anthem blue cross and blue shield ga medical policy and

Publish

Date

4/24/2019 New GENE.00050 Gene Expression Profiling for Coronary Artery Disease

9/1/2019 New SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

CONVERSION

5/9/2019Conversion

NewCG-DRUG-113 Inotuzumab ozogamicin (Besponsa®)

5/9/2019 Archived DRUG.00110 Inotuzumab ozogamicin (Besponsa®)

5/9/2019 Conversion

New

CG-GENE-06 Preimplantation Genetic Diagnosis Testing

5/9/2019 Archived GENE.00002 Preimplantation Genetic Diagnosis Testing

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.

Committee

ActionPolicy or Guideline Number

Policy or Guideline Title

Atlanta, GA 30326

Anthem Blue Cross and Blue Shield

GA Medical Policy and Clinical Guideline Updates 5/1/2019

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

5/9/2019 Conversion

New

CG-GENE-07 BCR-ABL Mutation Analysis

5/9/2019 Archived GENE.00005 BCR-ABL Mutation Analysis

5/9/2019 Conversion

New

CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome

5/9/2019 Archived GENE.00031 Genetic Testing for PTEN Hamartoma Tumor Syndrome

5/9/2019 Conversion

New

CG-GENE-09 Genetic Testing for CHARGE Syndrome

5/9/2019 Archived GENE.00040 Genetic Testing for CHARGE Syndrome

5/9/2019 Conversion

New

CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

5/9/2019 Archived MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

6/24/2019 Conversion

New

CG-SURG-97 Cardioverter Defibrillators

6/24/2019 Archived SURG.00033 Cardioverter Defibrillators

5/9/2019 Conversion

New

CG-SURG-99 Panniculectomy and Abdominoplasty

5/9/2019 Archived SURG.00048 Panniculectomy and Abdominoplasty

RECATEGORIZED

4/24/2019 Recategorized CG-MED-82 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

4/24/2019 Archived CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

REVISED

7/1/2019 Revised CG-ANC-07 Inpatient Interfacility Transfers

9/1/2019 Revised CG-DME-44 Electric Tumor Treatment Field (TTF)

3/28/2019 Revised CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®)

4/24/2019 Revised CG-DRUG-68 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

3/28/2019 Revised CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla®)

4/24/2019 Revised 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

3/28/2019 Revised CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules

4/24/2019 Revised CG-GENE-05 Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)

9/1/2019 Revised CG-MED-72 Hyperthermia for Cancer Therapy

4/24/2019 Revised CG-REHAB-08 Private Duty Nursing in the Home Setting

4/24/2019 Revised CG-SURG-09 Temporomandibular Disorders

4/24/2019 Revised CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy

4/24/2019 Revised CG-SURG-74 Total Ankle Replacement

4/24/2019 Revised DME.00032 Automated External Defibrillators for Home Use

3/28/2019 Revised DRUG.00053 Carfilzomib (Kyprolis®)

4/24/2019 Revised DRUG.00076 Blinatumomab (Blincyto®)

3/28/2019 Revised DRUG.00082 Daratumumab (DARZALEX®)

3/28/2019 Revised DRUG.00088 Atezolizumab (Tecentriq®)

4/24/2019 Revised GENE.00007 Cardiac Ion Channel Genetic Testing

4/24/2019 Revised GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

4/24/2019 Revised GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies

(including arrhythmogenic right ventricular dysplasia/cardiomyopathy)

Previous title: Genetic Testing for Diagnosis and Management of Hereditary

Cardiomyopathies (including ARVD/C)9/1/2019 Revised GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases

4/24/2019 Revised GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in

Lymphoid Cancers4/24/2019 Revised MED.00053 Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient

Setting

Prior title: Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) 9/1/2019 Revised MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)

4/24/2019 Revised MED.00125 Biofeedback and Neurofeedback

4/24/2019 Revised SURG.00022 Lung Volume Reduction Surgery

4/24/2019 Revised SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation

4/24/2019 Revised SURG.00121 Transcatheter Heart Valve Procedures

REVIEWED

4/24/2019 Reviewed ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

4/24/2019 Reviewed CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder

4/24/2019 Reviewed CG-DME-06 Pneumatic Compression Devices for Lymphedema

4/24/2019 Reviewed CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

4/24/2019 Reviewed CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®), and Direct

Thrombin Inhibitors in the Outpatient Setting

4/24/2019 Reviewed CG-DRUG-34 Docetaxel (Taxotere®)

Previous title: Docetaxel (Docefrez™, Taxotere®)

4/24/2019 Reviewed CG-DRUG-48 Azacitidine (Vidaza®)

4/24/2019 Reviewed CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection

4/24/2019 Reviewed CG-DRUG-51 Romidepsin (Istodax®)

4/24/2019 Reviewed CG-DRUG-53 Drug Dosage, Frequency, and Route of Administration

4/24/2019 Reviewed CG-DRUG-60 Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications

4/24/2019 Reviewed CG-DRUG-62 Fulvestrant (FASLODEX®)

4/24/2019 Reviewed CG-DRUG-67 Cetuximab (Erbitux®)

3/28/2019 Reviewed CG-DRUG-98 Bendamustine Hydrochloride

4/24/2019 Reviewed CG-DRUG-100 Interferon gamma-1b (Actimmune)

4/24/2019 Reviewed CG-DRUG-101 Ixabepilone (Ixempra®)

4/24/2019 Reviewed CG-DRUG-102 Olaratumab (Lartruvo™)

4/24/2019 Reviewed CG-GENE-02 Analysis of KRAS Status

4/24/2019 Reviewed CG-LAB-12 Testing for Oral and Esophageal Cancer

4/24/2019 Reviewed CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

4/24/2019 Reviewed CG-MED-37 Intensive Programs for Pediatric Feeding Disorders

4/24/2019 Reviewed CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

4/24/2019 Reviewed CG-MED-45 Transrectal Ultrasonography

4/24/2019 Reviewed CG-MED-47 Fundus Photography

4/24/2019 Reviewed CG-MED-48 Scrotal Ultrasound

4/24/2019 Reviewed CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials

4/24/2019 Reviewed CG-MED-52 Allergy Immunotherapy (Subcutaneous)

4/24/2019 Reviewed CG-MED-55 Level of Care: Advanced Radiologic Imaging

4/24/2019 Reviewed CG-MED-69 Inhaled Nitric Oxide

4/24/2019 Reviewed CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

4/24/2019 Reviewed CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces

4/24/2019 Reviewed CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar

4/24/2019 Reviewed CG-REHAB-10 Level of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-

Language Pathology Services4/24/2019 Reviewed CG-SURG-01 Colonoscopy

4/24/2019 Reviewed CG-SURG-17 Trigger Point Injections

4/24/2019 Reviewed CG-SURG-18 Septoplasty

4/24/2019 Reviewed CG-SURG-36 Adenoidectomy

4/24/2019 Reviewed CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion

4/24/2019 Reviewed CG-SURG-55 Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation

4/24/2019 Reviewed CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

4/24/2019 Reviewed CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

4/24/2019 Reviewed CG-SURG-80 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial

Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

4/24/2019 Reviewed CG-TRANS-02 Kidney Transplantation

4/24/2019 Reviewed DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting

4/24/2019 Reviewed DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

4/24/2019 Reviewed DRUG.00107 Avelumab (Bavencio®)

4/24/2019 Reviewed DRUG.00109 Durvalumab (Imfinzi®)

4/24/2019 Reviewed GENE.00001 Genetic Testing for Cancer Susceptibility

4/24/2019 Reviewed GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

4/24/2019 Reviewed GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

9/1/2019 Reviewed GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

4/24/2019 Reviewed GENE.00023 Gene Expression Profiling of Melanomas

4/24/2019 Reviewed GENE.00026 Cell-Free Fetal DNA-Based Prenatal Testing

4/24/2019 Reviewed GENE.00038 Genetic Testing for Statin-Induced Myopathy

4/24/2019 Reviewed LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

4/24/2019 Reviewed LAB.00011 Analysis of Proteomic Patterns

4/24/2019 Reviewed LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

4/24/2019 Reviewed LAB.00025 Topographic Genotyping

4/24/2019 Reviewed MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy,

Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

4/24/2019 Reviewed MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State

4/24/2019 Reviewed MED.00024 Adoptive Immunotherapy and Cellular Therapy

4/24/2019 Reviewed MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

4/24/2019 Reviewed MED.00059 Idiopathic Environmental Illness (IEI)

4/24/2019 Reviewed MED.00077 In-Vivo Analysis of Gastrointestinal Lesions

4/24/2019 Reviewed MED.00087 Imaging Techniques for Screening and Identification of Cervical Cancer

4/24/2019 Reviewed MED.00102 Ultrafiltration in Decompensated Heart Failure

4/24/2019 Reviewed MED.00104 Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin

4/24/2019 Reviewed MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of

Lymphedema4/24/2019 Reviewed MED.00111 Intracardiac Ischemia Monitoring

4/24/2019 Reviewed MED.00112 Autonomic Testing

4/24/2019 Reviewed MED.00118 Continuous Monitoring of Intraocular Pressure

4/24/2019 Reviewed MED.00120 Voretigene neparvovec-rzyl (Luxturna®)

Previously titled: Voretigene neparvovec-rzyl (Luxturna™)

4/24/2019 Reviewed OR-PR.00004 Partial-Hand Myoelectric Prosthesis

4/24/2019 Reviewed RAD.00001 Computed Tomography to Detect Coronary Artery Calcification

4/24/2019 Reviewed RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

4/24/2019 Reviewed RAD.00040 PET Scanning Using Gamma Cameras

4/24/2019 Reviewed RAD.00044 Magnetic Resonance Neurography

4/24/2019 Reviewed RAD.00052 Positional MRI

4/24/2019 Reviewed RAD.00054 MRI of the Bone Marrow

4/24/2019 Reviewed RAD.00059 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial

Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous

System (CNS) and Spinal Cord4/24/2019 Reviewed SURG.00016 Stereotactic Radiofrequency Pallidotomy

4/24/2019 Reviewed SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons

4/24/2019 Reviewed SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions

4/24/2019 Reviewed SURG.00053 Unicondylar Interpositional Spacer

4/24/2019 Reviewed SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence

4/24/2019 Reviewed SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses

4/24/2019 Reviewed SURG.00062 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion

Syndrome4/24/2019 Reviewed SURG.00070 Photocoagulation of Macular Drusen

4/24/2019 Reviewed SURG.00072 Lysis of Epidural Adhesions

4/24/2019 Reviewed SURG.00075 Intervertebral Stabilization Devices

4/24/2019 Reviewed SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation

4/24/2019 Reviewed SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

4/24/2019 Reviewed SURG.00107 Prostate Saturation Biopsy

4/24/2019 Reviewed SURG.00113 Artificial Retinal Devices

4/24/2019 Reviewed SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

4/24/2019 Reviewed SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

4/24/2019 Reviewed SURG.00137 Focused Microwave Thermotherapy for Breast Cancer

4/24/2019 Reviewed SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with

Radiofrequency Spectroscopy or Optical Coherence Tomography 4/24/2019 Reviewed SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy

4/24/2019 Reviewed SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue

4/24/2019 Reviewed SURG.00150 Leadless Pacemaker

4/24/2019 Reviewed SURG.00151 Balloon Dilation of Eustachian Tube

4/24/2019 Reviewed TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation

4/24/2019 Reviewed TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation

4/24/2019 Reviewed TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation

4/24/2019 Reviewed TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

4/24/2019 Reviewed TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin

Lymphoma4/24/2019 Reviewed TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous

Solid Tumors 4/24/2019 Reviewed TRANS.00035 Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders,

Autoimmune, Inflammatory and Degenerative Diseases

THIRD PARTY CRITERIA

Radiology

Clinical Appropriateness Guidelines:

• Advanced Imaging – Imaging of the Brain


• Advanced Imaging – Imaging of the Extremities


• Advanced Imaging – Imaging of the Spine


• Advanced Imaging – Imaging of the Head and Neck

Cardiology

By AIM AIM

Clinical Appropriateness Guidelines

• Advanced Imaging – Imaging of the Heart


• Percutaneous Coronary Intervention


• Percutaneous Coronary Intervention

Musculoskeletal

By AIM AIMClinical Appropriateness Guidelines

• Level of Care for Musculoskeletal Surgery and Procedures

Radiation Oncology

By AIM AIMClinical Appropriateness Guidelines

• Radiation Oncology – Proton Beam Therapy Guidelines

MCG MCG

MCG GUIDELINES 23rd EDITION and CUSTOMIZATION from the 22nd EDITION TO THE

23rd EDITION

MCG GUIDELINES 23rd EDITION - LICENSED MODULE

6/24/2019 New Module MCG Inpatient & Surgical Care (ISC)

General Recovery Care (GRG)

Recovery Facility Care (RFC)

Chronic Care (CCG)

Behavioral Health Care (BHG)

By AIM AIM

6/24/2019 New Module MCG Potentially Clinically Relevant Changes from 22nd to 23rd edition: ISC and GRG

Identified by MCG – Expanded, Tightened and Revised Criteria

• Hypertension ORG: M-197 (ISC)

• Myocardial Infarction ORG: M-230 (ISC)

• Aortic Aneurysm, Abdominal, Repair or Excision with Graft Replacement ORG: S-130

(ISC)

• Aortic Aneurysm, Thoracic, Repair with Graft ORG: S-140 (ISC)

• Liver Disease Complications ORG: M-570 (ISC)

• Telemetry Guidelines LOC: LOC-003 (ISC)

• Neonatal Jaundice ORG: P-265 (ISC)

• Introduction to Observation Care Guidelines

• Urethral Suspension Procedures ORG: S-850 (ISC)

• Asthma, Pediatric ORG: P-60 (ISC)

• Failure to Thrive ORG: P-187 (ISC)

• Malnutrition: Common Complications and Conditions CCC-023 (ISC) and Systemic or

Infectious Condition GRG MG-SIC (ISC GRG)

• Hip Arthroplasty ORG: S-560 (ISC)

• Knee Arthroplasty, Total ORG: S-700 (ISC)

• Gastroenterology GRG: MG-GAS and Pediatrics GRG PG-PED

• Thoracic Surgery or Procedure GRG: SG-TS

6/24/2019 New Module MCG Potentially Clinically Relevant Changes from 22nd to 23rd edition: ISC and GRG

(continued)

Identified by OMPTA – Potentially More Restrictive

• Cardiac Valvotomy, Percutaneous S-292 (ISC)

• Patent Ductus Arteriosus, Open, Thoracoscopic, or Transcatheter Closure ORG: S-950

(ISC)

• Vitrectomy ORG: S-1190 (ISC)

• Headaches ORG: M-185 (ISC)

• Urinary Tract Infection (UTI) ORG: M-300 (ISC)

• Cholecystectomy ORG: S-360 (ISC)

Cholecystectomy by Laparoscopy ORG: S-365 (ISC)

• Chronic Obstructive Pulmonary Disease ORG: M-100 (ISC)

• Mediastinoscopy ORG: S-868 (ISC)

• Supraventricular Arrhythmias ORG: M-510 (ISC)

Select criteria from ISC guidelines moved to Observation Care Guidelines or present in

current Observation Care Guidelines

• Asthma, Pediatric ORG: P-60 (ISC)

• Asthma ORG: M-60 (ISC)

• Chemotherapy, Pediatric ORG: P-87 (ISC)

• Chemotherapy ORG: M-87 (ISC)

• Inflammatory Bowel Disease ORG: M-565 (ISC)

• Sickle Cell Disease, Pediatric ORG: P-432 (ISC)

• Vomiting, Pediatric ORG: P-371 (ISC)

• Sepsis and Other Febrile Illness, without Focal Infection ORG: M-160 (ISC)

• Sepsis and Other Febrile Illness, without Focal Infection, Pediatric ORG: P-410 (ISC)

• Syncope, Pediatric ORG: P-448 (ISC)

6/24/2019 New Module MCG ISC Goal Length of Stay (GLOS) Changes

Cardiovascular Surgery

• Coronary Artery Bypass Graft, Minimally Invasive Direct (MIDCAB) S-392 (Change from

2 days postoperative to 3 days postoperative)

Endocrinology

• Diabetes M-130 (Change from Ambulatory or 1 day to Ambulatory or 2 days)

Gastroenterology

• Gastroenteritis M-170 (Change from Ambulatory or 1 day to Ambulatory or 2 days)

General Surgery

• Lysis of Adhesions S-840 (Change from 3 days postoperative to 4 days postoperative)

Head and Neck Surgery

• Laryngectomy, Complete S-780 (Change from 6 days postoperative to 7 days

postoperative)

Neurology

• Traumatic Brain Injury, Nonsurgical Treatment M-78 (Change from 2 days to

Ambulatory or 2 days)

Orthopedics MCG GUIDELINES 23rd EDITION (NEW GUIDELINES)

INPATIENT & SURGICAL CARE (ISC)

Behavioral Health

6/24/2019 New P-585

P-596

• Anorexia Nervosa, Child or Adolescent

• Substance-Related Disorders, Child or Adolescent

Cardiology

6/24/2019 New

Customization

W0157 • Left Atrial Appendage Closure, Percutaneous

Common Complications and Conditions

6/24/2019 New CCC-050 • Pain: Common Complications and Conditions

Pediatrics

6/24/2019 New P-05

P-414

P-411

P-185

P-1305

P-565

P-260

P-510

• Abdominal Pain, Undiagnosed, Pediatric

• Craniotomy for Traumatic Brain Injury or Intracerebral Hemorrhage, Pediatric

• Craniotomy, Supratentorial, Pediatric

• Headaches, Pediatric

• Hernia Repair (Non-Hiatal), Pediatric

• Inflammatory Bowel Disease, Pediatric

• Pelvic Inflammatory Disease (PID), Acute, Pediatric

• Supraventricular Arrhythmias, Pediatric

6/24/2019 New

Customization

W0156 • Spine, Scoliosis, Posterior Instrumentation, Pediatric

RECOVERY FACILITY CARE (RFC)

Orthopedics

6/24/2019 New M-7030 • Degenerative Joint Disease (DJD)

BEHAVIORAL HEALTH CARE (BHG)

Care Guidelines for Behavioral

Health

6/24/2019 New B-030-IP

B-029-IP

B-030-RES

B-030-PHP

B-030-IOP

B-030-AOP

• Obsessive-Compulsive and Related Disorders, Adult: Inpatient Care

• Obsessive-Compulsive and Related Disorders, Child or Adolescent: Inpatient Care

• Obsessive-Compulsive and Related Disorders: Residential Care

• Obsessive-Compulsive and Related Disorders: Partial Hospital Program

• Obsessive-Compulsive and Related Disorders: Intensive Outpatient Program

• Obsessive-Compulsive and Related Disorders: Acute Outpatient Care

Opioid Management

6/24/2019 New B-001-Rx

B-002-Rx

B-003-Rx

B-004-Rx

B-005-Rx

B-006-Rx

• Buprenorphine Extended-Release Injection

• Buprenorphine Implant

• Buprenorphine-Naloxone

• Long-Acting Opioids

• Naltrexone Extended-Release Injection

• Naltrexone Implant

MCG GUIDELINES 23rd EDITION (CUSTOMIZATION OR OTHER REVIEW)

INPATIENT & SURGICAL CARE (ISC)

Pediatrics

6/24/2019 MCG P-60

M-60

Pediatrics

• Asthma, Pediatric

Thoracic Surgery and Pulmonary Disease

• Asthma

Cardiology

6/24/2019 MCG -

Customization

W0120 Angioplasty, Percutaneous Coronary Intervention

General Surgery

6/24/2019 MCG -

Customization

W0002

W0022

W0023

• Mastectomy, Complete

• Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander

• Mastectomy, Complete, with Tissue Flap Reconstruction

Obstetrics and Gynecology

6/24/2019 MCG -

Customization

W0109

W0010

W0110

• Hysterectomy, Abdominal

• Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-Assisted

Original MCG title: Hysterectomy, Laparoscopic

• Hysterectomy, Vaginal

6/24/2019 MCG -

Customization

W0026

W0025

• Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and

Salpingectomy

• Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Orthopedics

6/24/2019 MCG -

Customization

W0097 • Cervical Laminectomy

Urology

6/24/2019 MCG -

Customization

W0029 • Prostatectomy, Transurethral, Alternatives to Standard Resection

INPATIENT & SURGICAL CARE (ISC) / BEHAVIORAL HEALTH CARE (BHG)

Eating Disorders

6/24/2019 MCG M-585

B-904-IP

B-913-IP

B-001-IP

B-016-IP

B-005-IP

B-021-IP

Inpatient & Surgical Care (ISC): Behavioral Health

• Anorexia

Behavioral Health Care (BHG): Level of Care Guidelines

• Eating Disorders, Inpatient Behavioral Health Level of Care, Adult

• Eating Disorders, Inpatient Behavioral Health Level of Care, Child or Adolescent

Behavioral Health Care (BHG): Care Guidelines for Behavioral Health

• Anorexia Nervosa, Adult: Inpatient Care

• Anorexia Nervosa, Child or Adolescent: Inpatient Care

• Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating

Disorders, Adult: Inpatient Care

• Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or Eating

Disorders, Child or Adolescent: Inpatient Care

Not to be used on or

after 05/01/2019

ARCHIVED MEDICAL POLICIES OR CLINICAL UM GUIDELINES TO ARCHIVE

5/1/2019 Archived CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

THIRD PARTY

CRITERIA THIRD PARTY CRITERIA

MCG GUIDELINES

ANNUAL REVIEW – CUSTOMIZATION TO MCG GUIDELINES carried forward from the

22nd Edition

to the 23rd Edition with an administrative note added to four documents

See Summary of Customization to MCG Care Guidelines on Pulse for detail

https://pulse.antheminc.com/webcenter/portal/medpolicy/pages_topic?contentID=PULSE_052

235INPATIENT & SURGICAL CARE (ISC)

Cardiology

6/24/2019 MCG-Annual

Review

W0114 Atrial Fibrillation


Review

W0011 Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion


Review

W0012 Electrophysiologic Study and Intracardiac Catheter Ablation

Cardiovascular Surgery


Review

W0084 Abdominal Aortic Aneurysm, Endovascular Repair


Review

W0133 Aortic Valve Replacement, Transcatheter


Review

W0016 Cardiac Septal Defect: Atrial, Transcatheter Closure


Review

W0093 Cardiac Septal Defect: Ventricular, Repair


Review

W0089 Cardiac Valve Replacement or Repair


Review

W0017 Heart Transplant


Review

W0121 Percutaneous Revascularization, Lower Extremity


Review

W0044 Sympathectomy by Thoracoscopy or Laparoscopy

Common Complication and Conditions


Review

W0130 Preoperative Days: Common Complications and Conditions


Review

W0136 Venous Thrombosis and Pulmonary Embolism: Common Complications and Conditions

General Surgery


Review

W0158 Fundoplasty, Esophagogastric, by Laparoscopy


Review

W00054 Gastric Restrictive Procedure with or without Gastric Bypass

Original MCG title: Gastric Restrictive Procedure with Gastric Bypass


Review

W0014 Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy


Review

W0033 Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy


Review

W0102 Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy


Review

W0159 Hiatal Hernia Repair, Abdominal


Review

W0160 Hiatal Hernia Repair, Transthoracic


Review

W0034 Liver Transplant


Review

W0008 Mastectomy, Partial (Lumpectomy)

Neonatology


Review

W0087 Newborn Care, Routine


Review

W0106 Newborn Care, Term, with Severe Illness or Abnormality


Review

W0107 Sepsis, Neonatal, Confirmed


Review

W0108 Sepsis, Neonatal, Suspected, Not Confirmed

Neurology


Review

W0115 EEG, Video Monitoring

Obstetrics and Gynecology


Review

W0045 Cesarean Delivery


Review

W0047 Vaginal Delivery


Review

W0048 Vaginal Delivery, Operative

Orthopedics


Review

W0139 Acromioplasty and Rotator Cuff Repair


Review

W0155 Ankle Arthroscopy


Review

W0071 Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy


Review

W0111 Cervical Fusion, Anterior


Review

W0112 Cervical Fusion, Posterior


Review

W0105 Hip Arthroplasty


Review

W0096 Hip Arthroscopy


Review

W0098 Hip Resurfacing


Review

W0081 Knee Arthroplasty, Total


Review

W0113 Knee Arthroscopy


Review

W0140 Knee Arthrotomy


Review

W0091 Lumbar Diskectomy, Foraminotomy, or Laminotomy


Review

W0072 Lumbar Fusion


Review

W0100 Lumbar Laminectomy


Review

W0137 Shoulder Arthroplasty


Review

W0138 Shoulder Hemiarthroplasty


Review

W0116 Spine, Scoliosis, Posterior Instrumentation

Pediatrics


Review

W0117 Diabetes, Pediatric


Review

W0122 EEG, Video Monitoring, Pediatric


Review

W0161 Fundoplasty, Esophagogastric, by Laparoscopy, Pediatric


Review

W0123 Heart Transplant, Pediatric


Review

W0124 Liver Transplant, Pediatric


Review

W0125 Lung Transplant, Pediatric


Review

W0126 Renal Transplant, Pediatric

Thoracic Surgery and Pulmonary Disease


Review

W0135 Deep Venous Thrombosis of Lower Extremities


Review

W0076 Lung Transplant


Review

W0134 Pulmonary Embolism

Urology


Review

W0027 Renal Transplant

Other Guidelines


Review

Neonatal Facility Level of Care Guidelines


Review

Assistant Surgeon Guidelines

GENERAL RECOVERY CARE (GRG)

Body System GRG


Review

W0099 Cardiovascular Surgery or Procedure GRG


Review

W0142 General Surgery or Procedure GRG


Review

W0118 Musculoskeletal Surgery or Procedure GRG


Review

W0119 Neurosurgery or Procedure GRG


Review

W0143 Obstetric and Gynecologic Surgery or Procedure GRG


Review

W0141 Urologic Surgery or Procedure GRG

General Recovery Guidelines Tools Section


Review

W0086 Inpatient Palliative Care Criteria

Problem Oriented GRG


Review

W0074 Medical Oncology GRG

BEHAVIORAL HEALTH CARE (BHG)

Testing Procedures


Review

W0150 Urine Toxicology Testing

Therapeutic Services


Review

W0153 Applied Behavioral Analysis


Review

W0151 Transcranial Magnetic Stimulation

OrthoNet

ORTHONET PHYSICAL AND OCCUPATIONAL THERAPY MANAGEMENT GUIDELINES

ANNUAL REVIEW

Information on Health Plan Contracts is available on OrthoNet’s web site at

https://www.orthonet-online.com/provider.html

By OrthoNet OrthoNet -

Annual Review

Physical and Occupational Therapy Management Programs

OrthoNet maintains 64 distinct guidelines addressing the medical necessity of physical

therapy (PT) and occupational therapy (OT), which includes the following atypical

guidelines; Bell’s Palsy, Congenital Infantile Muscular Torticollis, General Neuromuscular

Criteria, and Vestibular Disorders.

CODING CODING UPDATES OF EXISTING MEDICAL POLICIES OR CLINICAL UM GUIDELINES

PUBLISHED 03/28/2019

Codes Effective 04/01/2019

(These documents were not reviewed at the quarterly committee meeting)

3/28/2019 Coding Updates

of Existing

Documents

CG-DRUG-63 Levoleucovin Products

3/28/2019 Coding Updates

of Existing

Documents

CG-DRUG-78 Antihemophilic Factor and Clotting Factors

Interim Upload

Recategorized

Interim Upload

Recategorized

(These documents were not reviewed at the quarterly committee meeting)

4/24/2019 Recategorized CG-MED-83 Level of Care: Specialty Pharmaceuticals

4/24/2019 Archived CG-DRUG-47 Level of Care: Specialty Pharmaceuticals

4/24/2019 Recategorized MED.00127 Chelation Therapy

4/24/2019 Archived DRUG.00003 Chelation Therapy

4/24/2019 Recategorized MED.00128 Insulin Potentiation Therapy

4/24/2019 Archived DRUG.00034 Insulin Potentiation Therapy