MP/CG Update/Notice - January 2022 Form

P.O. Box 4330 Woodland Hills, CA 91365

1074-1221-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.

January 1, 2022

Dear Provider:

Anthem Blue Cross 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, or Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

NEW Medical Policies effective April 1, 2022

• DME.00044 Wheelchair Mounted Robotic Arm: This document addresses the use of a wheelchair mounted robotic arm attachment intended for use in individuals with upper extremity disability, to create a sense of independence with mobility restraints and gain autonomy due to neurologic conditions, trauma, or other problems.
o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective April 1, 2022

• MED.00138 Wearable Devices for Stress Relief and Management: This document addresses wearable devices for management, monitoring or prevention of stress and stress-related conditions. o Considered Investigational and Not Medically Necessary for all uses o Prior authorization required effective April 1, 2022

UPDATED Medical Policies and Clinical UM Guideline effective April 1, 2022

• CG-MED-81 Ultrasound Ablation for Oncologic Indications: This document addresses the use of high intensity focused ultrasound (HIFU) or magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of oncologic conditions. o Revised title (previous title: High Intensity Focused Ultrasound [HIFU] for Oncologic Indications) o Added Not Medically Necessary statement for transurethral ultrasound ablation (TULSA)

• CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies: This document addresses surgical excision and locoregional therapies to treat primary or metastatic cancer of the liver.
o Revised the clinical indications to add a Not Medically Necessary statement for histotripsy

• MED.00099 Navigational Bronchoscopy: This document addresses the use of navigational bronchoscopy (NB) devices as an aid in accessing peripheral lung lesions and masses, which may be inaccessible by standard bronchoscopy. o Revised title (previous title: Electromagnetic Navigational Bronchoscopy) o Removed the word “Electromagnetic” in the Position Statement

2

1074-1221-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 Insuran ce Companies, Inc.

• SURG.00010 Treatments for Urinary Incontinence: This document addresses the following treatments for urinary incontinence: vaginal weight training; injection of periurethral bulking agents; transvaginal radiofrequency bladder neck suspension; transurethral radiofrequency energy collagen micro-remodeling; artificial urinary sphincter devices; intraurethral valve-pump implantation; and adjustable balloon system implantation. o Added new criterion to Investigational and Not Medically Necessary statement on endovaginal cryogen- cooled, monopolar radiofrequency remodeling o Added “as treatments for urinary incontinence” to Investigational and Not Medically Necessary statement and removed wording on urinary incontinence

• SURG.00097 Scoliosis Surgery: This document addresses surgical treatments for scoliosis, specifically, a minimally invasive deformity correction system, vertebral body tethering, and vertebral body stapling. This document does not address spinal fusion for scoliosis treatment. o Revised title (previous title: Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents) o Added “minimally invasive deformity correction system” to the Scope and Position Statement

Medical Policies to require prior authorization effective April 1, 2022

DME.00032 Automated External Defibrillators for Home Use LAB.00011 Analysis of Proteomic Patterns MED.00002 Selected Sleep Testing Services MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders MED.00099 Electromagnetic Navigational Bronchoscopy MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management OR-PR.00005 Upper Extremity Myoelectric Orthoses OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices RAD.00053 Cervical and Thoracic Discography SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele SURG.00071 Percutaneous and Endoscopic Spinal Surgery SURG.00088 Coblation® Therapies for Musculoskeletal Conditions SURG.00107 Prostate Saturation Biopsy SURG.00119 Endobronchial Valve Devices SURG.00126 Irreversible Electroporation SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy SURG.00150 Leadless Pacemaker SURG.00151 Balloon Dilation of Eustachian Tube TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft) TRANS.00008 Liver Transplantation TRANS.00009 Lung and Lobar Transplantation TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome TRANS.00026 Heart/Lung Transplantation TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

3

1074-1221-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 Insuran ce Companies, Inc.

TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors TRANS.00033 Heart Transplantation TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus TRANS.00035 Therapeutic Use of Stem Cells, Blood and Bone Marrow Products (title updated December 29, 2021)

Medical Policies archived (i.e., no longer in use) November 18, 2021

• MED.00095 Anterior Segment Optical Coherence Tomography • MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders • OR-PR.00004 Partial-Hand Myoelectric Prosthesis (content moved to CG-OR-PR-05)

Medical Policies archived and Clinical UM Guideline de-adopted (i.e., no longer in use) December 29, 2021

• CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications • GENE.00036 Genetic Testing for Hereditary Pancreatitis (content moved to CG-GENE-13) • GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing(content moved to CG-GENE-13) • MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium

Clinical UM Guidelines de-adopted (i.e., no longer in use) January 1, 2022

• CG-ANC-05 Ambulance Services: Ground; Emergent • CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight • CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories • CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton • CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting • CG-SURG-77 Refractive Surgery • CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)

Clinical UM Guidelines de-adopted (i.e., no longer in use) February 1, 2022

• CG-SURG-12 Penile Prosthesis Implantation • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) • CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids • CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection • CG-SURG-104 Intraoperative Neurophysiological Monitoring • CG-SURG-105 Corneal Collagen Cross-Linking • CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

4

1074-1221-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 Insuran ce Companies, Inc.

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 by selecting “Providers”, selecting “Policies, Guidelines & Manuals” under the Provider Resources column, scrolling down and selecting “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

5

1074-1221-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 Insuran ce Companies, Inc.

Attachment A – Revised Medical Policies and Clinical UM Guidelines Policy/Guideline Number Title Medical Policy / Clinical UM Guideline Changes CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance • Removed the word “initial” and simplified criteria statement for criteria E under Medically Necessary section • Removed criteria B from Not Medically Necessary section and incorporated information into discussion section CG-GENE-04 (AIM Genetic Testing) Molecular Marker Evaluation of Thyroid Nodules • Added CPT Proprietary Laboratory Analyses (PLA) code 0287U effective January 1, 2022, for Thyroseq test to be reviewed for Medically Necessary criteria • Removed 0208U deleted December 31, 2021, for Afirma
Medullary Thyroid Carcinoma (MTC) test CG-GENE-10 (AIM Genetic Testing) Chromosomal Microarray Analysis for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies • Added CPT code 81349 for low pass sequencing to be reviewed for Medically Necessary criteria • Updated descriptors for CPT codes 81228, 81229, effective January 1, 2022 CG-GENE-13 (AIM Genetic Testing) Genetic Testing for Inherited Diseases • Moved content of GENE.00036 Genetic Testing for Hereditary Pancreatitis to this document
• Moved content of GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing to this document with no changes to criteria • Updated table of genes to add: PRSS1, SPINK1, CTRC. Exon 45 skipping, IL1RN, MOCS1, S1, MTHFR CG-GENE-22 (AIM Genetic Testing) Gene Expression Profiling for Managing Breast Cancer Treatment • Added CPT code 81523 effective January 1, 2022, for MammaPrint Next-Generation Sequencing (NGS) test to be reviewed for Medically Necessary criteria CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins • Updated descriptor for CPT code 93656 effective January 1, 2022
CG-MED-73
Hyperbaric Oxygen Therapy (Systemic/Topical) • Added clarification to Medically Necessary statement regarding continued treatment beyond 30 days for chronic non-healing diabetic lower extremity wounds CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices • Moved content addressing partial-hand prosthesis from OR- PR.00004 Partial-Hand Myoelectric Prosthesis to this document • Added new Medically Necessary criteria and codes (L6026, L6715) for partial-hand myoelectric prosthesis CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation • Updated descriptors for CPT codes 93653 and 93654 CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention • Updated descriptor for CPT code 64581 GENE.00023 Gene Expression Profiling of Melanomas • Updated descriptor for CPT code 0090U

6

1074-1221-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 Insuran ce Companies, Inc.

GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) • Revised title (previous title: Circulating Tumor DNA Panel Testing for Cancer [Liquid Biopsy]) • Removed “for the diagnosis or treatment of cancer” from the Investigational and Not Medically Necessary statement GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling • Added Medically Necessary criteria for breast cancer susceptibility and advanced non-small cell lung cancer using gene panels • Added Medically Necessary criteria for whole exome sequencing LAB.00024 Immune Cell Function Assay • Added CPT codes 0018M, 81560 and 81599 for Pleximark and Pleximmune tests, considered Investigational and Not Medically Necessary LAB.00026 Systems Pathology Testing for Prostate Cancer • Revised title (previous title: Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence) LAB.00031 Advanced Lipoprotein Testing • Added CPT code 84999 replacing 0423T deleted December 31, 2021, for Secretory type II phospholipase A2 (sPLA2-IIA) test MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography) • Added CPT Category III codes 0700T, 0701T effective January 1, 2022, for Orlucent fluorescent imaging, considered
Investigational and Not Medically Necessary MED.00102 Ultrafiltration in Decompensated Heart Failure • Added CPT Category III code 0692T replacing 37799 effective January 1, 2022, for ultrafiltration
MED.00110 Silver-based Products and Soft Tissue Applications • Revised title (previous title: Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications) • Moved content addressing autologous skin-, blood- or bone marrow-derived products for wound and soft tissue applications to TRANS.00035 • Moved content addressing bioengineered autologous skin- derived products (i.e., SkinTE, MyOwn Skin) to SURG.00011
MED.00111 Intracardiac Ischemia Monitoring • Added HCPCS code C1833 effective January 1, 2022, for the Guardian System ischemia monitor considered Investigational and Not Medically Necessary MED.00112 Autonomic Testing • Removed CPT code 95943 deleted December 31, 2021 MED.00116 Near-Infrared Spectroscopy Scanning for Brain Hematoma Screening • Revised title (previous title: Near-Infrared Spectroscopy Brain Screening for Hematoma Detection) SURG.00007 Vagus Nerve Stimulation • Updated descriptor for CPT code 64568 effective January 1, 2022

7

1074-1221-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 Insuran ce Companies, Inc.

SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Revised title (previous title: Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting) • Added bioengineered products to scope of document • Reorganized Medically Necessary section by indication • Simplified criteria for treatment of diabetic foot ulcers and venous stasis ulcers • Incorporated position statement addressing bioengineered autologous skin-derived products from MED.00110 (title change noted above) • Added new products to Investigational and Not Medically Necessary statement SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures • Added a reference to MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures that addresses fat grafting and other soft tissue augmentation procedures of the breast to the Scope of the document • Clarified the language in the Reconstructive statement with no change to stance or criteria SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation • Clarified Medically Necessary statement regarding deep brain stimulation (DBS) for epilepsy • Added new Medically Necessary criteria for DBS for obsessive-compulsive disorder SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention • Added CPT codes 33267, 33268 and 33269 effective January 1, 2022, for open left atrial appendage closure; if specified as device closure (clip) considered Investigational and Not Medically Necessary SURG.00037 Treatment of Varicose Veins (Lower Extremities) • Revised Medically Necessary criteria to state ‘truncal’ vein incompetence instead of ‘junctional’ incompetence SURG.00045 Extracorporeal Shock Wave Therapy • Updated descriptors for CPT codes 0101T, 0102T, 0512T and 0513T effective January 1, 2022; removed 20999 SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis • Added CPT code 43497 effective January 1, 2022, for peroral endoscopic myotomy (POEM) procedure to be reviewed for Medically Necessary criteria, replacing code 43499 and 43999 SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures • Added CPT codes 64628 and 64629 replacing C9752, C9753 and 64999 effective January 1, 2022, for basivertebral nerve destruction (Intracept procedure) considered Investigational and Not Medically Necessary SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) • Added CPT codes 66989, 66991 and 0671T replacing 0191T and 0376T effective January 1, 2022, for stents reviewed for Medically Necessary criteria SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures) • Updated descriptors for CPT codes 64568 and 64575 effective January 1, 2022 SURG.00121 Transcatheter Heart Valve Procedures • Added CPT add-on code 33370 effective January 1, 2022, for cerebral embolic protection device when associated with Medically Necessary transcatheter aortic valve replacement (TAVR) procedure

8

1074-1221-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 Insuran ce Companies, Inc.

SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring • Added CPT code 64582 replacing 0466T, 0467T, 0468T and 64568 effective January 1, 2022, for hypoglossal nerve stimulator to be reviewed for Medically Necessary criteria SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain • Updated descriptor for CPT code 64575 effective January 1, 2022 TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome • Revised the Myelodysplastic Syndrome Position Statement to add International Prognostic Scoring System (IPSS-R) criteria TRANS.00035 Therapeutic Use of Stem Cells, Blood and Bone Marrow Products • Revised title (previous title: Other Stem Cell Therapy) • Moved “Autologous Skin, Blood or Bone Marrow derived Products for Wound and Soft Tissue Applications” content from MED.00110 (title change noted above) to this document • Moved content from MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium to this document • Clarified Investigational and Not Medically Necessary statement for autologous cell therapy to include “for all indications”