Anthem BCBS Medical Policy Updates –  August 2018

Click here to view the Anthem Blue Cross Blue Shield Medical Policy Updates »

 August 2018 Medical Policy Updates:

• ADMIN.00002 Preventive Health Guidelines
• ADMIN.00004 Medical Necessity Criteria
• ADMIN.00005 Investigational Criteria
• ADMIN.00007 Immunizations
• ANC.00006 Biomagnetic Therapy
• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• CG-ADMIN-02 Clinically Equivalent Cost Effective Services – Targeted Immune Modulators
• CG-ANC-06 Ambulance Services: Ground; Non-Emergent
• CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
• CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
• CG-DME-05 Cervical Traction Devices for Home Use
• CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
• CG-DME-08 Infant Home Apnea Monitors
• CG-DME-15 Hospital Beds and Accessories
• CG-DME-35 Electric Breast Pumps
• CG-DME-36 Pediatric Gait Trainers
• CG-DRUG-05 Recombinant Erythropoietin Products
• CG-DRUG-09 Immune Globulin (Ig) Therapy
• CG-DRUG-11 Infertility Drugs
• CG-DRUG-21 Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence
• CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
• CG-DRUG-31 Oncology Drug Treatment Regimens for Adults **NOTE: At this time, this guideline is not implemented for medical benefit determinations
• CG-DRUG-33 Palonosetron
• CG-DRUG-47 Level of Care: Specialty Pharmaceuticals
• CG-DRUG-56 Galsulfase (Naglazyme®)
• CG-DRUG-65 Tumor Necrosis Factor Antagonists
• CG-DRUG-68 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
• CG-DRUG-69 Ustekinumab (Stelara®)
• CG-DRUG-72 Pertuzumab (Perjeta®)
• CG-DRUG-73 Denosumab (Prolia®, Xgeva®)
• CG-DRUG-81 Tocilizumab (Actemra®)
• CG-DRUG-90 Intravitreal Treatment for Retinal Vascular Conditions
• CG-GENE-02 Analysis of KRAS Status
• CG-GENE-03 BRAF Mutation Analysis
• CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
• CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
• CG-MED-26 Neonatal Levels of Care
• CG-MED-35 Retinal Telescreening Systems
• CG-MED-40 External Ambulatory Event Monitors to Detect Cardiac Arrhythmias
• CG-MED-44 Holter Monitors
• CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
• CG-MED-57 Cardiac Stress Testing with Electrocardiogram (ECG)
• CG-MED-58 Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI
• CG-MED-68 Therapeutic Apheresis
• CG-MED-71 Wound Care in the Home Setting
• CG-REHAB-03 Pulmonary Rehabilitation
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• CG-SURG-01 Colonoscopy
• CG-SURG-05 Maze Procedure
• CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib
• CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-11 Surgical Treatment for Dupuytren’s Contracture
• CG-SURG-12 Penile Prosthesis Implantation
• CG-SURG-25 Injection Treatment for Morton’s Neuroma
• CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar Facet Injections
• CG-SURG-33 Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA)
• CG-SURG-34 Diagnostic Infertility Surgery
• CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
• CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
• CG-SURG-39 Pain Management: Epidural Steroid Injections
• CG-SURG-42 Cervical Fusion
• CG-SURG-43 Knee Arthroscopy
• CG-SURG-44 Coronary Angiography in the Outpatient Setting
• CG-SURG-45 Bone Graft Substitutes
• CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity
• CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI)
• CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-50 Assistant Surgeons
• CG-SURG-51 Outpatient Cystourethroscopy
• CG-SURG-53 Elective Total Hip Arthroplasty
• CG-SURG-54 Elective Total Knee Arthroplasty
• CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
• CG-SURG-60 Cervical Total Disc Arthroplasty
• CG-SURG-65 Recombinant Human Bone Morphogenetic Protein
• CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
• CG-SURG-67 Treatment of Osteochondral Defects
• CG-SURG-68 Surgical Treatment of Femoroacetabular Impingement Syndrome
• CG-SURG-69 Meniscal Allograft Transplantation of the Knee
• CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
• DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease
• DME.00030 Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
• DME.00034 Standing Frames
• DME.00037 Cooling Devices and Combined Cooling/Heating Devices
• DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
• DRUG.00003 Chelation Therapy
• DRUG.00015 Prevention of Respiratory Syncytial Virus Infections
• DRUG.00031 Subcutaneous Hormone Replacement Implants
• DRUG.00046 Ipilimumab (Yervoy®)
• DRUG.00050 Eculizumab (Soliris®)
• DRUG.00075 Nivolumab (Opdivo®)
• DRUG.00088 Atezolizumab (Tecentriq™)
• DRUG.00089 Daclizumab (Zinbryta™)
• DRUG.00095 Ocrelizumab (Ocrevus™)
• DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®)
• DRUG.00111 Guselkumab (Tremfya™)
• GENE.00006 Epidermal Growth Factor Receptor (EGFR) Testing
• GENE.00021 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors
• GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome
• GENE.00041 Short Tandem Repeat Analysis for Specimen Provenance Testing
• GENE.00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome
• GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases
• LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• LAB.00031 Advanced Lipoprotein Testing
• LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
• LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
• MED.00024 Adoptive Immunotherapy and Cellular Therapy
• MED.00055 Wearable Cardioverter Defibrillators
• MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
• MED.00098 Hyperoxemic Reperfusion Therapy
• MED.00106 Autologous Cellular Immunotherapy for the Treatment of Prostate Cancer
• MED.00121 Implantable Interstitial Glucose Sensors
• OR-PR.00005 Upper Extremity Myoelectric Orthoses
• RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion
• RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
• RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
• SURG.00005 Partial Left Ventriculectomy
• SURG.00010 Treatments for Urinary Incontinence
• SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
• SURG.00071 Percutaneous and Endoscopic Spinal Surgery
• SURG.00076 Nerve Graft after Prostatectomy
• SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
• SURG.00084 Implantable Middle Ear Hearing Aids
• SURG.00105 Bicompartmental Knee Arthroplasty
• SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
• SURG.00118 Bronchial Thermoplasty
• SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation
• SURG.00122 Venous Angioplasty with or without Stent Placement
• SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
• SURG.00126 Irreversible Electroporation (IRE)
• SURG.00133 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
• SURG.00134 Interspinous Process Fixation Devices
• SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
• SURG.00143 SpaceOAR® System
• TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

Click here to view the Anthem Blue Cross Blue Shield Medical Policy Updates »

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