October 1, 2019

October 2019 Anthem Provider News - Wisconsin

Administrative

AdministrativeCommercialOctober 1, 2019

Updated Provider Manual

AdministrativeCommercialOctober 1, 2019

Anthem launches additional changes to anthem.com

AdministrativeCommercialOctober 1, 2019

National Accounts 2020 Pre-certification list*

Policy Updates

Reimbursement PoliciesCommercialOctober 1, 2019

Reimbursement Policy update: Place of Service-Professional*

Products & Programs

Products & ProgramsCommercialOctober 1, 2019

UPDATE: new AIM Rehabilitative Program will begin November 1, 2019

Federal Employee Program (FEP)CommercialOctober 1, 2019

US Antibiotic Awareness Week is November 11-18, 2019

Federal Employee Program (FEP)CommercialOctober 1, 2019

Pre-certification information for the Federal Employee Program*

PharmacyCommercialOctober 1, 2019

Pharmacy information available at anthem.com

PharmacyCommercialOctober 1, 2019

Important update to Anthem’s commercial drug lists

State & Federal

State & FederalMedicare AdvantageOctober 1, 2019

Aspire Telehealth Palliative Care program

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

June 2019 Medical Policies and Clinical Utilization Management Guidelines update

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

MCG Care Guidelines update and customizations

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Prior authorization requirements changes effective November 1, 2019

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Medical drug Clinical Criteria updates

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Reimbursement Policy Update: Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

New clinical guideline: pneumatic compression devices, effective December 1, 2019

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Authorization process update for identified HCBS procedure codes

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

March 2019 Medical Policies and Clinical Utilization Management Guidelines update

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

New pregnancy notification process using the Availity Portal Benefit Look-Up Tool

State & FederalMedicare AdvantageOctober 1, 2019

Prior authorization requirements changes effective November 1, 2019

State & FederalMedicare AdvantageOctober 1, 2019

Medical drug Clinical Criteria updates

State & FederalMedicare AdvantageOctober 1, 2019

Medicare preferred continuous glucose monitors

State & FederalMedicare AdvantageOctober 1, 2019

Update: 2019 risk adjustment provider trainings

State & FederalMedicare AdvantageOctober 1, 2019

June 2019 Medical Policies and Clinical Utilization Management Guidelines update

State & FederalMedicare AdvantageOctober 1, 2019

Medicare News -- October 2019

AdministrativeCommercialOctober 1, 2019

Notice of Material Changes/Amendments to Contract and Prior Authorization Changes -- October 2019

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 starred (*) below.

 

Administrative

  • National Accounts 2020 Pre-certification list*

 

Reimbursement Policies

  • Reimbursement Policy update: Place of Service- Professional*

 

Federal Employees Health Benefits (FEHB)

  • Federal Employee Program® Specialty Pharmacy Clinical Site-of-Care prior authorization review*
  • Pre-certification information for the Federal Employee Program*

 

Other Important Updates

  • Medicare and Medicaid News

 

AdministrativeCommercialOctober 1, 2019

Updated Provider Manual

An updated Wisconsin Provider Manual is available online and is effective October 1, 2019.  Failure to Comply With Utilization Management Program content within the Utilization Management Program section was updated to be consistent with notice provided in our July 2019 Newsletter at this link: Update to Provider UM reimbursement penalties and corresponding update to Provider Manual

AdministrativeCommercialOctober 1, 2019

Anthem launches additional changes to anthem.com

Exciting new changes are on the horizon for the public provider site at anthem.com. These next wave of updates include:
  • A new Contact Us page that gives providers easy access to important contact information
  • A redesigned Medicare Advantage page with an improved, effortless user experience
  • Clear and easy access to training and education materials through a new Training and Education page 
  • A new Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)

 

Below is a preview of the new Contact Us and Medicare Advantage page:
Contact us page

Medicare Advantage

AdministrativeCommercialOctober 1, 2019

Anthem engages Matrix to conduct mobile health clinics and in-home assessments for targeted members

Matrix Mobile Bus

 

As we continue our efforts to help ensure our members enrolled in Affordable Care Act (ACA) compliant plans have their chronic conditions assessed and documented each year, Anthem Blue Cross and Blue Shield (Anthem) is engaging Matrix to help encourage members – on our behalf – to schedule a mobile health clinic assessment.  A vendor, Matrix operates the largest fleet of mobile medical centers nationwide and has conducted more than 1,000,000 patient assessments since 1998 – providing convenient access to comprehensive health assessments.

 

The mobile clinic provides members with additional options to help them close any gaps in care that they may have.  In late July, Matrix began reaching out to members on our behalf by letter and phone. Our outreach efforts will continue until the end of this year.

 

Matrix works with hospitals and health plans like Anthem to deliver preventive health testing to the communities Matrix serves. Each mobile clinic has a reception area and private screening rooms. Matrix also helps members with scheduling follow-up appointments with their PCPs at the end of the assessments and forwards the PCPs a copy of any results from the health assessment.

 

Matrix In-Home Assessments

 

Matrix will perform in-home assessments where possible. The in-home assessments offer a board-certified nurse practitioner (NP) to come to a member’s home to provide a general exam, suggestions for important screenings or other tests, a full review of the medicines they take, answers to health-related questions and a personal health summary detailing their health information. A copy of the assessment will be sent to members’ PCPs to ensure continuity of care.

 

The overall goals of the mobile clinic program and the in-home program are to provide convenient, comprehensive appointments that are designed to complement the care provided by our network of physicians. These mobile clinic or in-home visits do not replace any active treatment plans members currently have with their physicians and are not considered wellness visits or a substitute for members’ annual physical examinations.

 

We’re including information about the program in this edition of Provider News should patients contact you about the program. Please refer members directly to Matrix if they have questions or need more information:

 

Mobile Bus: 888-822-3247

In-Home: 855-403-0967

AdministrativeCommercialOctober 1, 2019

National Accounts 2020 Pre-certification list*

The National Accounts 2020 Pre-certification list has been published.

 

Please note: Providers should continue to verify member eligibility and benefits prior to rendering services.

 

* 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.

Reimbursement PoliciesCommercialOctober 1, 2019

Reimbursement Policy update: Place of Service-Professional*

Beginning with dates of service on or after January 1, 2020, services reported by a professional provider with a place of service Telehealth (02) or School (03) will be eligible for non-office place of service reimbursement. 


* 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.

Products & ProgramsCommercialOctober 1, 2019

UPDATE: new AIM Rehabilitative Program will begin November 1, 2019

We announced in July that the AIM Rehabilitative Program for Anthem’s Commercial membership was delayed. The AIM Rehabilitative Program for prior authorization for physical, speech and occupational therapy services is scheduled to relaunch on November 1, 2019. Prior authorization requests for dates of service on or after November 1 may be submitted beginning October 21 via the AIM ProviderPortalSM.

 

Coverage for physical, speech and occupational therapy services with dates of service July 1, 2019 through October 31, 2019 will not require prior authorization; processes have been created to allow providers to continue to provide treatment and to allow claims to adjudicate for those dates of service without authorization.  Claims that were denied for no authorization in error for dates of service after July 1, 2019 are being reprocessed. The OrthoNet program is no longer active in applicable markets.

 

We invite you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the capabilities of the AIM ProviderPortalSM. Visit the AIM Rehabilitation microsite to register for an upcoming training session.

Federal Employee Program (FEP)CommercialOctober 1, 2019

US Antibiotic Awareness Week is November 11-18, 2019

This is a one week observance that gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has many tools for providers at https://www.cdc.gov/antibiotic-use/week/toolkit.html.  Posters, prescriptions pads, social media posts, patient education pieces, sticker and counter clings, and more can be found on the CDC website.

 

During U.S. Antibiotic Awareness Week and throughout the year, the CDC promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use. Be Antibiotics Aware has resources to help healthcare professionals (in outpatient and inpatient settings) educate patients and families about antibiotic use and risks for potential side effects. For more information visit: https://www.cdc.gov/antibiotic-use/?s_cid=NCEZID-AntibioticUse-005.

 

Federal Employee Program (FEP)CommercialOctober 1, 2019

Pre-certification information for the Federal Employee Program*

The Anthem Blue Cross and Blue Shield Service Benefit Plan®, also known as Federal Employee Program®, FEP®, would like to share information about the turnaround times for urgent or non-urgent precertification requests. 

 

Anthem FEP follows the National Committee for Quality Assurance (NCQA) standards for turnaround time for urgent or non-urgent precertification requests which are outlined below:

 

  • Urgent concurrent - 24 hours (1 day)
  • Urgent preservice - 72 hours (3 days)
  • Non-urgent preservice - 15 calendar days
  • Post-service - 30 calendar days

 

In addition, Anthem FEP offers an advanced benefit determination (ABD) for elective services.

 

  • ABD – 15 calendar days

 

This precertification service is offered as a courtesy. If you would like more information regarding the ABD review process or have additional questions, please contact FEP Utilization Management at 800-860-2156, 8:00 a.m. – 7:00 p.m., Monday – Friday.

 

* 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.

Federal Employee Program (FEP)CommercialOctober 1, 2019

Federal Employee Program® Specialty Pharmacy Clinical Site-of-Care prior authorization review*

The July 2019 edition of Provider News notified providers that certain Federal Employee Program® (FEP) plans (member IDs beginning with an “R”) utilize a prior approval process for specific specialty drugs and site of care. The prior approval process identifies members who meet appropriate site-of-care criteria and encourages ordering providers and members to consider using a lower level of care option for specific specialty drugs. There is no claim penalty for site of care under the current prior approval process. FEP will continue to use this process through December 31, 2019.

 

Effective with dates of service on or after January 1, 2020, Anthem FEP will implement a specialty pharmacy prior authorization review process for specific specialty drugs. The prior authorization review will include site-of-care criteria for outpatient hospital-based settings. As a result of this change, services provided on and after January 1, 2020, without a prior authorization will be denied.

 

FEP will continue to review Federal Employee Program medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.

 

What’s new beginning with dates of service on or after January 1, 2020?

 

  • Prior to administering the drugs noted below in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. Anthem FEP will begin accepting prior authorization requests on December 18, 2019 for dates of service on and after January 1, 2020. Request prior authorization review by calling the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.

 

  • Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review.

 

  • o A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.

 

  • o In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.

 

  • If the prior authorization is denied for either the drug not meeting medical necessity or the site-of-care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.

 

  • Services provided on or after January 1, 2020, without prior authorization will result in a denial of claims payment.

 

Drugs requiring medical necessity and site-of-care review:

 

Drug

Code

FEP Medical Policy

(Orencia)

J0129

5.70.18

(Benlysta)

J0490

5.99.01

(Privigen)

J1459

5.20.03

(Cuvitru)

J1555

5.20.08

(Bivigam)

J1556

5.20.03

(Gammaplex)

J1557

5.20.03

(Hizentra)

J1559

5.20.08

(Gamunex-c/Gammaked)

J1561

5.20.03-IV

(Gamunex-c/Gammaked)

J1561

5.20.08-Subq

(Carimune)

J1566

5.20.03

(Octagam)

J1568

5.20.03

(Gammagard liquid)

J1569

5.20.03-IV

(Gammagard liquid)

J1569

5.20.08-Subq

(Flebogamma)

J1572

5.20.03

(HyQvia)

J1575

5.20.08

(Panzyga)

J1599

5.20.03

(Simponi Aria)

J1602

5.70.51

(Remicade)

J1745

5.50.02

(Tysabri)

J2323

5.60.13

(Entyvio)

J3380

5.50.12

(Inflectra)

Q5103

5.50.02

(Renflexis)

Q5104

5.50.02

(Ixifi)

Q5109

5.50.02

 

These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.

 

* 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.

 

PharmacyCommercialOctober 1, 2019

Pharmacy information available at anthem.com

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.

 

PharmacyCommercialOctober 1, 2019

Anthem specialty pharmacy medical step therapy drug list- clarification

In the February and May editions of Provider News, we shared that the following clinical criteria will be effective May 1, 2019 for the non-oncology uses of these drugs. We will now also begin the medical step therapy review process for oncology uses of these drugs starting October 1, 2019.

 

Colony Stimulating Factor Agents ING-CC-0002

 

Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym®.

 

Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Additional information regarding biosimilar drugs can be found by viewing the reference document, “Biosimilar Drugs – What are they?” 

 

Click here to access the Clinical Criteria page on anthem.com.

 

Clinical Criteria

Status

Drug

HCPCS or CPT Code

NDC Code

ING-CC-0002

Preferred Agent

Zarxio®

Q5101

61314-0304-01

61314-0304-10

61314-0312-01

61314-0312-10

61314-0318-01

61314-0318-10

61314-0326-01

61314-0326-10

ING-CC-0002

Non-Preferred Agent

Neupogen®

J1442

55513-0530-01

55513-0530-10

55513-0546-01

55513-0546-10

55513-0924-01

55513-0924-10

55513-0924-91

55513-0209-01

55513-0209-10

55513-0209-91

ING-CC-0002

Non-Preferred Agent

Granix®

J1447

63459-0910-11

63459-0910-12

63459-0910-15

63459-0910-17

63459-0910-36

63459-0912-11

63459-0912-12

63459-0912-15

63459-0912-17

63459-0912-36

ING-CC-0002

Non-Preferred Agent

Nivestym™

Q5110

00069-0291-10

00069-0291-01

00069-0292-01

00069-0292-10

 

PharmacyCommercialOctober 1, 2019

Important update to Anthem’s commercial drug lists

Effective with dates of service on and after October 1, 2019, and in accordance with Anthem Blue Cross and Blue Shield (Anthem)’s Pharmacy and Therapeutic (P&T) process, Anthem will update its commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.

 

To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.

 

Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).

 

To view a summary of changes, click here.

State & FederalMedicare AdvantageOctober 1, 2019

Aspire Telehealth Palliative Care program

Aspire Health* for Medicare members in need of telephonic palliative care

 

The Aspire Telehealth Palliative Care program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on:

  • Helping patients understand their diagnosis.
  • Facilitating conversations with patients and their families around their goals of care.
  • Ensuring patients receive care aligned with their goals and values.

 

The program begins with an initial 30 to 60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need.

 

Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed.

 

Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6 to 8 months with some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to hospice when appropriate.

 

More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.

 

* Aspire Health is an independent company providing telephonic palliative care on behalf of Anthem Blue Cross and Blue Shield.

 

503077MUPENMUB

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

June 2019 Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • *DME.00037 — Added devices that combine cooling and vibration to the Investigational (INV) & not medically necessary (NMN) statement
  • *LAB.00027 — Added Mediator Release Test to INV&NMN statement.
  • *LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7
  • *OR-PR.00003:
    • Clarified medically necessary (MN) position statement criteria 2 to 4
    • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered INV&NMN for all indications
  • *SURG.00011:
    • Added new MN and INV&NMN statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
    • Added new products to INV&NMN statement.
  • *SURG.00045:
    • Added erectile dysfunction, Peyronie’s disease and wound repair to the INV&NMN statement
    • Revised title
  • *SURG.00121:
    • Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications
  • The following AIM Specialty Health® updates were approved on June 6, 2019:
    • Advanced Imaging:
      • Imaging of the Heart
      • Oncologic Imaging
      • Vascular Imaging
    • Proton Beam Therapy
    • Rehabilitative Therapies — Physical Therapy, Occupational Therapy and Speech Therapy (New)

 

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

Publish date

Medical Policy number

Medical Policy title

New or revised

6/13/2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

New

6/13/2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

6/13/2019

*SURG.00011

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

Revised

6/13/2019

SURG.00023

Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

6/13/2019

SURG.00028

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

Revised

6/27/2019

GENE.00025

Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies

 

Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

Revised

6/27/2019

DRUG.00046

Ipilimumab (Yervoy®)

Revised

6/27/2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

6/27/2019

DRUG.00062

Obinutuzumab (Gazyva®)

Revised

6/27/2019

DRUG.00067

Ramucirumab (Cyramza®)

Revised

6/27/2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

6/27/2019

DRUG.00075

Nivolumab (Opdivo®)

Revised

6/27/2019

DRUG.00107

Avelumab (Bavencio®)

Revised

6/27/2019

GENE.00044

Analysis of PIK3CA Status in Tumor Cells

Revised

6/27/2019

*SURG.00121

Transcatheter Heart Valve Procedures

Revised

6/27/2019

GENE.00001

Genetic Testing for Cancer Susceptibility

Revised

6/27/2019

GENE.00043

Genetic Testing of an Individual’s Genome for Inherited Diseases

Revised

6/27/2019

LAB.00011

Analysis of Proteomic Patterns

Revised

6/27/2019

LAB.00015

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

Revised

7/10/2019

GENE.00051

Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

New

7/10/2019

SURG.00153

Cardiac Contractility Modulation Therapy

New

7/10/2019

*DME.00037

Cooling Devices and Combined Cooling/Heating Devices

Revised

7/10/2019

DME.00038

Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

Revised

7/10/2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

7/10/2019

*LAB.00027

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Revised

7/10/2019

*LAB.00033

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

Revised

7/10/2019

MED.00109

Corneal Collagen Cross-Linking

Revised

7/10/2019

*OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

7/10/2019

SURG.00005

Partial Left Ventriculectomy

Revised

7/10/2019

*SURG.00045

Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions

Revised

7/10/2019

SURG.00120

Internal Rib Fixation Systems

Revised

9/4/2019

GENE.00010

Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

 

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for BadgerCare Plus members on July 5, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

6/24/2019

CG-SURG-97

Cardioverter Defibrillators

New

6/27/2019

CG-DRUG-48

Azacitidine (Vidaza®)

Revised

6/27/2019

CG-DRUG-62

Fulvestrant (FASLODEX®)

Revised

6/27/2019

CG-DRUG-106

Brentuximab Vedotin (Adcetris)

Revised

6/27/2019

CG-DRUG-98

Bendamustine Hydrochloride

Revised

6/27/2019

CG-LAB-09

Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain

Revised

6/27/2019

CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

Revised

7/10/2019

CG-SURG-100

Laser Trabeculoplasty and Laser Peripheral Iridotomy

New

7/10/2019

CG-ADMIN-01

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Revised

7/10/2019

CG-ANC-06

Ambulance Services: Ground; Non-Emergent

Revised

7/10/2019

CG-DME-03

Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Revised

7/10/2019

CG-DME-07

Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

Revised

7/10/2019

CG-DME-08

Infant Home Apnea Monitors

Revised

7/10/2019

CG-DME-39

Dynamic Low-Load Prolonged-Duration Stretch Devices

Revised

7/10/2019

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

7/10/2019

CG-DME-45

Ultrasound Bone Growth Stimulation

Revised

7/10/2019

CG-MED-41

Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Revised

7/10/2019

CG-MED-49

Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

Revised

7/10/2019

CG-MED-57

Cardiac Stress Testing with Electrocardiogram

Revised

7/10/2019

CG-MED-59

Upper Gastrointestinal Endoscopy in Adults

Revised

7/10/2019

CG-SURG-11

Surgical Treatment for Dupuytren's Contracture

Revised

7/10/2019

CG-SURG-17

Trigger Point Injections

Revised

7/10/2019

CG-SURG-35

Intracytoplasmic Sperm Injection (ICSI)

Revised

7/10/2019

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Revised

7/10/2019

CG-SURG-81

Cochlear Implants and Auditory Brainstem Implants

Revised

7/10/2019

CG-SURG-85

Hip Resurfacing

Revised

7/10/2019

CG-SURG-93

Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

Revised

9/4/2019

CG-GENE-11

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

New

9/4/2019

CG-GENE-10

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

New

9/4/2019

CG-SURG-101

Ablative Techniques as a Treatment for Barrett’s Esophagus

New

9/4/2019

CG-SURG-102

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

New

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Prior authorization requirements changes effective November 1, 2019

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

 

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Medicaid and Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

  • 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
  • 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
  • 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
  • 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
  • 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
  • 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
  • 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
  • 33271 — Insertion of subcutaneous implantable defibrillator electrode
  • 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
  • 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
  • 81219 — CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9 
  • 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
  • 81302 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
  • 81303 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
  • 81304 —  MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants 
  • 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis)
  • 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis)
  • 81400 — Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency
  • 81401 — Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance
  • 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
  • 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
  • 81407 — Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
  • 81408 — Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
  • 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
  • C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
  • C9043 — Injection, levoleucovorin, 1 mg
  • C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
  • D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
  • D9920 — or management, by report
  • J9999 — Not otherwise classified, antineoplastic drugs
  • S3850 — Genetic testing for sickle cell anemia

 

To request PA, you may use one of the following methods:

  • Web: Availity.com
  • Fax: 1-800-964-3627
  • Phone: 1-855-558-1443

 

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and non-contracted providers who are unable to access Availity may call our Provider Services at 1-855-558-1443 for assistance with PA requirements. To reach Medicare Advantage Provider Services, call the number on the back of member’s ID cards.

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Medical drug Clinical Criteria updates

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

 

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, please use this email.

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Reimbursement Policy Update: Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

(Policy 06-0149, effective 11/30/19)

 

Currently, Anthem Blue Cross and Blue Shield includes Early and Periodic Screening, Diagnosis and Treatment (EPSDT) component services in the reimbursement of preventive medicine evaluation and management (E&M) visits unless they are appended with Modifier 25 to indicate a significant, separately identifiable E&M service by the same physician on the same date of service.

 

However, effective November 30, 2019, the following EPSDT component services will be separately reimbursable from preventive medicine E&M visits:

  • Hearing screening with or without the use of an audiometer or other electronic device
  • Vision screening

 

For additional information, refer to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) reimbursement policy at https://mediproviders.anthem.com/wi.

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

New clinical guideline: pneumatic compression devices, effective December 1, 2019

Category: Medicaid

Anthem Blue Cross and Blue Shield will implement the following clinical guideline effective December 1, 2019, to support the review for unnecessary outpatient pneumatic compression devices (PCDs) postoperative orthopedic procedures.

 

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs

PCDs are used in clinics or can be purchased or rented for home use for prevention and treatment of a number of conditions. PCD therapy involves the use of an inflatable garment and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. This document only addresses the home use of PCDs postoperative outpatient orthopedic procedures for the prevention of deep vein thrombosis (DVT) of the lower limbs.

 

Note: This document addresses devices for the prevention of DVT only. Pneumatic devices used in the treatment or prevention of lymphedema, venous insufficiency and therapy for musculoskeletal injuries are not addressed in this document, nor are devices for prevention of DVT post-major surgical procedures.

 

Not medically necessary

The home use of PCDs for prevention of thromboembolism of the lower limbs following outpatient orthopedic surgery is considered not medically necessary for all indications.

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

Authorization process update for identified HCBS procedure codes

Anthem Blue Cross and Blue Shield (Anthem) is modifying the authorization process for the following home- and community-based services (HCBS) procedure code: Personal Care Services — T1019.

 

The above service will be authorized by Anthem for up to a year at a time, broken down into monthly units (January, February, March, etc.). This change will not allow unused units from a previous month to be provided and paid without prior authorization approval.

 

No additional services will be affected by these changes at this time. 

 

Authorizing services with monthly units will:

  • Allow easier matching of claims to authorizations.
  • Allow case managers to more efficiently track utilized services from month to month, identify gaps in care and more easily make revisions when a member has a change in condition that necessitates service changes.
  • Reduce authorization impact when service needs change. Authorizations can be revised for the impacted months only.
  • Affect only authorizations for members whose annual service plan is due beginning January 1, 2020. 

 

These changes will not:

  • Affect how a provider currently requests or bills for services.
  • Impact authorizations for members whose annual service plan is not due.

 

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-855-558-1443.

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

March 2019 Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Notes/updates

  • CG-DME-44 — Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
  • CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.
  • CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
  • CG-SURG-30 — Tonsillectomy for Children with or without Adenoidectomy was revised to:
    • Spell out number of episodes of throat infections in MN criteria (A1, A2, A3).
    • Clarify criterion addressing parapharyngeal abscess (B4) to say two or more.
    • Add “asthma” as potential condition improved by tonsillectomy in MN criteria (C1b).

The following AIM Specialty Health® updates took effect on September 28, 2019:
  • Advanced Imaging
    • Imaging of the Brain
    • Imaging of the Extremities
    • Imaging of the Spine

 

Medical Policies

On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

Publish date

Medical Policy number

Medical Policy title

New or revised

4/24/2019

MED.00127

Chelation Therapy

New

4/24/2019

GENE.00050

Gene Expression Profiling for Coronary Artery Disease

New

4/24/2019

MED.00128

Insulin Potentiation Therapy

New

4/24/2019

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

New

3/28/2019

DRUG.00088

Atezolizumab (Tecentriq®)

Revised

3/28/2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

4/24/2019

GENE.00045

Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

Revised

4/24/2019

GENE.00010

Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

4/24/2019

SURG.00139

Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

Revised

4/24/2019

GENE.00012

Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

Revised

4/24/2019

SURG.00121

Transcatheter Heart Valve Procedures

Revised

 

Clinical UM Guidelines

On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for members on May 7, 2019.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

3/28/2019

CG-ANC-07

Inpatient Interfacility Transfers

Revised

3/28/2019

CG-DRUG-50

Paclitaxel, protein-bound (Abraxane®)

Revised

3/28/2019

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

Revised

3/28/2019

CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

Revised

4/24/2019

CG-DME-44

Electric Tumor Treatment Field (TTF)

Revised

4/24/2019

CG-DRUG-68

Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

Revised

4/24/2019

CG-GENE-01

Janus Kinase 2, CALR, and MPL Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays

Revised

4/24/2019

CG-GENE-05

Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)

Revised

4/24/2019

CG-MED-82

Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

New

4/24/2019

CG-MED-83

Level of Care: Specialty Pharmaceuticals

New

4/24/2019

CG-SURG-30

Tonsillectomy for Children with or without Adenoidectomy

Revised

5/9/2019

CG-DRUG-113

Inotuzumab ozogamicin (Besponsa®)

New

5/9/2019

CG-GENE-06

Preimplantation Genetic Diagnosis Testing

New

5/9/2019

CG-GENE-07

BCR-ABL Mutation Analysis

New

5/9/2019

CG-GENE-08

Genetic Testing for PTEN Hamartoma Tumor Syndrome

New

5/9/2019

CG-GENE-09

Genetic Testing for CHARGE Syndrome

New

5/9/2019

CG-MED-81

High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

New

5/9/2019

CG-SURG-98

Prostate Multiparametric Magnetic Resonance Imaging

New

5/9/2019

CG-SURG-99

Panniculectomy and Abdominoplasty

New

6/24/2019

CG-SURG-97

Cardioverter Defibrillators

New

 

State & FederalBadgerCare Plus and Medicaid SSI ProgramsOctober 1, 2019

New pregnancy notification process using the Availity Portal Benefit Look-Up Tool

Anthem Blue Cross and Blue Shield (Anthem) offers pregnant women several services and benefits through the New Baby, New LifeSM program. Anthem provides education, support, resources and incentives to members throughout the prenatal and postpartum period. Our goal is to ensure all pregnant members are identified early in their pregnancies so that they can take full advantage of these services.

 

We are working with Availity, the vendor supporting the Benefit Look-Up Tool you may currently use in your OB office, to get information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect members to additional benefits as soon as possible using a few simple steps.

 

How it works

 

When an Anthem member of childbearing age visits the OB office, the office associate is prompted to ask the question “Is the member pregnant?” during the eligibility and benefits inquiry process. If the response is yes, the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other important information including the date of the first prenatal care visit, delivery date and postpartum visit date.

 

This new, user-friendly workflow generates timely information that aids members, providers and Anthem in improving birth outcomes with early intervention.

 

We are working hard to support providers throughout Wisconsin in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to reach out to Provider Services at 1-855-558-1443.

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

State & FederalMedicare AdvantageOctober 1, 2019

Prior authorization requirements changes effective November 1, 2019

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

  • 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
  • 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
  • 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
  • 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
  • 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
  • 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
  • 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
  • 33271 — Insertion of subcutaneous implantable defibrillator electrode
  • 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
  • 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
  • 81219 — CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9
  • 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
  • 81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
  • 81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
  • 81304 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants 
  • 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
  • 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
  • 81400 — Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
  • 81401 — Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
  • 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
  • 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
  • 81407 — Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
  • 81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
  • 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
  • C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
  • C9043 — Injection, levoleucovorin, 1 mg
  • C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
  • D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
  • D9920 — or management, by report
  • J9999 — Not otherwise classified, antineoplastic drugs
  • S3850 — Genetic testing for sickle cell anemia

 

To request PA, you may use one of the following methods:

  • Web: Availity.com
  • Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.

 

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com. Contracted and non-contracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements.

 

503100MUPENMUB

State & FederalMedicare AdvantageOctober 1, 2019

Medical drug Clinical Criteria updates

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

502142MUPENMUB

State & FederalMedicare AdvantageOctober 1, 2019

Medicare preferred continuous glucose monitors

On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 1-833-293-0661.

 

503236MUPENMUB

 

State & FederalMedicare AdvantageOctober 1, 2019

Update: 2019 risk adjustment provider trainings

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory Compliance team developed the following two provider trainings. This update outlines the training series:

 

Medicare risk adjustment and documentation guidance (general)

 

When: Offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 from 1 to 2 p.m. Eastern time

 

Learning objective: This training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

 

Credit: This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.

 

If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.

 

Medicare risk adjustment, documentation and coding guidance (condition specific)

 

When: Offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from 12 noon to 1 p.m. Eastern time

 

Learning objective: This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

 

Credit: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red flag HCCs, part one — Register for recording of live session.

Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.

https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html

 

2. Red Flag HCCs, part two Register for recording of live session.

Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.

https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html

 

3. Opioids and more: substance abuse and dependence — Recording will play upon registration.  4. Acute, chronic and status conditions Recording will play upon registration.

https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html

 
5. Behavioral health November 27, 2019

 

502690MUPENMUB

 

State & FederalMedicare AdvantageOctober 1, 2019

June 2019 Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

Please share this notice with other members of your practice and office staff.

 

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

 

Notes/updates

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

  • DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
  • LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
  • LAB.00033 — clarified investigational and not medically necessary statement to include 4K score and AR-V7
  • OR-PR.00003:
    • Clarified medically necessary 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 for all indications
  • SURG.00011:
    • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
    • Added new products to investigational and not medically necessary statement
  • SURG.00045:
    • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
    • Revised title
  • SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

 

The following AIM Specialty Health® updates were approved on June 6, 2019:

  • Advanced imaging:
    • Imaging of the heart
    • Oncologic imaging
    • Vascular imaging
    • Proton beam therapy
    • Rehabilitative therapies — physical therapy, occupational therapy and speech therapy (new)

 

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

 

Publish date

Medical Policy 

Medical Policy title

New or revised

June 13, 2019

MED.00129

Gene Therapy for Spinal Muscular Atrophy

New

June 13, 2019

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

June 13, 2019

* SURG.00011

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

Revised

June 13, 2019

SURG.00023

Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Revised

June 13, 2019

SURG.00028

Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

Revised

June 27, 2019

GENE.00025

Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors

Revised

June 27, 2019

DRUG.00046

Ipilimumab (Yervoy®)

Revised

June 27, 2019

DRUG.00053

Carfilzomib (Kyprolis®)

Revised

June 27, 2019

DRUG.00062

Obinutuzumab (Gazyva®)

Revised

June 27, 2019

DRUG.00067

Ramucirumab (Cyramza®)

Revised

June 27, 2019

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

June 27, 2019

DRUG.00075

Nivolumab (Opdivo®)

Revised

June 27, 2019

DRUG.00107

Avelumab (Bavencio®)

Revised

June 27, 2019

GENE.00044

Analysis of PIK3CA Status in Tumor Cells

Revised

June 27, 2019

* SURG.00121

Transcatheter Heart Valve Procedures

Revised

June 27, 2019

GENE.00001

Genetic Testing for Cancer Susceptibility

Revised

June 27, 2019

GENE.00043

Genetic Testing of an Individual’s Genome for Inherited Diseases

Revised

June 27, 2019

LAB.00011

Analysis of Proteomic Patterns

Revised

June 27, 2019

LAB.00015

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

Revised

July 10, 2019

GENE.00051

Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

New

July 10, 2019

SURG.00153

Cardiac Contractility Modulation Therapy

New

July 10, 2019

* DME.00037

Cooling Devices and Combined Cooling/Heating Devices

Revised

July 10, 2019

DME.00038

Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

Revised

July 10, 2019

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

July 10, 2019

* LAB.00027

Selected Blood, Serum and Cellular Allergy and Toxicity Tests

Revised

July 10, 2019

* LAB.00033

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

Revised

July 10, 2019

MED.00109

Corneal Collagen Cross-Linking

Revised

July 10, 2019

* OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

Revised

July 10, 2019

SURG.00005

Partial Left Ventriculectomy

Revised

July 10, 2019

* SURG.00045

Extracorporeal Shock Wave Therapy Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions

Revised

July 10, 2019

SURG.00120

Internal Rib Fixation Systems

Revised

September 4, 2019

GENE.00010

Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

Revised

 

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.

 

Publish date

Clinical UM Guideline #

Clinical UM Guideline title

New or revised

June 27, 2019

CG-SURG-97

Cardioverter Defibrillators

New

June 27, 2019

CG-DRUG-98

Bendamustine Hydrochloride

Revised

June 27, 2019

CG-LAB-09

Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain

Revised

June 27, 2019

CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

Revised

July 10, 2019

CG-SURG-100

Laser Trabeculoplasty and Laser Peripheral Iridotomy

New

July 10, 2019

CG-ADMIN-01

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Revised

July 10, 2019

CG-ANC-06

Ambulance Services: Ground; Non-Emergent

Revised

July 10, 2019

CG-DME-03

Neuromuscular Stimulation in the Treatment of Muscle Atrophy

Revised

July 10, 2019

CG-DME-07

Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)

Revised

July 10, 2019

CG-DME-08

Infant Home Apnea Monitors

Revised

July 10, 2019

CG-DME-39

Dynamic Low-Load Prolonged-Duration Stretch Devices

Revised

July 10, 2019

CG-DME-42

Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices

Revised

July 10, 2019

CG-DME-45

Ultrasound Bone Growth Stimulation

Revised

July 10, 2019

CG-MED-41

Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Revised

July 10, 2019

CG-MED-49

Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

Revised

July 10, 2019

CG-MED-57

Cardiac Stress Testing with Electrocardiogram

Revised

July 10, 2019

CG-MED-59

Upper Gastrointestinal Endoscopy in Adults

Revised

July 10, 2019

CG-SURG-11

Surgical Treatment for Dupuytren's Contracture

Revised

July 10, 2019

CG-SURG-17

Trigger Point Injections

Revised

July 10, 2019

CG-SURG-35

Intracytoplasmic Sperm Injection (ICSI)

Revised

July 10, 2019

CG-SURG-49

Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

Revised

July 10, 2019

CG-SURG-81

Cochlear Implants and Auditory Brainstem Implants

Revised

July 10, 2019

CG-SURG-85

Hip Resurfacing

Revised

July 10, 2019

CG-SURG-93

Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction

Revised

September 4, 2019

CG-GENE-11

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

New

September 4, 2019

CG-GENE-10

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

New

September 4, 2019

CG-SURG-101

Ablative Techniques as a Treatment for Barrett’s Esophagus

New

September 4, 2019

CG-SURG-102

Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

New

 

503273MUPENMUB

 

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