MP/CG Update/Notice - April 2022 Form

P.O. Box 4330 Woodland Hills, CA 91365 1 1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

April 1, 2022

[Provider Name] [Contact Name/Title] [Address] [City], [State] [Zip]

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with our new and updated Medical Policies and Clinical UM Guidelines. Please refer to the specific policy for coding, language, rationale updates and changes that are not summarized below.

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®), please visit www.fepblue.org > Policies & Guidelines.

Updates to AIM Specialty Health® (AIM) programs, a separate company, apply to local fully-insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by AIM.
They do not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

NEW Medical Policies effective July 1, 2022

• LAB.00043 Immune Biomarker Tests for Cancer: This document addresses immune response algorithmic tests for oncologic disease management.
o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective July 1, 2022

• LAB.00044 Saliva-based Testing to Determine Drug-metabolizer Status: This document addresses the use of saliva-based testing to determine drug-metabolizer status. o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective July 1, 2022

• LAB.00045 Selected Tests for the Evaluation and Management of Infertility: This document addresses selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment. o The following tests are considered Investigational and Not Medically Necessary: endometrial receptivity analysis; sperm-capacitation test; sperm deoxyribonucleic acid (DNA) fragmentation test; sperm penetration assay; and uterine natural killer (uNK) cells test. o Prior authorization required effective July 1, 2022

• LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease: This document addresses the use of testing for biochemical markers (for example, tau protein, AB-42, neural thread protein) as a diagnostic or screening technique for Alzheimer’s disease. o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective July 1, 2022

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

• RAD.00067 Quantitative Ultrasound for Tissue Characterization: This document addresses quantitative ultrasound to evaluate visceral organs and other anatomic structures by using imaging data and software to analyze tissue characteristics. o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective July 1, 2022

• SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease: This document addresses the use of a port delivery system to treat ocular disease. o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective July 1, 2022

• TRANS.00038 Thymus Tissue Transplantation: This document addresses thymus tissue transplantation (also known as culture thymus tissue [CTT] transplantation) using allogeneic processed thymus tissue-agdc, a regenerative therapy used for immune reconstitution in children with congenital athymia. o Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for thymus tissue transplantation o Prior authorization required effective July 1, 2022

UPDATED Medical Policy effective July 1, 2022

• SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema: This document addresses select surgical procedures for the prevention or treatment of lymphedema in the upper and lower extremities. Lymphedema is the abnormal accumulation of fluid in the body tissues that results from the disruption of lymphatic drainage. o Revised title (previously titled: Microsurgical Procedures for the Prevention or Treatment of Lymphedema) o Revised Position Statement to include the prevention of lymphedema

Medical Policy to be archived April 13, 2022

• GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease (content moved to CG-GENE-13 and LAB.00046)

Clinical Guidelines to be archived April 13, 2022

• CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays (content moved to CG-GENE-14) • CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome (content moved to CG-GENE-14) • CG-GENE-09 Genetic Testing for CHARGE Syndrome (content moved to CG-GENE-13)

Specialty Pharmacy updates

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM.

Clinical Criteria is available at www.anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization for your patients in order to review for continued use of these medications.

Effective for dates of service on and after July 1, 2022, the following specialty pharmacy codes from new clinical criteria documents will be included in our prior authorization review process.

Clinical Criteria Drug HCPCS Code(s) ING-CC-0166 Herzuma (trastuzumab-pkrb) Q5113 ING-CC-0166 Ogivri (trastuzumab-dkst) Q5114 ING-CC-0166 Ontruzant (trastuzumab-dttb) Q5112 ING-CC-0166 Trazimera (trastuzumab-qyyp) Q5116

 * Oncology use is managed by AIM.

Step therapy updates

Effective for dates of service on and after July 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Clinical Criteria Status Drug HCPCS Code(s) ING-CC-0209 Non-preferred Leqvio (inclisiran) J3490 ING-CC-0107 Preferred Avastin (bevacizumab) J9035 Mvasi (bevacizumab-awwb) Q5107 Non-preferred Zirabev (bevacizumab-bvzr) Q5118 ING-CC-0166 Preferred Herceptin (trastuzumab) J9355 Kanjinti (trastuzumab-anns) Q5117 Non-preferred Herzuma (trastuzumab-pkrb) Q5113 Ogivri (trastuzumab-dkst) Q5114 Ontruzant (trastuzumab-dttb) Q5112 Trazimera (trastuzumab-qyyp) Q5116

 *Oncology use is managed by AIM. 
 **Herceptin and Kanjinti are preferred trastuzumab agents that do not require prior authorization or step therapy.

MCG Care Guidelines 26th Edition

Effective July 1, 2022, we will upgrade to the 26th Edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CCG), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal Length of Stay (GLOS) for Inpatient & Surgical Care (ISC)

Guideline MCG Code 25th Edition GLOS
26th Edition GLOS
Aortic Valve Replacement, Transcatheter S-1320 [W0133] 2 days postoperative 1 day postoperative Apnea, Neonatal (Non-Preterm Infants) P-15 3 days 2 days Renal Failure, Chronic M-325 3 days 2 days Subarachnoid Hemorrhage, Nonsurgical Treatment M-79 4 days 3 days

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Guideline MCG Code 25th Edition GLOS
26th Edition GLOS
Craniotomy, Supratentorial S-410 3 days postoperative 2 day postoperative Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF) S-100 Ambulatory or 1 day postoperative Ambulatory Hip Arthroplasty S-560 [W0105] Ambulatory or 2 days postoperative Ambulatory or 1 day postoperative Humerus Fracture, Closed or Open Reduction S-632 Ambulatory or 1 day postoperative Ambulatory Knee Arthroplasty, Total S-700 [W0081] Ambulatory or 2 days postoperative Ambulatory or 1 day postoperative Lumbar Laminectomy S-830 [W0100] Ambulatory or 1 day postoperative Ambulatory Nephrectomy S-870 3 days postoperative 2 days postoperative Prostatectomy, Radical S-960 1 day postoperative Ambulatory or 1 day postoperative Dehydration M-123 1 day 2 days Esophageal Disease M-550 1 day 2 days Gastritis and Duodenitis M-560 1 day 2 days Pneumothorax, Neonatal P-355 2 days 3 days Seizure M-327 1 day 2 days Back Pain M-63 1 day 2 days

New Guidelines for Inpatient & Surgical Care (ISC)

Body System Guideline Title MCG - Code Hospital-at-Home Cellulitis: Hospital-at-Home
M-70-HaH
Hospital-at-Home Chronic Obstructive Pulmonary Disease: Hospital-at-Home M-100-HaH Hospital-at-Home Heart Failure: Hospital-at-Home
M-190-HaH Hospital-at-Home Pneumonia: Hospital-at-Home
M-282-HaH Hospital-at-Home Urinary Tract Infection (UTI): Hospital-at-Home
M-300-HaH Observation Care Pancreatitis: Observation Care OC-065
Observation Care Renal Failure, Acute: Observation Care OC-066 Observation Care Stroke: Ischemic: Observation Care OC-067

To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines/, scroll down to other criteria section and select Customizations to MCG Care Guidelines 26th Edition. For questions, please contact the provider service number on the back of the member's ID card.

Updates to AIM Specialty Health Clinical Appropriateness Guidelines

Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Advanced Imaging

Imaging of the Spine • Perioperative and periprocedural imaging – added requirement for initial evaluation with radiographs

Imaging of the Extremities • Trauma – added CT as an alternative to MRI for tibial plateau fracture; added indication for evaluation of supracondylar fracture • Rotator cuff tear – combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks • Shoulder arthroplasty – modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty • Perioperative imaging – excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty

Vascular Imaging • Stenosis or occlusion, extracranial carotid arteries: - New indications for post neck irradiation, incidental carotid calcification scenarios. • Stroke/TIA, extracranial evaluation - Subacute stroke/TIA: CTA/MRA Neck allowed without prerequisite ultrasound (US), in alignment with 2021 AHA/ASA guidelines. • Chronic stroke/TIA - New indication; modality approach by circulation presentation. • Pulmonary Embolism - Removal of nondiagnostic CXR requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID infection, etc). • Imaging study modality and/or site expansion - Pulsatile Tinnitus, Acute Aortic Syndrome, Abdominal venous thrombosis • Stenosis or occlusion, extracranial carotid arteries - Post-revascularization scenario aligned with SVS guidelines to allow annual surveillance regardless of residual stenosis.
• Aneurysm of the abdominal aorta or iliac arteries - Management/surveillance scenarios aligned with SVS guidelines. • Upper or Lower Extremity Peripheral arterial disease (PAD):
o Suspected PAD without physiologic testing (including exercise testing) not indicated o New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)

MSK

Spine Surgery • Lumbar disc arthroplasty – add indication for 2-level lumbar disc arthroplasty when using a 2-level FDA- approved implant • Lumbar discectomy – remove exclusion for annular closure devices (note: medical necessity of the implant is determined by health plan medical policy) • Lumbar fusion – remove exclusion for anterior lumbar interbody fusion for indirect lumbar decompression in the absence of instability • Cervical decompression with or without Fusion – add criteria for when revision or replacement may be medically necessary • Cervical disc arthroplasty – add criteria for when revision or replacement may be medically necessary • Two-level cervical disc arthroplasty – add indication for second level arthroplasty when prior arthroplasty already performed • Lumbar disc arthroplasty – add requirement to manage underlying psychiatric disorder; add contraindications including prior fusion, poorly managed psychiatric disorder, chronic radiculopathy; add exclusion for prior lumbar fusion • Scheuermann’s kyphosis – removed “associated neurological deficits” as a clinical consideration

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

• Scoliosis – expand indication to include thoracic for progressive adolescent idiopathic scoliosis; increased Cobb angle for skeletally mature patients to greater than 50 degrees
• Spinal stenosis – require surgeon’s interpretation of flexion-extension lateral spine x-ray documented in the medical record; added indications for recurrent stenosis, adjacent-level stenosis after a prior fusion, and planned indirect decompression via anterior approach

Joint Surgery • Total shoulder arthroplasty – add fracture indication for total shoulder arthroplasty (although reverse total shoulder arthroplasty is preferred) to align with AAOS feedback • Total shoulder arthroplasty – add exception for Kellgren-Lawrence grade 4 to be consistent with total knee and total hip arthroplasty • Hemiarthroplasty – added indications for hemiarthroplasty for glenohumeral arthritis with irreparable rotator cuff and for malignancy involving the glenohumeral joint or surrounding soft tissue • Reverse shoulder arthroplasty – add indication when glenoid bone stock inadequate to support anatomic glenoid prosthesis • Labrum repair – remove requirement that MRI-demonstrated SLAP lesion is traumatic in nature • Adhesive capsulitis – match requirements in knee arthroscopy; reduce timeframe of conservative management to 6 weeks post-surgery for lysis of adhesions/capsular release and MUA • Total knee arthroplasty – add patellofemoral osteoarthritis as an indication for total knee arthroplasty • Knee arthroscopy – new indication for abrasion arthroplasty/microfracture • Knee/arthroscopically assisted lysis of adhesions – remove 12-week post-surgery requirement
• Knee/manipulation under anesthesia – remove 12-week post-surgery requirement • Treatment of osteochondral defects – remove BMI 35 or less from patient selection criteria • Autologous chondrocyte implantation – Added contraindications from MACI package insert, including severe osteoarthritis, inflammatory joint disease, knee surgery other than biopsy or MACI preparation, and inability to cooperate with postoperative rehab program

Small Joint Surgery • Hallux rigidus – add criteria for select implant arthroplasties in great toe; remove exclusion for percutaneous osteotomy • Hallux valgus/bunionette – remove exclusion for implant arthroplasties • Lesser toe deformities – remove exclusions for implant arthroplasties and intramedullary fixation devices • First metatarsophalangeal joint arthrodesis – remove requirement for 6 months of symptoms • First metatarsophalangeal joint arthroplasty – new indication • Hallux rigidus/exclusions – clarified specific types of excluded implants; excluded metatarsophalangeal joint arthroplasties for any other indications; excluded peripheral neuropathy/Charcot joint Sacroiliac Joint (SU) Fusion • Expand indication to include any FDA-approved minimally invasive/percutaneous SI joint fusion device with fixation • Require a trial of at least one therapeutic intra-articular SI joint injection • New criteria for revision minimally invasive SI joint fusion • Add exclusion for posterior (dorsal) minimally invasive SI joint fusion procedures using only bone grafts and no internal fixation device

Sleep Disorder Management

• Established sleep disorder (OSA or other) – follow-up laboratory studies – added indication for one follow- up in-lab sleep study as appropriate following insertion of a hypoglossal nerve stimulator • Multiple Sleep Latency Testing (MSLT) and/or Maintenance of Wakefulness Testing (MWT) – new indication for MWT in occupational safety evaluation • Management of OSA using Oral Appliances (OA) – limit guideline for oral appliance use to patients 16 years and older

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
• Access AIM’s ProviderPortalSM directly at www.providerportal.com
o 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 www.availity.com
• Call the AIM Contact Center toll-free number: 877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Current and upcoming guidelines are available at https://aimspecialtyhealth.com/anthem185/.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem Blue Cross Web site at http://www.anthem.com/ca and then selecting “Providers”, then selecting “Policies, Guidelines & Manuals” under the Provider Resources column, scrolling down to select “View Medical Policies & Clinical UM Guidelines”, then selecting ”Full List page” or by entering a keyword or code in the search box.

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality health care for Californians.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Attachment A – Revised Medical Policies and Clinical Guidelines Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes CG-GENE-10 (AIM Genetic Testing) Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies • Added CPT code 0318U effective April 1, 2022, as Medically Necessary when criteria met CG-GENE-13 (AIM Genetic Testing) Genetic Testing for Inherited Diseases • Moved content of GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease into this document with no revisions to criteria • Moved content of CG-GENE-09 Genetic Testing for CHARGE Syndrome into this document with no revisions to criteria CG-GENE-14 (AIM Genetic Testing) Gene Mutation Testing for Cancer Susceptibility and Management
• Revised title (previously titled Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management) • Expanded scope of document to address solid and non-solid tumors
• Updated Table A and Table B • Moved content of CG-GENE-01 Janus Kinase 2, CALR and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document CG-GENE-19 (AIM Genetic Testing) Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing • Revised title (previously titled Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers) • Revised Not Medically Necessary statement to read “Next generation sequencing of tumor DNA to detect or quantify measurable (minimal) residual disease in individuals with all other lymphoid cancer is considered Not Medically Necessary” CG-MED-26 Neonatal Levels of Care • Added “Infants who continue to require inpatient care but do not require a neonatal intensive care unit (NICU) level of care are suitable for care in a well-baby nursery” to the Medically Necessary General Nursery or Well-Baby Nursery level of care section • Revised the Medically Necessary Level I Surveillance Special Care Nursery section to change nipple feedings to greater than 50% of total enteral feedings CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) • Added Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) with criteria to Medically Necessary statement • Removed ISSHL from Not Medically Necessary statement CG-SURG-99 Panniculectomy and Abdominoplasty • Removed code 00802 for associated anesthesia services CG-TRANS-02 Kidney Transplantation • Clarified Medically Necessary Clinical Indications by adding a note referring to Definitions section for additional information on end stage renal disease

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring • Added HCPCS codes K1028, K1029 effective April 1, 2022 considered Investigational and Not Medically Necessary, replacing NOC code (E1399) GENE.00023 Gene Expression Profiling of Melanomas • Added CPT code 0314U effective April 1, 2022, considered Investigational and Not Medically Necessary GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) • Added CPT codes 0306U, 0307U effective April 1, 2022, considered Investigational and Not Medically Necessary GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling • Added polygenic risk score testing to the scope as Investigational and Not Medically Necessary • Clarified criteria for Lynch Syndrome to add “containing 5-50 genes” and “at a minimum • Added Medically Necessary statement for testing for initial evaluation of myelodysplastic syndromes • Added Medically Necessary statement for testing for initial evaluation of acute myeloid leukemia • Added Medically Necessary statement for initial evaluation of acute lymphoblastic leukemia • Clarified criteria for Whole Exome Sequencing (WES) to state “live” fetus • Revised Medically Necessary criteria for gene panel testing for prostate cancer to remove “Lynparza” and add “a poly (ADP-ribose) polymerase (PARP) inhibitor” GENE.00056 Gene Expression Profiling for Bladder Cancer • Added CPT code 81479 for tests not specifically addressed in CPT codes LAB.00015 Detection of Circulating Tumor Cells • Added CPT code 0317U effective April 1, 2022, considered Investigational and Not Medically Necessary LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus • Added CPT code 0312U effective April 1, 2022, considered Investigational and Not Medically Necessary MED.00104 Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin
• Revised title (previously titled: Non-invasive Measurement of Advanced Glycation Endproducts [AGEs] in the Skin) SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Moved StrataGraft from Investigational and Not Medically Necessary section to Medically Necessary section for burns • Added mVASC to Medically Necessary section for treatment of diabetic foot ulcers • Clarified product terminology regarding AlloDerm products • Added new products to Investigational and Not Medically Necessary statement SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations • Clarified unit of measurement for body mass index (BMI) in Medically Necessary criteria • Added Medically Necessary criteria for fetoscopic endoluminal tracheal occlusion (FETO) SURG.00096 Surgical and Ablative Treatments for Chronic Headaches • Removed criteria addressing nasal and sinus surgery from Investigational and Not Medically Necessary statement SURG.00153 Cardiac Contractility Modulation Therapy • Added HCPCS code K1030 effective April 1, 2022, considered Investigational and Not Medically Necessary

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1962-0322-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem B lue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema
• Revised title (previously titled Microsurgical Procedures for the Prevention or Treatment of Lymphedema) • Revised Position Statement to include the prevention of lymphedema TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) • Revised Investigational and Not Medically Necessary statement to include all other indications and reformatted to combine into a single statement