Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Indiana Form

Update: April 1, 2026 State CG number CG title CG category Date adopted by central Date--current version implemented Special Notes Central CG-ANC-04 Ambulance services Air and Water
Ancillary Services prior to 1/1/16 1/3/2024 Central CG-ANC-07 Inpatient Interfacility Transfers Ancillary Services 9/1/2019 1/3/2024 Central CG-BEH-14 Intensive In-Home Behavioral Health Services Behavioral Health 7/1/2016 1/3/2024 Central CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome Behavioral Health 6/28/2018 1/3/2024 Central CG-DME-06 Compression Devices for Lymphedema DME
10/16/2025 4/1/2026 Central CG-DME-10 Durable Medical Equipment
DME
prior to 1/1/16 9/27/2023 Central CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) DME
prior to 1/1/16 12/1/2023 Central CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting DME
9/1/2022 6/28/2023 Central CG-DME-54 Mechanical Insufflation-Exsufflation Devices DME
8/11/2025 1/1/2026 Central CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Gene 12/27/2017 6/28/2023 Central CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability Gene 9/4/2019 6/28/2023 Central CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status Gene 9/4/2019 9/27/2023 Central CG-GENE-13 Genetic Testing for Inherited Diseases Gene 2/5/2020 9/1/2023 Central CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management Gene 2/5/2020 1/3/2024 Central CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis Gene 2/5/2020 1/3/2024 Central CG-GENE-16 RCA Testing for Breast and/or Ovarian Cancer Syndrome Gene 2/5/2020 4/12/2023 Central CG-GENE-18 Genetic Testing for TP53 Mutations Gene 2/5/2020 1/3/2024 Central CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing Gene 3/29/2023 4/1/2023 Central CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing Gene 4/12/2023 4/12/2023 Central CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment Gene 6/28/2023 Central CG-LAB-13 Skin Nerve Fiber Density Testing LAB 6/28/2018 1/3/2024 Central CG-MED-19 Custodial Care
Medicine prior to 1/1/16 1/3/2024 Central CG-MED-26 Neonatal Levels of Care
Medicine prior to 1/1/16 4/12/2023 Central CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting Medicine 11/1/2020 12/1/2023 Central CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Medicine 11/1/2018 1/1/2026 Managed by Carelon Medical Benefits Management Central CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue Medicine 12/27/2017 6/28/2023 Central CG-MED-69 Inhaled Nitric Oxide Medicine 6/28/2018 9/27/2023 Central CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) Medicine 9/20/2018 4/12/2023 Central CG-MED-83 Level of Care: Specialty Pharmaceuticals Medicine 4/24/2019 9/27/2023 Central CG-MED-89 Home Parenteral Nutrition Medicine 11/1/2021 6/28/2023 Central CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease Medicine 3/7/2025 6/1/2026 Central CG-MED-99 Intradialytic Parenteral Nutrition Medicine 5/21/2025 11/1/2025 Central CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine Medicine 5/21/2025 11/1/2025 Central CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services
Rehabilitation prior to 1/1/16 9/27/2023 Central CG-REHAB-08 Private Duty Nursing in the Home Setting
Rehabilitation prior to 1/1/16 9/27/2023 Central CG-SURG-12 Penile Prosthesis Implantatation
Surgery prior to 1/1/16 6/28/2023 Central CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Surgery 6/28/2023 8/1/2025 Central CG-SURG-28 Transcatheter Uterine Artery Embolization
Surgery prior to 1/1/16 9/27/2023 Managed by Carelon Medical Benefits Management Central CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Surgery 5/1/2019 9/27/2023 Central CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver Surgery 12/27/2017 8/1/2025 Central CG-SURG-63 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Surgery 12/27/2017 2/1/2024 Central CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018 6/28/2023 Central CG-SURG-73 Balloon Sinus Ostial Dilation Surgery 6/28/2018 6/28/2023 Central CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Surgery 12/28/2023 12/1/2023 Central CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids Surgery 9/20/2018 6/28/2023 Central CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/2018 8/1/2026 Managed by Carelon Medical Benefits Management Central CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Surgery 9/20/2018 6/28/2023 Central CG-SURG-88 Mastectomy for Gynecomastia Surgery 9/20/2018 5/1/2025 Central CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence Surgery 3/21/2019 5/1/2025 Managed by Carelon Medical Benefits Management Central CG-SURG-97 Cardioverter Defibrillators Surgery 6/24/2019 4/12/2023 Central CG-SURG-99 Panniculectomy and Abdominoplasty Surgery 5/9/2019 4/12/2023 Indiana • Kentucky • Missouri • Ohio • Wisconsin | Anthem Blue Cross and Blue Shield | Commercial Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio, and Wisconsin NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered ‘Adopted’ for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes. Certain items and/or criteria referenced in this document apply to local fully-insured Anthem Blue Cross members and select members who are covered under self-insured (ASO) benefit plans with services medically managed as part of a purchased program. It does not apply to BlueCard ® , Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program ® (FEP ® ). The provider will be notified upon requesting precertification if precertification is required for the member. If the program has not been purchased, precertification is not required and clinical review will not be performed for the member. For more information, please contact the phone number of the back of the member ID card.

Indiana • Kentucky • Missouri • Ohio • Wisconsin | Anthem Blue Cross and Blue Shield | Commercial Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio, and Wisconsin NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered ‘Adopted’ for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes. Certain items and/or criteria referenced in this document apply to local fully-insured Anthem Blue Cross members and select members who are covered under self-insured (ASO) benefit plans with services medically managed as part of a purchased program. It does not apply to BlueCard ® , Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program ® (FEP ® ). The provider will be notified upon requesting precertification if precertification is required for the member. If the program has not been purchased, precertification is not required and clinical review will not be performed for the member. For more information, please contact the phone number of the back of the member ID card. Central CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone Surgery 2/5/2020 9/1/2023 Central CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) Surgery 5/13/2024 10/1/2024 Central CG-SURG-120 Vagus Nerve Stimulation Surgery 5/13/2024 1/1/2026 Managed by Carelon Medical Benefits Management Central CG-SURG-126 Tibial Nerve Stimulation Surgery 7/18/2019 1/1/2026 Managed by Carelon Medical Benefits Management Central CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses Surgery 8/11/2025 10/1/2025 Managed by Carelon Medical Benefits Management Central CG-SURG-129 Internal Rib Fixation Systems Surgery 8/11/2025 1/1/2026 Managed by Carelon Medical Benefits Management Central CG-TRANS-02 Kidney Transplantation Transplant 8/1/2021 4/12/2023 IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI IN-OH-KY-MO-WI Carelon Medical Benefits Management For more detail please visit the Carelon Medical Benefits Management clinical appropriateness guidelines and cancer treatment pathways site with links to Carelon Medical Benefit Managment programs THIRD PARTY CRITERIA ADOPTED: The health plan may use guidelines developed by third parties to perform utilization management services of some procedures for certain health plan members. General - Guideline outlines the clinical appropriateness framework for diagnostic and therapeutic interventions addressed in Carelon guidelines, simultaneous ordering, repeat intervention, and interventions not otherwise addressed in specific Carelon guidelines. https://guidelines.carelonmedicalbenefitsmanagement.com/ You may also email Carelon Medical Benefits Management at: medicalbenefitsmanagement.guidelines@carelon.com Radiology Guidelines for imaging modalities, including CT, MRI, MRA, PET, arterial ultrasound, and nuclear scintigraphy. Cardiology Guidelines for cardiac imaging modalities, including echocardiography, nuclear cardiology, cardiac CT, cardiac MRI, and cardiac PET. Outpatient Sleep Testing and Therapy Services - Testing and treatment of sleep disorders, including obstructive sleep apnea Musculoskeletal - Spine Surgery, Joint Surgery, and Interventional Pain Management Rehabilitation - Physical Therapy, Occupational Therapy, and Speech Therapy. Genetic Testing - Guidelines for genetic testing, including for pharmacogenomics, prenatal diagnosis, cardiac disease, cancer susceptibility, and tumors and malignancies. Radiation Oncology - Guidelines for radiation therapies, including brachytherapy, image-guided radiotherapy, intensity-modulated radiation therapy, proton beam therapy, and therapeutic radiopharmaceuticals. Cancer Treatment Pathways and Guidelines - Cancer treatment pathways and guidelines for common types of cancer, including breast cancer, colorectal cancer, prostate cancer, melanoma, lung cancer, and lymphoma. New and Emerging Interventions - New and emerging healthcare interventions defined as drugs, devices, tests, or procedures.