Page 1
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
Page 2
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
Page 3
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®)
Page 4
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
Page 5
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
Page 6
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
Page 7
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
Clinical Appropriateness Guidelines:
• Advanced Imaging – Imaging of the Extremities
Clinical Appropriateness Guidelines:
• Advanced Imaging – Imaging of the Spine
Clinical Appropriateness Guidelines:
• Advanced Imaging – Imaging of the Head and Neck
Cardiology
By AIM AIM
Page 8
Clinical Appropriateness Guidelines
• Advanced Imaging – Imaging of the Heart
Clinical Appropriateness Guidelines
• Percutaneous Coronary Intervention
Clinical Appropriateness Guidelines
• 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
Page 9
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
Page 10
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)
Page 11
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
Page 12
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)
Page 13
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)
Page 14
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
Page 15
6/24/2019 MCG-Annual
Review
W0011 Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion
6/24/2019 MCG-Annual
Review
W0012 Electrophysiologic Study and Intracardiac Catheter Ablation
Cardiovascular Surgery
6/24/2019 MCG-Annual
Review
W0084 Abdominal Aortic Aneurysm, Endovascular Repair
6/24/2019 MCG-Annual
Review
W0133 Aortic Valve Replacement, Transcatheter
6/24/2019 MCG-Annual
Review
W0016 Cardiac Septal Defect: Atrial, Transcatheter Closure
6/24/2019 MCG-Annual
Review
W0093 Cardiac Septal Defect: Ventricular, Repair
6/24/2019 MCG-Annual
Review
W0089 Cardiac Valve Replacement or Repair
6/24/2019 MCG-Annual
Review
W0017 Heart Transplant
6/24/2019 MCG-Annual
Review
W0121 Percutaneous Revascularization, Lower Extremity
6/24/2019 MCG-Annual
Review
W0044 Sympathectomy by Thoracoscopy or Laparoscopy
Common Complication and Conditions
6/24/2019 MCG-Annual
Review
W0130 Preoperative Days: Common Complications and Conditions
6/24/2019 MCG-Annual
Review
W0136 Venous Thrombosis and Pulmonary Embolism: Common Complications and Conditions
General Surgery
6/24/2019 MCG-Annual
Review
W0158 Fundoplasty, Esophagogastric, by Laparoscopy
6/24/2019 MCG-Annual
Review
W00054 Gastric Restrictive Procedure with or without Gastric Bypass
Original MCG title: Gastric Restrictive Procedure with Gastric Bypass
6/24/2019 MCG-Annual
Review
W0014 Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy
Page 16
6/24/2019 MCG-Annual
Review
W0033 Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy
6/24/2019 MCG-Annual
Review
W0102 Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy
6/24/2019 MCG-Annual
Review
W0159 Hiatal Hernia Repair, Abdominal
6/24/2019 MCG-Annual
Review
W0160 Hiatal Hernia Repair, Transthoracic
6/24/2019 MCG-Annual
Review
W0034 Liver Transplant
6/24/2019 MCG-Annual
Review
W0008 Mastectomy, Partial (Lumpectomy)
Neonatology
6/24/2019 MCG-Annual
Review
W0087 Newborn Care, Routine
6/24/2019 MCG-Annual
Review
W0106 Newborn Care, Term, with Severe Illness or Abnormality
6/24/2019 MCG-Annual
Review
W0107 Sepsis, Neonatal, Confirmed
6/24/2019 MCG-Annual
Review
W0108 Sepsis, Neonatal, Suspected, Not Confirmed
Neurology
6/24/2019 MCG-Annual
Review
W0115 EEG, Video Monitoring
Obstetrics and Gynecology
6/24/2019 MCG-Annual
Review
W0045 Cesarean Delivery
6/24/2019 MCG-Annual
Review
W0047 Vaginal Delivery
6/24/2019 MCG-Annual
Review
W0048 Vaginal Delivery, Operative
Orthopedics
6/24/2019 MCG-Annual
Review
W0139 Acromioplasty and Rotator Cuff Repair
6/24/2019 MCG-Annual
Review
W0155 Ankle Arthroscopy
Page 17
6/24/2019 MCG-Annual
Review
W0071 Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy
6/24/2019 MCG-Annual
Review
W0111 Cervical Fusion, Anterior
6/24/2019 MCG-Annual
Review
W0112 Cervical Fusion, Posterior
6/24/2019 MCG-Annual
Review
W0105 Hip Arthroplasty
6/24/2019 MCG-Annual
Review
W0096 Hip Arthroscopy
6/24/2019 MCG-Annual
Review
W0098 Hip Resurfacing
6/24/2019 MCG-Annual
Review
W0081 Knee Arthroplasty, Total
6/24/2019 MCG-Annual
Review
W0113 Knee Arthroscopy
6/24/2019 MCG-Annual
Review
W0140 Knee Arthrotomy
6/24/2019 MCG-Annual
Review
W0091 Lumbar Diskectomy, Foraminotomy, or Laminotomy
6/24/2019 MCG-Annual
Review
W0072 Lumbar Fusion
6/24/2019 MCG-Annual
Review
W0100 Lumbar Laminectomy
6/24/2019 MCG-Annual
Review
W0137 Shoulder Arthroplasty
6/24/2019 MCG-Annual
Review
W0138 Shoulder Hemiarthroplasty
6/24/2019 MCG-Annual
Review
W0116 Spine, Scoliosis, Posterior Instrumentation
Pediatrics
6/24/2019 MCG-Annual
Review
W0117 Diabetes, Pediatric
6/24/2019 MCG-Annual
Review
W0122 EEG, Video Monitoring, Pediatric
6/24/2019 MCG-Annual
Review
W0161 Fundoplasty, Esophagogastric, by Laparoscopy, Pediatric
6/24/2019 MCG-Annual
Review
W0123 Heart Transplant, Pediatric
Page 18
6/24/2019 MCG-Annual
Review
W0124 Liver Transplant, Pediatric
6/24/2019 MCG-Annual
Review
W0125 Lung Transplant, Pediatric
6/24/2019 MCG-Annual
Review
W0126 Renal Transplant, Pediatric
Thoracic Surgery and Pulmonary Disease
6/24/2019 MCG-Annual
Review
W0135 Deep Venous Thrombosis of Lower Extremities
6/24/2019 MCG-Annual
Review
W0076 Lung Transplant
6/24/2019 MCG-Annual
Review
W0134 Pulmonary Embolism
Urology
6/24/2019 MCG-Annual
Review
W0027 Renal Transplant
Other Guidelines
6/24/2019 MCG-Annual
Review
Neonatal Facility Level of Care Guidelines
6/24/2019 MCG-Annual
Review
Assistant Surgeon Guidelines
GENERAL RECOVERY CARE (GRG)
Body System GRG
6/24/2019 MCG-Annual
Review
W0099 Cardiovascular Surgery or Procedure GRG
6/24/2019 MCG-Annual
Review
W0142 General Surgery or Procedure GRG
6/24/2019 MCG-Annual
Review
W0118 Musculoskeletal Surgery or Procedure GRG
6/24/2019 MCG-Annual
Review
W0119 Neurosurgery or Procedure GRG
6/24/2019 MCG-Annual
Review
W0143 Obstetric and Gynecologic Surgery or Procedure GRG
6/24/2019 MCG-Annual
Review
W0141 Urologic Surgery or Procedure GRG
Page 19
General Recovery Guidelines Tools Section
6/24/2019 MCG-Annual
Review
W0086 Inpatient Palliative Care Criteria
Problem Oriented GRG
6/24/2019 MCG-Annual
Review
W0074 Medical Oncology GRG
BEHAVIORAL HEALTH CARE (BHG)
Testing Procedures
6/24/2019 MCG-Annual
Review
W0150 Urine Toxicology Testing
Therapeutic Services
6/24/2019 MCG-Annual
Review
W0153 Applied Behavioral Analysis
6/24/2019 MCG-Annual
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)
Page 20
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