MP/CG Update/Notice - January 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 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.

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January 1, 2021

[Provider Name]
[Address] [City], [State] [Zip]

Dear Provider:

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

UPDATED Medical Policies and Clinical Guidelines effective April 1, 2021

• GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity: This document addresses risk stratification of inflammatory bowel disease (IBD) severity using gene expression profiling from peripheral blood biomarkers. This document does not address initial irritable bowel syndrome (IBS), IBD diagnosis, ongoing IBD disease management nor the use of inflammatory markers, fecal samples or tissue biopsies for risk stratification of IBD disease severity. o Prior authorization required for non-AIM eligible members effective April 1, 2021

• SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain: This document addresses implantable peripheral nerve stimulation devices as a treatment for pain. o Prior authorization required effective April 1, 2021

Specialty pharmacy medical step therapy drug review clarification

Correction to a prior authorization update We included updates for ING-CC-0174 (Kesempta) in our October and November letters. To clarify, the NOC codes, J3490, J3590 and C9399 are valid codes for Kesimpta. The code J9302 is not a valid code for Kesimpta.

Update on Ocrevus Step Therapy Notification
Ocrevus will still be non-preferred as noted below, but please note that the step therapy criteria have been updated since the last publication.

Effective for dates of service on and after February 1, 2021, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

The step therapy drug list is available at https://www.anthem.com/ms/pharmacyinformation/Ocrevus.pdf

Clinical Criteria Status Drug(s) HCPCS Codes ING-CC-0011 Non-preferred Ocrevus J2350

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.

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MCG Care Guidelines 24th Edition Customizations

Effective April 1, 2021, the following new customizations will be implemented:

• Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) – Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
• Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) – Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.

To view a detailed summary of customizations go to https://www.anthem.com/ca/provider/policies/clinical-guidelines/ then scroll down to other criteria section and select Customizations to MCG Care Guidelines 24th Edition.

A Message About California Senate Bill 855

As you may already be aware, California Senate Bill 855 was recently signed into law by Governor Newsom. This legislation affects both mental health and substance use coverage effective January 1, 2021. One of the salient changes is the use of current generally accepted standards of mental health and substance use disorder care for reviewing service determinations by the health plan. Hence, in order to comply with the state law, Anthem is adopting additional sets of criteria for making utilization management determinations.

For members seeking treatment for a primary substance use condition(s) at various levels of care, including professional outpatient mental health, intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment program (RTC), and acute inpatient psychiatric level of care, we will apply the American Society of Addiction Medicine (ASAM) criteria. For adult members seeking treatment for primarily mental health issues, we will apply the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) by the American Association of Community Psychiatrists (AACP) and the Child and Adolescent Level of Care Utilization System (CALOCUS) for members under the age of 18. The changes will allow us to enhance collaboration and coordination with treatment providers and facilities who may already be using the above set of guidelines. The ASAM, LOCUS and CALOCUS will help us to make determinations regarding admissions and for continued stay clinical reviews. For non-California based treatment facilities, we will continue to use the current evidence-based MCG Guidelines.

We want to thank you for working with Anthem in moving to our new level of care determination criteria and hope the new change will make determination reviews more expedient, foster a stronger collaboration relationship with providers, and ultimately lead to enhanced care to our members.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem 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

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.

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Attachment A – Updates as of January 1, 2021 Revised Medical Policies and Clinical Guidelines Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes CG-GENE-01 Janus Kinase 2, CALR and MPL Gene Mutation Assays • AIM eligible members only • Added CPT codes 81279 for JAK2 and 81338, 81339 for thrombopoietin receptor (MPL) genes effective January 1, 2021, replacing Tier 2 codes CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules • AIM eligible members only • Added PLA codes 0208U, 0204U effective October 1, 2020 for Afirma MTC classifier and Afirma Atlas; CPT code 81546 effective January 1, 2021 replacing 81545 deleted December 31, 2020 CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome • AIM eligible members only • Added PLA code 0235U effective January 1, 2021 to pend for review of Medically Necessary criteria CG-GENE-13 Genetic Testing for Inherited Diseases • AIM eligible members only • Added PLA codes 0230U, 0231U, 0232U, 0233U, 0234U, 0236U effective January 1, 2021 to pend for review of Medically Necessary criteria CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management • AIM eligible members only • Updated Appendix A; added CPT codes 81191, 81192, 81193, 81194 for gene neurotrophic receptor tyrosine kinase
effective January 1, 2021, replacing Tier 2 code CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome • AIM eligible members only • BRCA testing codes will pend for additional diagnosis code C61 (prostate cancer) CG-GENE-18 Genetic Testing for TP53 Mutations • AIM eligible members only • Added CPT codes 81351, 81352, 81353 for TP53 gene effective January 1, 2021, replacing Tier 2 codes; added ICD- 10-CM diagnosis codes to pend CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing • AIM eligible members only • Removed CPT codes 88271, 88275, 88365 (FISH testing, not specific to gene amplification); will no longer pend CG-SURG-27 Gender Reassignment Surgery • Revised descriptors for 19318 and 19325 effective January 1, 2021 CG-MED-23 Home Health • Added Medicare Home Infusion Therapy codes G0068, G0069, G0070, G0088, G0089, G0090 effective 01/01/2021; removed revenue codes CG-MED-59 Upper Gastrointestinal Endoscopy in Adults • AIM eligible members only • Removed list of risk factors related to screening for Barrett’s esophagus from Clinical Indications in Medically Necessary statement on screening esophagogastroduodenoscopy in adults
• Added Note to see Discussion/General Information section for risk factor discussion CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications • Added CPT code 55880 effective January 1, 2021 for HIFU of malignant prostate tissue replacing NOC code 55899; considered Not Medically Necessary

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.

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CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities • Added CPT Category III code 0620T for LimFlow Percutaneous Deep Vein Arterialisation (pDVA) System effective January 1, 2021; FDA IDE, in clinical trials CG-SURG-71 Reduction Mammaplasty • Listed additional symptom diagnosis codes to pend; updated 19318 descriptor with January 1, 2021 CPT change CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary) • Clarified diagnosis codes specific to intravascular scope of guideline GENE.00023 Gene Expression Profiling of Melanomas • Added CPT MAAA code 81529 effective January 1, 2021 (was NOC code); considered Investigational and Not Medically Necessary GENE.00049 Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) • Added PLA codes 0229U, 0239U effective January 1, 2021 as Investigational and Not Medically Necessary GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting • Revised descriptor 0152U effective January 1, 2021 MED.00128 Insulin Potentiation Therapy • Insulin codes J1815, J1817 will pend for related diagnoses; clarified only Investigational and Not Medically Necessary if specified as IPT SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures • Updated descriptors with January 1, 2021 CPT changes; codes 19324, 19366 deleted December 31, 2020 SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation • CPT code 61870 deleted December 31, 2020 SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) • Added CPT code 33995 and revised descriptors for 33990, 33991, 33993 effective January 1, 2021 SURG.00151 Balloon Dilation of Eustachian Tubes • Added 69705, 69706 for eustachian tube balloon dilation replacing NOC codes effective January 1, 2021 TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection • CPT Category III code 0085T deleted December 31, 2020; replaced by 84999 NOC TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias • Added diagnosis codes specifically mentioned as Investigational and Not Medically Necessary