MP/CG Update/Notice - December 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 991-1121-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.

December 1, 2021

Dear Provider:

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

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.

Specialty Pharmacy updates

Effective for dates of service on and after March 1, 2022, the following specialty pharmacy codes from current Clinical Criteria documents will be included in our prior authorization (PA) review process. Note: PA requests for certain medications may require additional documentation to determine medical necessity.

Please note that 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.

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

Clinical Criteria Drug HCPCS or CPT Code ING-CC-0018 Nexviazyme (avalglucosidase alfa-ngpt) C9399, J3490, J3590 ING-CC-0034 Sajazir (icatibant) J1744

Quantity limit updates

Effective for dates of service on and after March 1, 2022, the following specialty pharmacy codes from current Clinical Criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS or CPT Code ING-CC-0018 Nexviazyme (avalglucosidase alfa-ngpt) C9399, J3490, J3590 ING-CC-0034 Sajazir (icatibant) J1744

Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guideline

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM 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.

Percutaneous Coronary Intervention • Removed requirement to calculate SYNTAX score for patients scheduled to undergo renal transplantation • For patients scheduled for percutaneous valvular procedures (e.g., transcatheter aortic valve replacement/implantation (TAVR/TAVI) or mitral valve repair), added clarification that PCI should only be attempted for complex triple vessel disease when CABG is not an option.

991-1121-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.

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 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: 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 aimspecialtyhealth.com/anthem185/.

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