Connecticut – Anthem BCBS Clinical Guideline Updates

January 2019 ~

On January 1, Anthem BCBS of Connecticut posted new and recently revised clinical guidelines for several medical policies.

According to the insurer, the following new and revised medical policies were endorsed at the November 8, 2018 Medical Policy & Technology Assessment Committee (MPTAC) meeting.

Revised Clinical Guideline effective November 15, 2018

• CG-DRUG-88 – Dupilumab (Dupixent^®)

Revised Clinical Guidelines effective December 12, 2018

• CG-DRUG-62 – Fulvestrant (FASLODEX^®)
• CG-DRUG-63 – Levoleucovorin Products
• CG-DRUG-65 – Tumor Necrosis Factor Antagonists
• CG-DRUG-78 – Antihemophilic Factor and Clotting Factors
• CG-DRUG-107 – Pharmacotherapy for Hereditary Angioedema
• CG-GENE-03 – BRAF Mutation Analysis
• CG-SURG-60 – Cervical Total Disc Arthroplasty
• CG-THER-RAD-03 – Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

Revised Clinical Guidelines effective December 12, 2018

• CG-DRUG-38 – Pemetrexed (Alimta^®)
• CG-DRUG-42 – Asparagine Specific Enzymes (Asparaginase)
• CG-DRUG-44 – Pegloticase (Krystexxa^®)
• CG-DRUG-45 – Octreotide Acetate (Sandostatin, Sandostatin LAR)
• CG-DRUG-54 – Agalsidase beta (Fabrazyme^®)
• CG-DRUG-64 – FDA-Approved Biosimilar Products
• CG-DRUG-66 – Panitumumab (Vectibix^®)
• CG-DRUG-70 – Eribulin mesylate (Halaven^®)
• CG-DRUG-71 – Ziv-aflibercept (Zaltrap^®)
• CG-DRUG-75 – Romiplostim (Nplate^®)
• CG-DRUG-76 – Plerixafor Injection (Mozobil^™)
• CG-DRUG-79 – Siltuximab (Sylvant^®)
• CG-DRUG-80 – Cabazitaxel (Jevtana)
• CG-DRUG-87 – Vedolizumab (Entyvio^®)
• CG-MED-19 – Custodial Care
• CG-MED-26 – Neonatal Levels of Care
• CG-MED-67 – Melanoma Vaccines
• CG-MED-68 – Therapeutic Apheresis
• CG-REHAB-07 – Skilled Nursing and Skilled Rehabilitation Services
• CG-SURG-60 – Cervical Total Disc Arthroplasty
• CG-SURG-62 – Radiofrequency Ablation to Treat Tumors Outside the Liver
• CG-THER-RAD-04 – Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

Revised Clinical Guideline effective December 12, 2018

• CG-DRUG-16 – White Blood Cell Growth Factors

Revised Clinical Guidelines effective December 27, 2018

• CG-BEH-02 – Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-DME-43 – Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
• CG-DRUG-29 – Hyaluronan Injections
• CG-DRUG-61 – Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
• CG-DRUG-68 – Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
• CG-DRUG-90 – Intravitreal Treatment for Retinal Vascular Conditions
• CG-DRUG-94 – Rituximab (Rituxan®) for Non-Oncologic Indications
• CG-MED-74 – Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

Archived Clinical Guideline effective January 1, 2019

• CG-SURG-60 – Cervical Total Disc Arthroplasty

Revised Clinical Guidelines effective January 1, 2019

• CG-DME-40 – Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
• CG-MED-65 – Manipulation Under Anesthesia

Adopted Clinical Guidelines effective January 3, 2019

• CG-MED-79 – Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-MED-80 – Positron Emission Tomography (PET) and PET/CT Fusion

Revised Clinical Guidelines effective April 1, 2019

• CG-DRUG-77 – Radium Ra 223 Dichloride (Xofigo^®)
• CG-GENE-01 – Janus Kinase 2 (JAK2) V617F and JAK2 exon 12 Gene Mutation Assays
• CG-SURG-27 – Sex Reassignment Surgery
• CG-SURG-61 – Cryosurgical Ablation of Solid Tumors Outside the Liver

For more information and full details on these changes, refer to Anthem’s Medical Policies and Clinical UM Guidelines.

Source(s): Anthem BSBS Connecticut Provider Communications;