Quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal^SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

^{* 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.}

Prostate Cancer

Added criteria for the appropriate use of PET-CT with the radiotracers Axumin and 11-Choline, establishing the position of this test in the care continuum for prostate cancer primarily related to biochemical recurrence

Neuroendocrine Tumors

Added criteria for the appropriate use of PET-CT with the radiotracer DOTA-TATE, establishing the position of this test in the care continuum for neuroendocrine tumors

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal^SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

• Sinonasal cancer: Added criteria and diagnosis codes for locally advanced sinonasal cancer when tumor involves base of skull and proton beam therapy is needed to spare orbit, optic nerve, optic chiasm, or brainstem
• Ocular Melanoma: Removed tumor size restrictions for treating melanoma of the uveal tract
• Pediatric tumors: Clarified proton beam therapy appropriate for all pediatric tumors requiring radiation therapy

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal^SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Please note, this program does not apply to FEP or National Accounts.

View reimbursement policies online at anthem.com

To find Anthem’s professional and facility reimbursement policies online, select your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.

^{* 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.}

View reimbursement policies online at anthem.com

To find Anthem’s professional and facility reimbursement policies online, select your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.

^{* 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.}

Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health^® (AIM), a separate company.

Revised Clinical Criteria effective June 10, 2019

The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

Revised Clinical Criteria effective September 1, 2019

The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

Revised Clinical Criteria effective November 1, 2019

The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0048 Spinraza (nusinersen)
• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]

New Clinical Criteria effective November 1, 2019

The following clinical criteria are new.

• ING-CC-0137 Cablivi (caplacizumab-yhdp)
• ING-CC-0138 Asparlas (calaspargase pegol-mknl)
• ING-CC-0139 Evenity (romosozumab-aqqg)
• ING-CC-0140 Zulresso (brexanolone)

Expanded specialty pharmacy prior authorization list

Effective for dates of service on and after November 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria will be included in our prior authorization review process. Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health^® (AIM), a separate company.

* 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.

In the June newsletter we announced the transition of the medical non-oncology specialty drug review process from AIM Specialty Health^® (AIM) to Anthem Blue Cross and Blue Shield (Anthem)’s medical specialty drug review team, effective June 15, 2019. Here’s a reminder of the changes.

What has changed?

• Beginning June 15, 2019 all requests, regardless of service date, providers need to submit a new prior authorization request by contacting Anthem’s medical specialty drug review team:
  • o by phone at 1-833-293-0659 or
  • o by fax at 1-888-223-0550 or
  • o Online access at Availity.com available 24/7.
• All inquiries about an existing request (initially submitted to AIM or Anthem), peer-to-peer review, or reconsideration are being managed by Anthem’s medical specialty drug review team.

What has not changed?

• AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
• Clinical criteria for medical non-oncology specialty drugs continues to reside on the Clinical Criteria page on anthem.com
• Post Service Clinical Coverage Reviews and Grievance and Appeals process and teams have not changed.

Here is a summary of the medical specialty drug changes, beginning June 15, 2019:

Visit anthem.com/pharmacyinformation for more information on:

• Copayment/coinsurance requirements and their applicable drug classes
• Drug lists and changes
• Prior authorization criteria
• Procedures for generic substitution
• Therapeutic interchange
• Step therapy or other management methods subject to prescribing decisions
• Any other requirements, restrictions, or limitations that apply to using certain drugs

The commercial drug list is posted to the web site quarterly (the first of the month for January, April, July and October).

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.