anthem blue cross and blue shield ga medical …...2/1/2020 revised trans.00035...

Publish

Date

2/1/2020 New CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

9/25/2019 New CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the

Outpatient Setting9/25/2019 New CG-SURG-103 Male Circumcision

2/1/2020 New MED.00130 Surface Electromyography Devices for Seizure Monitoring

CONVERSION

11/12/2019 Conversion

Revised/New

CG-GENE-12 PIK3CA Mutation Testing

REVISED

2/1/2020 Revised CG-ANC-07 Inpatient Interfacility Transfers

Committee

Action

Policy or Guideline

Number

Policy or Guideline Title

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless

there is a group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally,

as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical

Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims

when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted”

for those purposes.

Atlanta, GA 30326

Anthem Blue Cross and Blue Shield

GA Medical Policy and Clinical Guideline Updates 11/1/2019

The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales,

medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be

either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Anthem Blue Cross and Blue Shield and all the Medical Policies are

available at the Anthem Blue Cross and Blue Shield website (Choose Providers > Medical Policies). Please note our medical policies now include NOC (Not Otherwise Classified)

codes to expedite the process of determining services that may require medical review. If you don’t have access to the Internet, you may request a hard copy of a specific Medical or

Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday - Friday from 8 AM to 7 PM or send written requests (specifying medical

policy or guideline of interest, your name and address to where information should be sent) to:

Anthem Blue Cross and Blue Shield

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

2/1/2020 Revised CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the

Extremities

Previous title : Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of 9/25/2019 Revised CG-GENE-02 Analysis of RAS Status

Previous title : Analysis of KRAS Status9/25/2019 Revised CG-MED-39 Bone Mineral Density Testing Measurement

Previous title : Central (Hip or Spine) Bone Density Measurement and Screening for

Vertebral Fractures Using Dual Energy X-Ray Absorptiometry9/25/2019 Revised CG-MED-68 Therapeutic Apheresis

9/25/2019 Revised CG-REHAB-08 Private Duty Nursing in the Home Setting

9/25/2019 Revised CG-SURG-52 Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

9/25/2019 Revised CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter

Defibrillator for the Treatment of Heart Failure9/25/2019 Revised CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver

Malignancies

9/25/2019 Revised CG-SURG-79 Implantable Infusion Pumps

9/25/2019 Revised CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

8/29/2019 Revised DRUG.00071 Pembrolizumab (Keytruda®)

8/29/2019 Revised DRUG.00082 Daratumumab (DARZALEX®)

9/25/2019 Revised GENE.00010 Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

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

Metabolizer Status

9/25/2019 Revised GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment

2/1/2020 Revised GENE.00023 Gene Expression Profiling of Melanomas

9/25/2019 Revised GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome

9/25/2019 Revised GENE.00046 Prothrombin (Factor II) Genetic Testing

Previous Title : Prothrombin G20210A (Factor II) Mutation Testing

2/1/2020 Revised MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft

Tissue Grafting, and Regenerative Therapy8/29/2019 Revised OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis

8/29/2019 Revised RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

2/1/2020 Revised SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures

9/25/2019 Revised SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or

Snoring2/1/2020 Revised TRANS.00035 Non-Hematopoietic Adult Stem Cell Therapy

Previous title : Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament

Disorders, Autoimmune, Inflammatory and Degenerative Diseases

REVIEWED

9/25/2019 Reviewed ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable

Medical Policy or Clinical Utilization Management (UM) Guideline9/25/2019 Reviewed BEH.00002 Transcranial Magnetic Stimulation

9/25/2019 Reviewed CG-ANC-03 Acupuncture

9/25/2019 Reviewed CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion

Pump During the Post-Operative Period9/25/2019 Reviewed CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia

9/25/2019 Reviewed CG-DME-16 Pressure Reducing Support Surfaces - Groups 1, 2 & 3

9/25/2019 Reviewed CG-DME-18 Home Oxygen Therapy

9/25/2019 Reviewed CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses

9/25/2019 Reviewed CG-DME-23 Lifting Devices for Use in the Home

9/25/2019 Reviewed CG-DME-25 Seat Lift Mechanisms

9/25/2019 Reviewed CG-DME-26 Back-Up Ventilators in the Home Setting

9/25/2019 Reviewed CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use

9/25/2019 Reviewed CG-DME-44 Electric Tumor Treatment Field (TTF)

9/25/2019 Reviewed CG-GENE-03 BRAF Mutation Analysis

9/25/2019 Reviewed CG-LAB-10 Zika Virus Testing

9/25/2019 Reviewed CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals

9/25/2019 Reviewed CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting

9/25/2019 Reviewed CG-MED-02 Esophageal pH Monitoring

9/25/2019 Reviewed CG-MED-08 Home Enteral Nutrition

9/25/2019 Reviewed CG-MED-24 Electromyography and Nerve Conduction Studies

9/25/2019 Reviewed CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring

9/25/2019 Reviewed CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies

9/25/2019 Reviewed CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography

9/25/2019 Reviewed CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries

9/25/2019 Reviewed CG-MED-62 Resting Electrocardiogram Screening in Adults

9/25/2019 Reviewed CG-MED-63 Treatment of Hyperhidrosis

9/25/2019 Reviewed CG-MED-65 Manipulation Under Anesthesia

9/25/2019 Reviewed CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue

9/25/2019 Reviewed CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures

9/25/2019 Reviewed CG-REHAB-04 Physical Therapy

9/25/2019 Reviewed CG-REHAB-05 Occupational Therapy

9/25/2019 Reviewed CG-REHAB-06 Speech-Language Pathology Services

9/25/2019 Reviewed CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)

9/25/2019 Reviewed CG-SURG-01 Colonoscopy

9/25/2019 Reviewed CG-SURG-15 Endometrial Ablation

9/25/2019 Reviewed CG-SURG-28 Transcatheter Uterine Artery Embolization

9/25/2019 Reviewed CG-SURG-31 Treatment of Keloids and Scar Revision

9/25/2019 Reviewed CG-SURG-37 Destruction of Pre-Malignant Skin Lesions

9/25/2019 Reviewed CG-SURG-40 Cataract Removal Surgery for Adults

9/25/2019 Reviewed CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization

of the Lower Extremities9/25/2019 Reviewed CG-SURG-57 Diagnostic Nasal Endoscopy

9/25/2019 Reviewed CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions

9/25/2019 Reviewed CG-SURG-59 Vena Cava Filters

9/25/2019 Reviewed CG-SURG-90 Mohs Micrographic Surgery

9/25/2019 Reviewed CG-SURG-100 Laser Trabeculoplasty and Laser Peripheral Iridotomy

9/25/2019 Reviewed DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and

Percutaneous Devices9/25/2019 Reviewed DME.00012 Intrapulmonary Percussive Ventilation Devices for Airway Clearance

9/25/2019 Reviewed GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site

9/25/2019 Reviewed GENE.00020 Gene Expression Profile Tests for Multiple Myeloma

9/25/2019 Reviewed GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis

9/25/2019 Reviewed GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies

9/25/2019 Reviewed GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing

9/25/2019 Reviewed LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver

Disease9/25/2019 Reviewed LAB.00028 Serum Biomarker Tests for Multiple Sclerosis

9/25/2019 Reviewed LAB.00029 Rupture of Membranes Testing in Pregnancy

9/25/2019 Reviewed LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to

Monoclonal Antibody Drugs9/25/2019 Reviewed MED.00055 Wearable Cardioverter Defibrillators

9/25/2019 Reviewed MED.00082 Quantitative Sensory Testing

9/25/2019 Reviewed MED.00085 Antineoplaston Therapy

9/25/2019 Reviewed MED.00089 Quantitative Muscle Testing Devices

9/25/2019 Reviewed MED.00095 Anterior Segment Optical Coherence Tomography

9/25/2019 Reviewed MED.00096 Low-Frequency Ultrasound Therapy for Wound Management

9/25/2019 Reviewed MED.00099 Electromagnetic Navigational Bronchoscopy

9/25/2019 Reviewed MED.00103 Automated Evacuation of Meibomian Gland

9/25/2019 Reviewed OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

9/25/2019 Reviewed RAD.00037 Whole Body Computed Tomography Scanning

9/25/2019 Reviewed RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary

Imaging9/25/2019 Reviewed RAD.00061 PET/MRI

9/25/2019 Reviewed RAD.00062 Intravascular Optical Coherence Tomography (OCT)

9/25/2019 Reviewed RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission

Computed Tomography (SPECT)9/25/2019 Reviewed SURG.00008 Mechanized Spinal Distraction Therapy

9/25/2019 Reviewed SURG.00037 Treatment of Varicose Veins (Lower Extremities)

9/25/2019 Reviewed SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

9/25/2019 Reviewed SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the

Appendicular System9/25/2019 Reviewed SURG.00088 Coblation® Therapies for Musculoskeletal Conditions

9/25/2019 Reviewed SURG.00092 Implanted Devices for Spinal Stenosis

9/25/2019 Reviewed SURG.00095 Viscocanalostomy and Canaloplasty

9/25/2019 Reviewed SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent

9/25/2019 Reviewed SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

9/25/2019 Reviewed SURG.00114 Facet Joint Allograft Implants for Facet Disease

9/25/2019 Reviewed SURG.00119 Endobronchial Valve Devices

9/25/2019 Reviewed SURG.00127 Sacroiliac Joint Fusion

9/25/2019 Reviewed SURG.00128 Implantable Left Atrial Hemodynamic Monitor

9/25/2019 Reviewed SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of

Gastroesophageal Reflux Disease (GERD)

9/25/2019 Reviewed SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves

9/25/2019 Reviewed SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia

9/25/2019 Reviewed SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous

Ventricular Assist Devices and Artificial Hearts)

11/1/2019 Reviewed SURG.00153 Cardiac Contractility Modulation Therapy

9/25/2019 Reviewed TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease

Cardiology

By AIM AIM Clinical Appropriateness Guidelines:

• Advanced Imaging – Imaging of the Heart: Cardiac CT for Quantitative Evaluation of

Coronary CalcificationMusculoskeletal


• Spine Surgery


• Spine Surgery

(continued)Radiation Oncology


• Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body

radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines

Clinical Appropriateness Guidelines:

• Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body

radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines

(continued)

Radiology

THIRD PARTY CRITERIA


• Advanced Imaging – Imaging of the Abdomen and PelvisBy AIM AIM Clinical Appropriateness Guidelines:

• Advanced Imaging – Imaging of the Abdomen and Pelvis

(continued)By AIM AIM Clinical Appropriateness Guidelines:








(continued)Sleep Disorder Management


• Sleep Disorder Management Diagnostic & Treatment GuidelinesNot to be used on or

after (date)

ARCHIVED

11/12/2019 Archived CG-SURG-80 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization

(TAE) for Treating Primary or Metastatic Liver Tumors

11/12/2019 Archived CG-THER-RAD-04 Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

9/25/2019 Archived MED.00041 Microvolt T-Wave Alternans

11/12/2019 Archived RAD.00004 Peripheral Bone Mineral Density Measurement

9/25/2019 Archived RAD.00040 PET Scanning Using Gamma Cameras

CODING

10/1/2019 Coding Updates

of Existing

Documents

CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain


of Existing

Documents

CG-MED-42 Maternity Ultrasound in the Outpatient Setting


of Existing

Documents

CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of

Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)


of Existing

Documents

CG-SURG-09 Temporomandibular Disorders


of Existing

Documents

CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic

Dissection and Aortic Transection


of Existing

Documents

CG-SURG-97 Cardioverter Defibrillators


of Existing

Documents

GENE.00001 Genetic Testing for Cancer Susceptibility


of Existing

Documents

GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer


of Existing

Documents

GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent


of Existing

Documents

GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility


of Existing

Documents

GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens


of Existing

Documents

GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases


of Existing

Documents

LAB.00011 Analysis of Proteomic Patterns


of Existing

Documents

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

Tissue Grafting


of Existing

Documents

SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency


of Existing

Documents

TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation


of Existing

Documents

TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell

Dyscrasias


of Existing

Documents

TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic

Syndrome


of Existing

Documents

TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors


of Existing

Documents

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin

Lymphoma


of Existing

Documents

TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias


of Existing

Documents

TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors


of Existing

Documents

TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous

Solid Tumors


of Existing

Documents

TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

Obstetrics and Gynecology

11/1/2019 MCG -

Customization

W0163 Repair of Pelvic Organ Prolapse

MCG Coding Update

11/1/2019 Revised MED.00129 Gene Therapy for Spinal Muscular Atrophy