October 2016
In this issue
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Health care reform update
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Health care reform updates on anthem.com
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Administrative and policy update
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Sign-up today for Network eUPDATE – it’s free!
Update to claims processing edits and reimbursement policies
AOPS retirement coming: transition to Availity Web Portal now
Enhancements to AIM clinical appropriateness guidelines for
advanced imaging effective February 18, 2017
Reminder: NOC oncology and biologic drugs added to pre-service
clinical review recommendation list effective November 1, 2016
Pre-service clinical review changes for specialty pharmacy drugs
effective January 1, 2017
Update: prior authorization required for IOP and PHP for Blue Choice
and Comp-Care members effective December 1, 2016
Important information about habilitative and rehabilitative services
Reminder - Specialty pharmacy level of care clinical reviews began
July 18, 2016
LiveHealth Online Psychology - easy access to therapists and
psychologists from the comfort of home
Enhanced Personal Health Care: referral providers benefit by
improving quality and controlling costs
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Medicare update
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Medicare Supplement members to receive new ID cards November 1
Complete Medicare Advantage AIM OptiNet® registration for X-ray,
ultrasound or high-tech imaging services
Please follow CMS guidelines for Medicare Advantage Part B
immunizations claims filing
Use JW modifier when submitting claims for discarded drugs
Medicare billing requirements for TAVR and TMVR
Anthem to conduct periodic audits to ensure CMS requirements met
Help ensure Medicare Part D members receive comprehensive
medication review
Anthem follows CMS guidelines for DME customization
Self-administered drugs should not be billed to MA members
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anthem.com
Important phone numbers
ME16007
MENL1016
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In this issue (continued)
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Medicare update (continued)
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Precertification requirements updated for 2017
Keep up with Medicare news
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Behavioral health update
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Update: prior authorization required for IOP and PHP for Blue Choice
and Comp-Care members effective December 1, 2016
Ambulatory detoxification, H0014, added to physician fee schedules
effective October 1, 2016
LiveHealth Online Psychology -easy access to therapists and
psychologists from the comfort of home
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Quality programs update
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Communicating the importance of childhood vaccinations
Clinical practice and preventive health guidelines on anthem.com
Care & Cost Finder powered by Castlight to be launched
HEDIS Spotlight: Comprehensive Diabetes Care
Anthem Whole Health Connection SM
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Pharmacy update
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Pharmacy information available on anthem.com
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Medical policy update
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Medical policy updates available on anthem.com
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Clinical guidelines update
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Clinical guideline updates available on anthem.com
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Health care reform update
Health care reform updates on anthem.com
Please be sure to check the Health Care Reform Updates and Notifications and Information about Health Insurance
Exchanges sections of our website regularly for the latest updates on health care reform and Health Insurance Exchanges.
Administrative and policy update
Sign-up today for Network eUPDATE – it’s free!
Connecting with us and staying informed is easy, faster and convenient with our Network eUPDATEs. Network eUPDATE is
our web tool for sharing vital information with you. It features short topic summaries on late breaking news that impacts
providers:
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Important website updates
System changes
Medical policy updates
Claims and billing updates
……and much more
Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you
can submit as many email addresses as you like.
Update to claims processing edits and reimbursement policies
On October 1, 2016, we will be updating our Anthem Online Provider Services (AOPS) website with the following new and/or
revised reimbursement policies. The updates below identify if the article pertains to professional or facility provider billing.
Assistant Surgeon Coding and Assistant Surgeon Services – professional
On August 1, 2016, we updated our Assistant Surgery Services Coding Chart effective January 1, 2016, to include the
Current Procedural Terminology (CPT®) code range 12001-13151. These codes were inadvertently omitted from the original
January 1, 2016 coding list.
On September 1, 2016, the Assistant Surgery Services Coding Chart was updated to add new CPT codes effective July 1,
2016--0437T, 0438T, 0440T, 0441T, 0442T, 0444T and 0445T--to the existing codes that are not eligible for reimbursement
for assistant at surgery services reported with modifiers 80, 81, 82, or AS. We also updated the effective date on the
Assistant Surgeon policy to July 1, 2016 to align with our updated Assistant Surgery Services Coding Chart.
Bundled Services and Modifiers 59 and XE, XP, XS, & XU – professional
CPT describes code 95957 as digital analysis of electroencephalogram (EEG) (e.g., for epileptic spike analysis). When the
service is simply the paperless acquisition and recording of an EEG via computer-based instrumentation, our position is that
providers should not report 95957 with EEG testing. Therefore, beginning with dates of service on or after January 1, 2017,
code 95957 will be considered incidental to EEG testing codes 95951, 95953, 95954, or 95956 and will not be eligible for
separate reimbursement when reported by the same provider on the same date of service. Modifiers will not override the edit.
In addition, we consider 95957 incidental to EEG testing codes 95950, 95951, 95953, 95954, 95955 and 95956 when
reported on subsequent dates of service. Therefore, beginning with dates of service on or after January 1, 2017, digital EEG
analysis procedure code 95957 will not be eligible for reimbursement when reported subsequent to the date of service for
EEG testing codes 95950, 95951, 95953, 95954, 95955 and 95956. Modifiers will not override the edit.
Modifiers 59 and XE, XP, XS, & XU – professional
Our current bundled services edit denies CPT code 29822 (arthroscopy, shoulder, surgical; debridement, limited) when
reported 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy), 29807 (arthroscopy, shoulder, surgical; repair of slap
lesion), 29821 (arthroscopy, shoulder, surgical; synovectomy, complete), and 29823 (arthroscopy, shoulder, surgical;
debridement, extensive) when performed on the same shoulder. We consider this to be correct coding; therefore, beginning
with claims processed on or after November 21, 2016, we will update our current edit so that modifiers 59, XE, XP, XS, and
XU will not override the denial of 29822 when performed on the same shoulder as arthroscopy surgical codes 29806, 29807,
29821, and 29823.
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Place of Service – professional
As documented in our policy, there are CPT and HCPCS codes that are specific to services provided in the home setting.
When such services are provided in a place of service other than the patient’s home, the service is not eligible for
reimbursement. Therefore, for claims processed on or after August 22, 2016, our claims editing system, ClaimsXten TM , was
updated to deny those codes that include the home setting in their description when such codes are reported with a place of
service other than a home setting (e.g., when 99504 (home visit for mechanical ventilation care) is reported with an inhospital place of service (21), the service will not be eligible for reimbursement).
In addition, as documented in our policy, we consider hearing screening services 92586, 92558, and 92587 to be included
under a facility’s reimbursement and not eligible for separate reimbursement. For claims processed on or after August 22,
2016, we updated our claims editing system to deny these hearing screening codes when submitted by a professional
provider in an outpatient hospital setting (19 (off campus outpatient hospital) and 22 (on campus outpatient hospital)).
Routine Obstetric Services – professional
We consider that evaluation and management (E/M) visits are included in the reimbursement for global obstetrical care when
reported with a routine maternity diagnosis code. Beginning with dates of service on or after January 1, 2017, we are
updating our policy to include ICD-10 code Z36 (encounter for antenatal screening of mother) to our list of diagnoses we
consider to be routine maternity diagnoses. In addition, because ICD-10 diagnosis codes were effective for dates of service
on or after October 1, 2015, we are removing the ICD-9 codes that are currently listed in our policy. See our policy for further
information.
Annual reviews – professional
The following professional reimbursement policies received an annual review and include minor language revisions; however,
there were no changes to the policy position or criteria:
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Documentation and Reporting Guidelines for Evaluation and Management
Global Surgery
Health and Behavior Assessment Intervention
Moderate Sedation
Overhead Expenses for Office Based Surgical and Diagnostic Testing
Standby Services
Anthem Online Provider Services (AOPS) retirement coming: transition to Availity Web Portal now
We continue to transition provider tools to the Availity Web Portal, featuring ease of use and broad functionality. Remittance
Inquiry and the Professional Fee Schedule Inquiry tool are now available under Payer Spaces on the Availity Web Portal with
the appropriate access.
Therefore, we are targeting February 2017 to retire AOPS. All provider tools and information will then be available
exclusively via the Availity Web Portal. After this date, web portal access to Eligibility, Benefits, Claim Status Inquiry,
Remittance Inquiry, Professional Fee Schedule and important proprietary information will be available exclusively through
Availity, our multi-payer portal solution. Note: This change does not affect the anthem.com public website or electronic
transactions submitted via our Enterprise EDI Gateway; you may continue to submit all X12 transactions through your current
EDI transmission channels.
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See something you can’t access, but you need it?
Contact your organization’s administrator to request the role you need. To determine who your organization’s administrator
is, select “Who controls my access” from your account drop down box located in the upper right corner of the Availity Web
Portal’s top menu bar.
Do you have all of your tax IDs registered on the Availity Web Portal?
If not, now is the time to register. Your organization’s administrator can add additional tax IDs by selecting Maintain
Organization from the Admin Dashboard.
If your organization is not registered for Availity:
Have your organization’s designated administrator go to www.availity.com and select Register. Complete the online
registration wizard. The administrator will receive an e-mail from Availity with a temporary password and next steps.
Free Training
Once you log into the secure portal, you'll have access to many resources to help jumpstart your learning, including free live
training, on-demand training, frequently asked questions, and comprehensive help topics. To view the current training
resources, access the Help menu on the Availity Web Portal.
Enhancements to AIM clinical appropriateness guidelines for advanced imaging effective
February 18, 2017
On February 18, 2017, the following changes to AIM Clinical Appropriateness Guidelines for Radiology and Cardiology will
become effective:
Oncologic imaging (CT, MRI and PET)
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Enhanced criteria around surveillance following completion of therapy for colorectal cancer
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Updated criteria for appropriate use of imaging studies in the management of prostate cancer and breast cancer
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New guidelines for appropriate use of multiparametric MRI in the diagnosis of prostate cancer
Breast MRI
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Enhanced criteria for appropriateness of MRI in DCIS, atypical ductal hyperplasia, and follow up imaging of BIRADs
3 studies
Abdominal and pelvic imaging (CT and MRI)
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Updated criteria for appropriateness of imaging in inflammatory bowel disease
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Guidelines for follow up of incidental liver lesions utilizing advanced imaging
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Enhanced criteria for imaging in chronic abdominal pain and nephrolithiasis
Reminder: NOC oncology and biologic drugs to be added to pre-service clinical review
recommendation list effective November 1, 2016
This is a reminder that effective November 1, 2016, in partnership with AIM Specialty Health, we will expand pre-service
review to include medical necessity of coverage requests for all not otherwise classified “NOC” oncology and biologic drugs.
Pre-service clinical review will be based on specific medical policy or clinical guideline when available. In instances where a
specific policy or guideline is unavailable, clinical guideline CG-DRUG-01, Off-Label Drug and Approved Orphan Drug Use,
will be used for HCPCS codes J9999 and J3590. If the drug is not reviewed pre-service, we will conduct a post-service
review based on the same clinical criteria and may request records as part of that review. This pre-service clinical review
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program will apply to our Commercial, local ASO, National Accounts and Medicare Advantage members. Please contact 800676-BLUE (2583) to verify any pre-service review recommendations or requirements for BlueCard® business.
Ordering physicians may submit a request for services on or after November 1, 2016, to AIM through the AIM
ProviderPortal SM (available 24/7 to process orders in real-time), through the Availity Web Portal or by calling the AIM call
center at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
Pre-service clinical review changes for specialty pharmacy drugs effective January 1, 2017
We will be expanding the list of specialty pharmacy drugs that are a part of the pre-service clinical review process. Listed
below are specialty pharmacy codes from new or current medical policies and/ or clinical UM guidelines that will be added to
our existing pre-service review process effective January 1, 2017.
Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM®), a separate
company administering the program on behalf of Anthem, as applicable.
Clinical UM Guideline or Medical Policy
Drug Name
Drug Code(s)
CG-DRUG-43: Natalizumab (Tysabri®)
Natalizumab (Tysabri)
J2323
CG-DRUG-49: Doxorubicin Hydrochloride Liposome Injection
Lipodox
Q2049
CG-DRUG-49: Doxorubicin Hydrochloride Liposome Injection
Doxil
Q2050
CG-DRUG-50: Paclitaxel, protein-bound (Abraxane®)
Abraxane
J9264
CG-DRUG-51: Romidepsin (Istodax®)
Isotodax
J9315
DRUG.00087
Strensiq
J3490
DRUG.00088
Tecentriq
C9483, J3590, J9999
DRUG.00089
Zinbryta
J3490, J3590
DRUG.00091
Naltrexone
J3490, J7999
DRUG.00092
Probuphine
J3490
DRUG.00093
Kanuma
J3490
Ordering physicians can submit a pre-service clinical review request to AIM for these drugs starting January 1, 2017, through
one of the following options:
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AIM ProviderPortal SM available 24/7 to process orders in real-time
Access AIM’s portal via the Availity Web Portal
AIM’s call center - 866-714-1107, 8:00 a.m. – 5:00 p.m.
Requests received by AIM more than two business days after the date of service will not be accepted by AIM. Post service
clinical review will be handled by Anthem.
These medical policies and/or clinical UM guidelines can be accessed at anthem.com > Providers > Maine > Medical
Policy, Clinical UM Guidelines, Pre-Cert Requirements > Medical Policies and Clinical UM Guidelines (for Local Plan
Members). Recent changes to Medical Policies can be found under “Recent Updates”.
Update: prior authorization required for IOP and PHP for Blue Choice and Comp-Care members
effective December 1, 2016
In July, we sent an email to announce that effective November 1, 2016, prior authorization would be required for intensive
outpatient (IOP) and partial hospital (PHP) programs for Blue Choice members. We’d like to advise you of a change in the
effective date and the products to which prior authorization will apply.
Effective with group renewals on and after December 1, 2016, all Blue Choice PPO and Comp-Care products will require
prior authorization for intensive outpatient (IOP) and partial hospital (PHP) programs. To obtain prior authorization or to
verify member eligibility, benefits or account information, please call the telephone number listed on the member's ID card.
Covered and allowable services are subject to the member's benefits and eligibility at the time the service is performed.
Services rendered to our members must meet our medical necessity criteria for these covered services.
Important information about billing habilitative and rehabilitative services
In compliance with requirements of the Notice of Benefit and Payment Parameters for 2016 issued pursuant to the Affordable
Care Act, we will apply separate and distinct benefit limits for habilitative and rehabilitative services for all Anthem individual
and small group On-Exchange and Off-Exchange health plans beginning with dates of service on and after January 1, 2017.
This means these plans will no longer have a combined visit limit for habilitative and rehabilitative services. Habilitative
services help a person keep, learn, or improve skills and functioning for daily living which have not (but normally would have)
developed. Rehabilitative services help a person keep, restore, or improve skills and functioning for daily living which have
been lost or impaired after an illness or injury, such as a car accident or stroke.
Beginning with dates of service on and after January 1, 2017, the appropriate use of the modifier SZ is necessary when
billing habilitative services to us for members seeking care in an outpatient facility or professional office setting. The SZ
modifier was effective in 2014 and distinguishes between habilitative and rehabilitative services. Appropriate use of the
modifier will help reduce claims issues and adjustments related to habilitative services.
Please review your current coding practices as it relates to the use of modifier SZ and the billing of habilitative and
rehabilitative services.
Reminder - Specialty pharmacy level of care clinical reviews began July 18, 2016
The April 2016 and June 2016 editions of Network Update shared information about the expansion of the Specialty Pharmacy
program to include level of care clinical review for specialty pharmacy infusions and injections. Additionally, in early July, we
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notified providers via email that the implementation of level of care clinical reviews for specialty pharmacy infusions and
injections would begin with dates of service on and after July 18, 2016. In this edition of Network Update, we are sharing
these details again, as a reminder and for easy reference.
We are committed to the Institute for Healthcare Improvement (IHI) Triple Aim --- a framework developed by IHI that
describes an approach to optimizing health system performance using the following dimensions:
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Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
We recognize that most members prefer to receive their infusion or injection therapy in the physician’s office, ambulatory
infusion suite (AIS) or at home by a licensed home infusion therapy (HIT) provider. This is more convenient for the member,
may result in lower member financial responsibility and, in many cases, is a clinically appropriate setting.
There may be clinical circumstances that require a member to receive infusions or injections in a hospital outpatient facility.
Therefore, beginning with dates of service on and after July 18, 2016, we expanded the Specialty Pharmacy program to
include a review of the requested level of care. A new clinical guideline Level of Care: Specialty Pharmaceuticals CG-DRUG47 applies to the review process beginning with dates of service on and after July 18, 2016. The expanded program
continues to be administered by AIM Specialty Health (AIM), a separate company. Based on the information you provide, AIM
reviews the drug for both clinical appropriateness and the level of care against health plan clinical criteria. The level of care
review does not apply to requests for the review of drugs prescribed for oncology, hemophilia, or end stage renal disease
drug indications. Physician offices that currently administer specialty drugs in the office setting were not impacted by this
change.
Providers will continue to request authorization for specialty drugs in one of several ways:
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Access AIM’s ProviderPortal SM directly at providerportal.com. Online access is available 24/7 to process orders in
real-time, and is the fastest and most convenient way to request authorization.
Access AIM via the Availity Web Portal at availity.com
Call the AIM Contact Center toll-free number: 866-714-1107
For dates of service on and after July 18, 2016:
When providers select a hospital-based outpatient facility as the level of care, a list of alternate locations, such as
ambulatory infusion suites and home infusion providers, is made available. Medical specialty pharmacy providers are also
listed as an alternate option to supply the infusion medication to physician offices who can administer it to the member. (See
below to learn how to register as an alternate level of care location.)
If an alternate level of care is not selected, providers are prompted to indicate the reason hospital-based level of care is
medically necessary.
If a request for hospital-based level of care does not meet medical necessity criteria upon review by a physician reviewer, the
request will not be approved. We encourage you to discuss with members the alternate level of care options, such as
physician office, infusion center or home infusion therapy.
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The expanded program applies to local Anthem members who have specialty pharmacy services medically managed by AIM
Specialty Health. The expanded program does not apply to the following plans: BlueCard®, Medicare Advantage, Medicaid,
Medicare Supplement, and Federal Employee Program (FEP).
For more information, including a list of drugs that are reviewed for level of care, go to www.aimprovider.com/specialtyrx.
You may also view our list of frequently asked questions at anthem.com.
Register as an alternate level of care location
Beginning October 23, 2016, ambulatory infusion suites, home infusion providers, and other eligible provider locations can
visit www.aimprovider.com/specialtyrx/optinet to register with AIM to be included as an alternate location for the
administration of specialty drugs. Registration will require only three pieces of information—your practice’s place of service
type (e.g., ambulatory infusion suite), the drugs your practice administers, and your coverage area. Additionally, providers
can access an interactive training module and other helpful registration materials on the site.
LiveHealth Online Psychology - easy access to therapists and psychologists from the comfort of
home
Launched in January 2016, LiveHealth Online Psychology is a convenient and easy way for members to connect one on one
with a behavioral health provider using their smartphone, tablet or computer.
Through two-way video chat, members can interact with a therapist or psychologist, day or night, by appointment.
Appointments are available within 4 days or less and the cost is the same as a regular in-person therapy office visit. The
therapists available on LiveHealth Online Psychology can treat issues such as anxiety, depression, stress, grief and
relationship issues. For new users, it’s as simple as signing up with a name and email address. Originally available to adults,
LiveHealth Online Psychology also launched its Teen edition in July, accessible by 10 to 17 year olds. To learn more, visit
livehealthonline.com/psychology or call 844-784-8409.
Enhanced Personal Health Care: Referral providers benefit by improving quality and controlling
costs
A key goal of the Enhanced Personal Health Care Program is to improve quality while controlling health care costs. One of
the ways this is done is by giving primary care physicians (PCPs) in the Program quality and cost information about the
health care providers (the referral providers) to which the PCPs refer their attributed members. If referral providers are higher
quality and/or lower cost, this component of the Program should result in their getting more referrals from PCPs. The
converse should be true if referral providers are lower quality and/or higher cost. We will share data on which we relied in
making these evaluations upon request, and will discuss it with referral providers including any opportunities for
improvement. Any such requests should be directed to [email protected].
Medicare update
Medicare Supplement members to receive new ID cards November 1
All Anthem Medicare Supplement Individual members will receive new member ID cards beginning November 1, 2016. The
new ID cards will have both a new member ID number as well as a new group ID number. Please obtain a copy of the new
member ID cards to file claims for dates of service November 1, 2016 and beyond. Medicare will be notified of these changes
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for Anthem Medicare crossover claim purposes. If you need to submit a claim that is not reflected as a Medicare crossover
claim, please use the correct member ID number beginning November 1, 2016.
Please ask our members to present their most current ID cards each time they receive services – especially on or after
November 1. This helps ensure appropriate claims routing and processing. Provider offices should carefully review member
ID numbers when filing claims.
Further information can be found in the spotlight section of the anthem.com at the Answers@Anthem tab at the top of the
provider home page.
Complete your Medicare Advantage AIM OptiNet® registration for X-ray, ultrasound or high-tech
imaging services
All participating providers who provide imaging services must complete registration for AIM’s online registration tool,
OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum,
gynecological and obstetrical services only at this time), magnetic resonance (MR), computed tomography (CT), nuclear
medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services. Areas of assessment include
facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration.
These data will be used to calculate site scores for providers who render imaging services for our individual Medicare
Advantage members.
All participating providers who provide imaging services, including x-rays and ultrasounds as noted above, must complete the
registration. Providers who do not register, who have a score of less than 76 or who do not complete the survey by January
1, 2017 will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. Facilities
billing on a UB-04 will be excluded form line item denials at this time.
Learn more: Attend a webinar
We continue to offer webinars to help providers complete their OptiNet surveys. Learn how to:
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Access the OptiNet Assessment
Copy previously completed OptiNet Assessments to your Anthem Medicare Advantage account
Complete a new AIM OptiNet registration
Interpret and improve your site score
Check Important Medicare Advantage Updates at anthem.com/medicareprovider for additional information, including webinar
information.
Please follow CMS guidelines for Medicare Advantage Part B immunizations claims filing
We follow the Centers for Medicare & Medicaid Services’ (CMS) Medicare Part B Immunization Billing guidelines. Please use
the following forms when filing flu, pneumonia or Hepatitis B claims for Anthem individual and group-sponsored Medicare
Advantage members.
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Professional claims should be filed on the CMS 1500 form with the appropriate Current Procedural Terminology
code and/or Healthcare Common Procedure Coding System (HCPCS) code for the vaccine and administration.
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Institutional claims should be filed on the UB04 form with the appropriate revenue codes
– Revenue Codes (except Rural Health Clinics and Federally Qualified Health Centers):
0636 – vaccine (and CPT or HCPCS code)
0771 – administration (and HCPCS code)
– Rural Health Clinics and Federally Qualified Health Centers – 052X revenue code series
Please refer to page three of the Medicare Part B Immunization Billing Guide for specifics on institutional billing.
Use JW modifier when submitting claims for discarded drugs
Effective January 1, 2017, we will follow CMS’ requirement for contracted and non-contracted providers to:
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Use the JW modifier for claims with unused drugs or biologicals from single-use vials or single- use packages that
are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B
drugs and biologicals)
Document the discarded drug or biological in the patient's medical record when submitting claims with unused Part
B drugs or biologicals from single use-vials or single-use packages that are appropriately discarded.
Medicare billing requirements for TAVR and TMVR
When an individual or group-sponsored Medicare Advantage (MA) plan participant receives inpatient transcatheter aortic
valve replacement (TAVR) or inpatient transcatheter mitral valve replacement (TMVR) surgery, the MA plan is responsible for
paying the claim. All other clinical trial related services to Medicare Advantage members must continue to be submitted to
Original Medicare for processing. Coding information and additional details can be found at
www.anthem.com/medicareprovider under Important Medicare Advantage Updates.
Anthem to conduct periodic audits to ensure CMS requirements are met
CMS requires providers to notify every Medicare beneficiary (including Medicare Advantage members) of their discharge
appeal rights using the Notice of Medicare Non-Coverage (NOMNC) for skilled nursing facilities, home health agencies, and
comprehensive outpatient rehabilitation facilities, and the Important Message from Medicare About Your Rights (IM) for
inpatient hospitals. Providers must obtain the signature of the beneficiary or representative to indicate that the
beneficiary/representative received and understood the notice.
To help providers meet CMS requirements, we periodically conduct IM and NOMNC audits to proactively identify
opportunities for improvement. We make recommendations and work with providers to improve processes and compliance
with CMS requirements.
Additional details can be found at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.
Help ensure Medicare Part D members receive a comprehensive medication review
CMS requires that plans with Medicare Part D benefits offer a comprehensive medication review (CMR) as part of the
Medication Therapy Management (MTM) program. A CMR is offered to members who have three or more chronic diseases
and who are receiving eight or more maintenance medications. We will contact our qualifying individual and group-sponsored
Medicare Part D members to complete the interactive consultation. The CMR consists of a consultation followed by a written
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medication summary to help educate and support provider recommendations for medication adherence. Please ask these
members if they have received a letter or postcard inviting them to participate in a Medication Review.
Check Important Medicare Advantage Updates at anthem.com/medicareprovider for additional information.
Anthem follows CMS guidelines for DME customization
Our Medicare Advantage programs follow the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines for
durable medical equipment (DME). CMS has a high threshold for what it considers a reimbursable customized DME item. We
have noticed an increase in authorization requests for customized items, including wheelchairs, and would like to provide this
reminder.
Items that are measured, assembled, fitted or adapted in consideration of a patient’s body size, weight, disability, period of
need, or intended use (i.e., custom fitted items) or have been assembled by a supplier or ordered from a manufacturer who
makes available customized features, modification, or components for wheelchairs that are intended for an individual
patient’s use in accordance with instructions from the patient’s physician do not meet the definition of customized items.
These items are not uniquely constructed or substantially modified and can be grouped with other items for pricing purposes.
To learn more please see IOM CMS Publication, 100-04, Chapter 20, Section 30.3.
Outpatient billing departments and practitioners -- self-administered drugs should not be billed to
MA members
In accordance with Centers for Medicare & Medicaid Services regulations, Anthem Medicare Advantage plans pay for drugs
that usually are considered self-administered by the patient when such drugs are an integral component of a covered
procedure or are directly related to a covered procedure. In these situations, the hospital may NOT bill the member for these
types of drugs. The drugs, whether coded or uncoded with their charges, must be reported under the appropriate revenue
code (cost center under which the hospital accumulates the costs for the drugs).
In situations where the member needs a prescription for medication to be used at home following the outpatient treatment,
physicians and practitioners are encouraged to give written or electronic prescriptions to members rather than supplying the
drug from the hospital pharmacy.
Additional details can be found at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.
Precertification requirements updated for 2017
Please refer to your provider agreement, Medicare Advantage HMO & PPO Provider Guidebook/ provider manual and the
Medicare Advantage Precertification Guidelines found at the Medical Policy, UM Guidelines and Precertification
Requirements link on the provider home page at anthem.com for further information on existing precertification requirements
and new precertification requirements for 2017. Non-contracted providers should contact us.
Keep up with Medicare news
Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare
Advantage information, including:
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Prior Authorization Requirements for New Injectable/Infusible Drugs: Darzalex and Empliciti
Prior Authorization Requirements for New Injectable/Infusible Drugs: Istodax, Ixempra, and Taltz
Hospital Observation Service Limits
June Reimbursement Policy Provider Bulletin
Medicare Advantage Reimbursement Policies
2016 Diabetic Supply Coverage for Individual Medicare Advantage Members
Providers Must Enroll with Medicare to be able to Prescribe Part D Beginning Feb. 1, 2016
Contact Medicare Part B Specialty Pharmacy before Injections, Infusion Drug Prior Authorization Expire
Routine Cervical Cancer Screening Coverage Guidelines
Enhancements to AIM Clinical Appropriateness Guidelines for Advanced Imaging Effective November 1, 2016
61516MUPENMUB 08/03/2016
Behavioral health update
Behavioral health providers – please review the entire newsletter
While the articles in this section are of specific interest to participating behavioral health providers, there are other articles in
this publication that apply to or could be of interest to behavioral health providers as well. Please review the entire issue. In
addition, please note that the information and articles in this newsletter related to behavioral health services are for plans
and products managed by Anthem Behavioral Health.
Update: prior authorization required for IOP and PHP for Blue Choice and Comp-Care members
effective December 1, 2016
Please read this article in the Administrative and policy update section of this newsletter.
Ambulatory detoxification, H0014, added to physician fee schedules effective October 1, 2016
Effective October 1, 2016, we have added a new code to physician fee schedules. H0014, ambulatory detoxification, may be
billed for the induction phase of buprenorphine treatment. Once a member is stabilized on a maintenance dosage of
buprenorphine, typically within a few visits, E&M codes may be used for subsequent treatment. We have several options for
ancillary psychosocial treatment; please contact our behavioral health department if referrals are needed.
LiveHealth Online Psychology -easy access to therapists and psychologists from the comfort of
home
Please read this article in the Administrative and policy update section of this newsletter.
Quality programs update
Communicating the importance of childhood vaccinations
Parents consider healthcare professionals one of the most trusted sources in answering questions and addressing concerns
about their child’s health. A recent survey on parents’ attitudes, knowledge, and behaviors regarding vaccines for young
children – including vaccine safety and trust – found that 8 out of 10 parents consider pediatric healthcare professionals to
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be one of their most trusted sources of vaccine information. With so many parents relying on advice about vaccines, a
healthcare professional’s recommendation plays a key role in guiding parents’ vaccination decisions.
Make sure to address questions or concerns by tailoring responses to the level of detail the parent is looking for. Some
parents may be prepared for a fairly high level of detail about vaccines – how they work and the diseases they prevent –while
others may be overwhelmed by too much science and may respond better to a personal example of a patient you’ve seen
with a vaccine-preventable disease. A strong recommendation from you as a healthcare professional can also make parents
feel comfortable with their decision to vaccinate.
We are committed to helping close the gap on childhood immunizations. That’s why we are sending a targeted reminder
mailing to parents of children from 0 to 2 years old who may have missed an important immunization. It is very important that
babies receive all doses of each vaccine, as well as receive each vaccination on time. These reminder letters encourage
parents to contact their healthcare provider to verify that their children are up to date on all recommended vaccines and to
schedule an appointment to get the immunizations they might have missed. In addition, we provide a colorful schedule of
these recommendations created by the CDC that parents can use as a reference.
More resources to aid in the communication about vaccine-preventable diseases, vaccines, and vaccine safety are available
online at www.cdc.gov/vaccines/conversations.
Clinical practice and preventive health guidelines available on anthem.com
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical
research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website
at anthem.com > Providers > Select state > Health & Wellness > Practice Guidelines.
Care & Cost Finder powered by Castlight to be launched
We are pleased to update you on our strategic collaboration with Castlight Health. As we shared in late 2015, we have come
together with Castlight to co-develop a best-in-breed cost and quality transparency solution for Anthem members. The first
release will be launched to 27 early adopter clients in October followed by an additional 15 early adopters in January 2017.
Both releases focus on large local groups and national clients. Care & Cost Finder will continue to be rolled out to our
members through 2018. We will continue to share details and information as we scale Care & Cost Finder to our members.
HEDIS Spotlight: Comprehensive Diabetes Care (CDC)
Approximately 29.1 million people (about 1 in 11 people) in the United States have diabetes. In 2012, the American Diabetes
Association (ADA) reported that diabetes care cost the US health care system $245 billion.
Given the prevalence, associated costs and complexity of this chronic disease, health plans collect data on diabetes
monitoring. The Comprehensive Diabetes Care (CDC) measure looks for the percentage of members with diabetes (type 1
and type 2) who had each of the following during the year:
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Hemoglobin A1c (HbA1c) testing
HbA1c poor control (>9.0%)
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HbA1c control (<8%)
HbA1c control (<7%)
Eye exam (retinal) performed
Medical attention for nephropathy
BP control (<140/90 mm Hg)
Nationally-recognized clinical guidelines recommend that:
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HbA1c test at least twice per year;
Retinal eye exam by an optometrist or ophthalmologist annually;
Nephropathy screening annually;
Blood pressure reading at each routine medical visit, not including readings on the same day as a
procedure/diagnostic screening test or an acute inpatient hospital or emergency room visit.
Medical chart reviews from the 2016 HEDIS data collection showed the following factors contribute to low CDC rates:
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Lack of communication and continuity of care between primary care and specialists
Members may have a prescription, but no record of an office visit or lab test/result during the year.
Test results may not have been clearly recorded in the member’s medical chart.
Tests may not have been done or recommended.
Members may not have completed the recommended tests or returned for recommended follow-up visits.
Strategies to improve Comprehensive Diabetes Care rates include:
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Establish and maintain a secure office diabetes registry to identify members with diabetes to help track doctor and
lab test appointments, results, and specialists.
Clearly document lab/test dates and results in each member’s medical record.
Repeat tests for high results, specifically for HbA1c (over 7%) and blood pressure (over 140/90 mm HG).
Improve communication both within the member’s care team, including among specialists.
Work with our members to set goals to improve or maintain their control over their diabetes.
Anthem Whole Health ConnectionSM
Anthem Whole Health Connection is a program that enhances clinical care with more data including dental, vision, disability
and pharmacy, and creates a bigger picture of member health 1 . It also consolidates data from primary care physicians,
specialists, ancillary providers like eye doctors and dentists, pharmacies and labs. Sophisticated data analytics are applied to
the data to deliver relevant, HIPAA compliant member health profiles and actionable insights. The insights are then shared
with physicians and care managers to allow for more informed treatment plans and better health outcomes.
How it Works
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Data Collection – we consolidate all claims and benefit information from all coverage lines (medical, dental, vision,
disability, pharmacy and behavioral health) in a central repository.
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Analytics – Data is analyzed to deliver condensed, relevant member health profiles and actionable insights via care
alerts and proactive care management referrals.
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Connect, share and manage – we connect physicians to this data via the Member Medical History Plus (MMH+)
tool. Sharing of information allows for more informed treatment plans to manage a member’s condition. The data is
further shared with care managers, and ancillary providers such as vision providers.
Why is it important to connect dental, vision, disability and pharmacy data to population health?
It’s important because oral health, eye health and productivity contribute to overall health.
The value to your practice
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More efficient data collection. The MMH+ supplements the physician’s patient health records with the following
information:
– Medications and utilization (if not carved out)
– Labs
– Medical diagnoses (non-sensitive)
– Other providers and utilization
– Care management status
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Earlier detection of medical conditions. For example, a vision exam could be the first indicator of a chronic condition
like diabetes. The vision claim diagnosis of diabetes would populate the MMH+ for viewing by PCPs and care
managers.
Proactive care management for improved health outcomes. That same vision claim could trigger a member care
alert to the PCP or a referral to Anthem Care Management allowing for proactive outreach to the member by the
PCP and care manager.
Reduced cost of care. A recent American Journal of Preventive Medicine study shows that patients with chronic
disease or pregnancy who treat their periodontal disease have 6%-74% lower medical costs and hospitalizations 2 .
Opportunities for your practice
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View the MMH+ to complement your electronic health record (EHR) and get a bigger picture of each member’s
health.
Interesting in learning more about the MMH+ advantages?
Access our Member Medical History Plus (MMH+) Training document online. Go to anthem.com > Providers > select state >
Self Service and Support > Enhanced Personal Health Care Program > Provider Toolkit, Milestone 2: Risk Stratifying
Populations, Member Medical History Plus (MMH+) Training.
This self-guided presentation introduces Member Medical History Plus, or MMH+, our longitudinal patient record. In addition
to basic logon information, this presentation shows the kinds of information available via MMH+, and includes hypothetical
scenarios that demonstrate how using MMH+ can help improve patient care.
Already have access to MMH+?
Log in today and start using it: http://mmhehr.anthem.com/mmhplus
Need to request access to MMH+?
Please email us at [email protected].
1 Anthem Whole Health Connection applies to employer groups that have purchased an Anthem pharmacy, dental, vision or disability plan, in addition to their medical plan.
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2 American Journal of Preventive Medicine's Impact of Periodontal Therapy on General Health Study, June 2014
Pharmacy update
Pharmacy information available on anthem.com
Visit the applicable websites noted below for more information on the following:
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copayment/coinsurance requirements and their applicable drug classes
drug lists and changes
prior authorization criteria
procedures for generic substitution
therapeutic interchange
step therapy or other management methods subject to prescribing decisions
other requirements, restrictions or limitations that apply to certain drugs
To locate the commercial drug list, go to anthem.com > Customer Support > Maine > Download forms > Anthem Blue Cross
and Blue Shield Drug Lists.
The commercial drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January,
April, July and October).
To locate the Marketplace Select Formulary and pharmacy information for health plans offered on the Exchange Marketplace,
go to anthem.com > Customer Support > Maine > Download forms > Maine Select Drug List.
Website links for the Federal Employee Program formulary Basic and Standard Options are:
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Basic Option: https://www.caremark.com/portal/asset/z6500_drug_list807.pdf
Standard Option: https://www.caremark.com/portal/asset/z6500_drug_list.pdf
This drug list is also reviewed and updated regularly as needed.
Medical policy update
Medical policy updates are available on anthem.com
The following new and revised policies were endorsed at the August 4, 2016 Medical Policy & Technology Assessment
Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com > Providers > Select
state > Enter > Medical Policies and Clinical UM Guidelines.
If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call
Center.
Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit
Plans > Brochures and Forms > Medical Policies.
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Revised medical policy effective August 1, 2016
(The following policy was revised prior to the August 4, 2016 meeting to expand medical necessity indications or criteria.)
Gene.00006
Epidermal Growth Factor Receptor (EGFR) Testing
Revised medical policies effective August 18, 2016
(The following policies were revised to expand medical necessity indications or criteria.)
BEH.00002
DRUG.00024
DRUG.00058
RAD.00042
SURG.00014
SURG.00020
SURG.00055
SURG.00103
SURG.00121
Transcranial Magnetic Stimulation
Omalizumab (Xolair®)
Pharmacotherapy for Hereditary Angioedema
SPECT/CT Fusion Imaging
Cochlear Implants and Auditory Brainstem Implants
Bone-Anchored and Bone Conduction Hearing Aids
Cervical Total Disc Arthroplasty
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Transcatheter Heart Valve Procedures
New medical policy effective August 18, 2016
LAB.00032
Zika Virus Testing
Revised medical policies effective October 1, 2016
(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the
policy position or criteria.)
DRUG.00017
DRUG.00031
DRUG.00057
DRUG.00078
SURG.00054
SURG.00122
Hyaluronan Injections in Joints other than the Knee
Subcutaneous Hormone Replacement Implants
Canakinumab (Ilaris®)
Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic
Transection
Venous Angioplasty with or without Stent Placement
Revised medical policies effective October 4, 2016
(The following policies were revised to expand medical necessity indications or criteria.)
MED.00005
MED.00051
Hyperbaric Oxygen Therapy (Systemic/Topical)
Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
Revised medical policies effective October 4, 2016
(The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the
policy position or criteria.)
ADMIN.00002
ADMIN.00004
ADMIN.00005
October 2016
Preventive Health Guidelines
Medical Necessity Criteria
Investigational Criteria
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ANC.00006
ANC.00007
DME.00004
DME.00009
DME.00024
DME.00027
DME.00030
DME.00037
DRUG.00002
DRUG.00042
DRUG.00064
GENE.00021
GENE.00022
GENE.00040
GENE.00041
GENE.00042
GENE.00043
LAB.00016
LAB.00031
MED.00055
MED.00064
MED.00081
MED.00090
MED.00098
MED.00107
MED.00109
MED.00112
OR.PR.00005
RAD.00019
RAD.00034
RAD.00035
RAD.00045
RAD.00046
RAD.00063
SURG.00005
SURG.00023
SURG.00026
SURG.00048
SURG.00049
SURG.00051
SURG.00066
SURG.00071
October 2016
Biomagnetic Therapy
Cosmetic and Reconstructive Services: Skin Related
Electrical Bone Growth Stimulation
Vacuum Assisted Wound Therapy in the Outpatient Setting
Transtympanic Micropressure for Treatment of Ménière’s Disease
Ultrasound Bone Growth Stimulation
Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
Cooling Devices and Combined Cooling/Heating Devices
Tumor Necrosis Factor Antagonists
Ustekinumab (Stelara®)
Enteral Carbidopa and Levodopa Intestinal Gel Suspension
Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual
Disability (Intellectual Developmental Disorder) and Congenital Anomalies
In Vitro Companion Diagnostic Devices
Genetic Testing for CHARGE Syndrome
Short Tandem Repeat Analysis for Specimen Provenance Testing
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and
Leukoencephalopathy (CADASIL) Syndrome
Genetic Testing of an Individual’s Genome for Inherited Diseases
Fecal Analysis in the Diagnosis of Intestinal Disorders
Advanced Lipoprotein Testing
Wearable Cardioverter Defibrillators
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation
or Atrial Flutter (Radiofrequency and Cryoablation)
Cognitive Rehabilitation
Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
Hyperoxemic Reperfusion Therapy
Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett
Syndrome
Corneal Collagen Cross-Linking
Autonomic Testing
Upper Extremity Myoelectric Orthoses
Magnetic Source Imaging and Magnetoencephalography
Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA),
Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI)
Cerebral Perfusion Imaging using Computed Tomography
Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging
Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
Partial Left Ventriculectomy
Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Deep Brain, Cortical, and Cerebellar Stimulation
Panniculectomy, Abdominoplasty
Mandibular/Maxillary (Orthognathic) Surgery
Hip Resurfacing
Percutaneous Neurolysis for Chronic Neck and Back Pain
Percutaneous and Endoscopic Spinal Surgery
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SURG.00074
SURG.00076
SURG.00077
SURG.00084
SURG.00085
SURG.00090
SURG.00093
SURG.00105
SURG.00116
SURG.00118
SURG.00125
SURG.00126
SURG.00127
SURG.00132
SURG.00133
SURG.00134
SURG.00140
SURG.00141
TRANS.00035
Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring
Nerve Graft after Prostatectomy
Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
Implantable Middle Ear Hearing Aids
Mastectomy for Gynecomastia
Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia (TGN
Treatment of Osteochondral Defects
Bicompartmental Knee Arthroplasty
High-Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of
the Anus
Bronchial Thermoplasty
Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
Irreversible Electroporation (IRE)
Sacroiliac Joint Fusion
Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery
Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
Interspinous Process Fixation Devices
Peripheral Nerve Blocks for Treatment of Neuropathic Pain
Doppler-Guided Transanal Hemorrhoidal Dearterialization
Mesenchymal Stem Cell Therapy for Orthopedic Indications
New medical policy effective October 4, 2016
(The policy listed below might result in services that were previously covered now being considered either not medically
necessary and/or investigational.)
DRUG.00088
Atezolizumab (Tecentriq™)
Revised medical policy effective November 1, 2016
(The policy listed below might result in services that were previously covered now being considered either not medically
necessary and/or investigational.)
ADMIN.00007
Immunizations
Revised medical policies effective January 1, 2017
(The policies listed below might result in services that were previously covered now being considered either not medically
necessary and/or investigational.)
DRUG.00015
DRUG.00031
DRUG.00078
GENE.00026
LAB.00027
MED.00051
SURG.00024
SURG.00028
October 2016
Prevention of Respiratory Syncytial Virus Infections
Subcutaneous Hormone Replacement Implants
Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
Cell-Free Fetal DNA-Based Prenatal Testing
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other
Genitourinary Conditions
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New medical policies effective January 1, 2017
(The policies listed below might result in services that were previously covered now being considered either not medically
necessary and/or investigational.)
DME.00039
DRUG.00087
DRUG.00089
DRUG.00091
DRUG.00092
DRUG.00093
GENE.00046
GENE.00047
RAD.00066
SURG.00144
Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
Asfotase Alfa (Strensiq™)
Daclizumab (Zinbryta™)
Naltrexone Implants for the Treatment of Alcohol and Opioid Use Disorders
Probuphine (buprenorphine implant)
Sebelipase alfa (KANUMA™)
Prothrombin G20210A (Factor II) Mutation Testing
Methylenetetra-hydrofolate Reductase Mutation Testing
Multiparametric Magnetic Resonance Imaging Fusion Targeted Prostate Biopsy
Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
Clinical guidelines update
Clinical guideline updates are available on anthem.com
The following new and revised clinical guidelines were endorsed at the August 4, 2016 Medical Policy & Technology
Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com > Providers
> Select state > Enter > Medical Policies and Clinical UM Guidelines.
If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call
Center.
Revised clinical guideline effective August 18, 2016
(The following guideline was revised to expand the medical necessity indications or criteria.)
CG-BEH-02
CG-SURG-27
Adaptive Behavioral Treatment for Autism Spectrum Disorder
Sex Reassignment Surgery
Revised clinical guidelines effective October 4, 2016
(The following guidelines were revised and had no significant changes to the position or criteria.)
CG-BEH-07
CG-BEH-14
CG-DME-07
CG-DRUG-09
CG-DRUG-11
CG-DRUG-24
CG-DRUG-47
CG-MED-26
CG-MED-31
CG-MED-46
CG-REHAB-09
October 2016
Psychological Testing
Intensive In-home Behavioral Health Services
Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Immune Globulin (Ig) Therapy
Infertility Drugs
Repository Corticotropin Injection (H.P. Acthar® Gel)
Level of Care: Specialty Pharmaceuticals
Neonatal Levels of Care
Skilled Nursing Facility Services
Ambulatory and Inpatient Video Electroencephalography
Acute Inpatient Rehabilitation
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CG-SURG-05
CG-SURG-08
CG-SURG-12
CG-SURG-24
CG-SURG-38
CG-SURG-44
CG-SURG-48
Maze Procedure
Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
Penile Prosthesis Implantation
Functional Endoscopic Sinus Surgery (FESS)
Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
Coronary Angiography in the Outpatient Setting
Elective Percutaneous Coronary Interventions (PCI)
Revised clinical guidelines effective January 1, 2017
(The guidelines listed below might result in services that were previously covered now being considered either not medically
necessary and/or investigational.)
CG-BEH-03
CG-DRUG-28
CG-SURG-27
October 2016
Psychiatric Disorder Treatment
Alglucosidase alfa (Lumizyme®, Myozyme®)
Sex Reassignment Surgery
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