MP/CG Update/Notice - June 2019 Form

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.

June 1, 2019

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

Dear Provider:

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

Anthem expands specialty pharmacy prior authorization list

Effective for dates of service on and after September 1, 2019, the following new and updated clinical criteria will be included in our clinical criteria review process.

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

To access the clinical criteria information please go to www.anthem.com/ca > Provider > Pharmacy > then scroll down to Review our Commercial Drug Lists.

Clinical Criteria

New or Update HCPCS or CPT Code(s) NDC Code(s) Drug ING-CC-0041

Update C9399 J3590 25682-0022-01 Ultomiris™ ING-CC-0086

New J3490 50458-0028-00 50458-0028-02 50458-0028-03 Spravato™ ING-CC-0087

New C9399 J3590 72171-0501-01 72171-0505-01 Gamifant® ING-CC-0088

New C9399 J9999 72187-0401-01 Elzonris™

AIM programs may require additional prior authorization documentation

These updates 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 on the back of the member ID card.

Providers currently submit pre-service requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, please be aware that certain review requests require documentation that supports the clinical appropriateness of the requests to be uploaded during the intake process.

When requested, providers must submit documentation from the patient’s medical record and/or participate in a prior authorization consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as 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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Updates to AIM Advanced Imaging Clinical Appropriateness Guidelines

Effective for dates of service on and after September 28, 2019, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.

Brain Imaging Guideline contains updates to the following:
Infection, Multiple sclerosis and other white matter diseases, Movement disorders (Adult only), Neurocognitive disorders (Adult only), Trauma, Pituitary adenoma, Tumor, Hematoma or hemorrhage – intracranial or extracranial, Hydrocephalus/ventricular assessment, Pseudotumor cerebri, Spontaneous intracranial hypotension, Abnormality on neurologic exam, Ataxia, Dizziness or Vertigo, Headache, Hearing loss and Tinnitus.

Extremity Imaging Guideline contains updates to the following:
Congenital or developmental anomalies of the extremity (Pediatrics only), Discoid meniscus (Pediatrics only), Soft tissue infection, Osteomyelitis, Septic arthritis, Bursitis, Capitellar osteochondritis, Fracture, Patellar dislocation, patellar sleeve avulsion, Trauma complications, Bone lesions, Soft tissue mass – not otherwise specified, Lisfranc injury, Labral tear – hip, Labral tear – shoulder, Meniscal tear and ligament tear of the knee, Rotator cuff tear (Adult only), Avascular necrosis, Lipohemarthrosis (Pediatrics only), Paget’s disease – new multimodality indication and General Perioperative Imaging (including delayed hardware failure), not otherwise specified.
Spine Imaging Guideline contains updates to the following:
Multiple sclerosis or other white matter disease, Spinal infection, Cervical injury, Thoracic or lumbar injury, Paget’s disease, Spontaneous (idiopathic) intracranial hypotension (SIH), Perioperative Imaging, including delayed hardware failure, not otherwise specified, Neck pain (cervical), Mid-back pain (thoracic). As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
• Access AIM’s ProviderPortallSM 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: 1-877-291-0360, 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. Additionally, you may access and download a copy of the current guidelines at http://www.aimspecialtyhealth.com/.

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 Senior Clinical Officer