Anthem BCBS – Medical Policy and Clinical Guideline Updates

August 2017 ~

Anthem Blue Cross and Blue Shield has posted updates to its medical policies and clinical guidelines. These updates were reviewed on May 4 for Indiana, Kentucky, Missouri, Ohio and Wisconsin and will be implemented on November 1, 2017.

These updated policies are as follows:

  • 00121 – Implantable Interstitial Glucose Sensors
    • This document addresses the use of implantable interstitial glucose sensors (for example, the Eversense™ Continuous Glucose Monitoring System).
  • 00122 – Wilderness Programs
    • This document addresses wilderness programs, including services such as adventure therapy or wilderness therapy when part of wilderness programs provided in an outdoor environment and proposed as a treatment option for a variety of medical conditions or behavioral health disorders.
  • 00148 – Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
    • This document addresses the use of spectral analysis of prostate tissue by fluorescence spectroscopy, which involves using fiber optics to differentiate between normal prostate tissue and suspicious prostate tissue.
  • 00149 – Percutaneous Ultrasonic Ablation of Soft Tissue
    • This document addresses the use of percutaneous ultrasonic ablation (emulsification) of soft tissue for the treatment of any condition.
  • 00150 – Leadless Pacemakers
    • This document addresses a single chamber implantable transcatheter pacing system to monitor and regulate the heart rate and rate-responsive bradycardia.
  • 00062 – Obinutuzumab (Gazyva®)
    • The revised policy clarifies that obinutuzumab is MN as a first-line treatment of CLL/SLL without del(17P) mutation when used in combination with chlorambucil and revised MN criteria for the treatment of follicular lymphoma by adding additional chemotherapy regimens to be used in combination with obinutuzumab
  • 00113 – Artificial Retinal Devices
    • The revised policy adds CPT category III codes 0472T, 0473T.
  • THER-RAD.00002 – Proton Beam Radiation Therapy
    • The revised policy adds existing CPT code 77301 for treatment planning when specified as related to proton beam radiation therapy.
  • 00103 – Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
    • The revised policy adds CPT category III code 0474T for CyPass, replacing 66999 NOC.

New Musculoskeletal Program

Also effective November 1, 2017, Anthem will transition medical necessity review of certain surgeries of the spine and joints, as well as interventional pain treatment for Anthem members to AIM.

According to the insurer, the new musculoskeletal program reviews certain spine and joint surgeries, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. Moving forward, AIM’s clinical guidelines and related Anthem Medical Policies will be applied to the review.

In additional, Anthem’s new program includes a member engagement initiative, designed to educate patients about the surgeries and treatments recommended for them, prior to the scheduled procedure. The insurer states this initiative is designed to reduce anxiety, drive adherence to care plans, motivate preventive action, and improve appropriate use of care. Members will be contacted by email or telephone and provided a link to review educational multimedia programs, based on the order requests providers submit to AIM for the procedures and treatments noted. As they view these multimedia programs, members will have an opportunity to note and submit any questions and concerns. Member input will be sent to practices, providing an opportunity to follow up and provide any additional education and information required.

For surgeries and pain treatment that are scheduled to begin on or after November 1, all providers must contact AIM to obtain pre-service review for the following non-emergency modalities:

Spinal Surgeries – Cervical, thoracic, lumbar, and sacral (including all concurrent spinal procedures and all associated revision surgeries):

  • Fusion surgery
  • Decompression
  • Disc replacement
  • Surgical treatment of scoliosis
  • Sacroiliac joint fusion
  • Total disc arthroplasty
  • Vertobroplasty/kyphoplasty

Joint Replacement (including all associated revision surgeries)

  • Total knee arthroplasty
  • Partial knee replacement
  • Total hip arthroplasty
  • Hip resurfacing
  • Total shoulder arthroplasty
  • Total elbow arthroplasty
  • Total ankle arthroplasty

Interventional Pain Management

  • Spinal cord stimulators
  • Facet injections
  • Epidural steroid injections
  • Percutaneous neurolysis
  • Peripheral nerve blocks for treatment of neuropathic pain
  • Pain management devices
  • Implantable pain pumps
  • Radio ablations
  • Sacroiliac joint

NOTE: Surgeries and pain treatments performed as part of an inpatient admission are included.

All members in the provider’s area are included except for the following groups: Medicare Advantage, (Individual and Employee Group Retiree, or EGR), Medicare supplement, Medicaid, Healthy Indiana-Medicaid, Anthem National Accounts (ANA), Federal Employee Program (FEP), self-funded accounts (ASO), HealthLink, Auto UM groups, MO Mercy Hospital Group, Indiana state sold membership, and Anthem as secondary payer.

CPT ® is a registered trademark of the American Medical Association.


Source(s): Anthem BlueCross BlueShield Network Update;