MP/CG Update/Notice - July 2023 Form

California | Commercial

• Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan. 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.
  CABC-CM-028232-23 June 2023 July 1, 2023

  Subject: Medical Policies and Clinical Guidelines updates

  Dear Provider:

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

  New Medical Policy • SURG.00161 Nanoparticle-Mediated Thermal Ablation: This document addresses the use of nanoparticle-medicated thermal ablation to treat solid tumors. o Considered Investigational and Not Medically Necessary o Prior authorization required effective October 1, 2023

  Updated Clinical Guidelines and Medical Policies effective October 1, 2023 • CG-ANC-06 Ambulance Services: Ground; Non-Emergent: This document addresses the use of ground ambulances in non-emergency situations only.
  o Revised Medically Necessary and Not Medically Necessary statements regarding mileage. o Revised Not Medically Necessary statement to remove list of non-covered indications. • CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention: This document addresses sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) in those with chronic, refractory urinary and fecal incontinence, as well as urinary retention. o Revised title (previously titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention). o Added Medically Necessary criteria for the temporary Sacral Nerve Stimulation for urinary and fecal conditions. o Reformatted the Medically Necessary criteria for permanent Sacral Nerve Stimulation for urinary and fecal conditions. o Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices.

  • MED.00004 Noninvasive Technologies for the Evaluation of Skin Lesions: This document addresses the use of photographic, optical, video, and other imaging technologies for the evaluation of skin lesions. o Revised title (previously titled: Technologies for the Evaluation of Skin Lesions [including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography]).
  o Added additional technologies to Investigational and Not Medically Necessary section.

  Medical Policy archivals effective May 25, 2023 • GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy — merged into GENE.00052) • LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

Anthem Blue Cross New Medical Policy Page 2 of 10

Expansion of Carelon Medical Benefits Management, Inc. Cardiology programs effective October 1, 2023 Updates to Carelon Medical Benefits Management, Inc.* programs, a separate company, apply to local fully insured Anthem Blue Cross (Anthem) members and select members who are covered under self- insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management, Inc. 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.

Effective October 1, 2023, Carelon Medical Benefits Management, a specialty health benefits company, will perform medical necessity reviews for procedures for Anthem members, as outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for pacemakers as part of the Carelon Medical Benefits Management Cardiology program. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 18, 2023, for dates of service October 1, 2023, and after.

Pre-service review requirements For procedures that are scheduled to begin on or after October 1, 2023, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following non-emergency modalities.

Please refer to the clinical guidelines at the links below for more details including code lists. • Anthem SURG.00150 Leadless Pacemakers related to the insertion, removal, or replacement of permanent leadless pacemakers (https://www.anthem.com/dam/medpolicies/abc/active/policies/mp_pw_c196773.html)
• Carelon Permanent Implantable Pacemakers clinical appropriateness guideline related to insertion, repair, removal, repositioning, or replacement of permanent implantable pacemakers, pacemaker pulse generators, or electrodes (https://guidelines.carelonmedicalbenefitsmanagement.com/permanent-implantable- pacemakers-2023-10-01)

To determine if prior authorization is needed for a member on or after October 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on Availity Essentials* to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management)

Anthem Blue Cross New Medical Policy Page 3 of 10

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortalSM is available twenty-four hours a day, seven days a week at processing requests in real-time using clinical criteria. Go to providers.carelonmedicalbenefitsmanagement.com/ to register.

For more information go to https://providers.carelonmedicalbenefitsmanagement.com/cardiology for resources to help your practice get started with the Cardiology program. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs. You can also call your local Network Relations Representative.

Updates to Carelon Medical Benefits Management Joint Surgery, Small Joint Surgery and MSK Level of Care Clinical Appropriateness Guidelines Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

• Joint Surgery (updates by section)
o Multiple joints:  Loose body — Added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee.  Synovectomy — Added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee. o Shoulder:  Rotator cuff repair — Modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear.  Revision rotator cuff repair — Added exclusion for patients with rotator cuff arthropathy.  Labrum repair — Broadened MRI findings to allow for any labral tear other than a Bankart lesion.  Adhesive capsulitis — Extended required conservative management from 6 weeks to 12 weeks.  Capsulorraphy — Added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation.  Subacromial decompression/acromioplasty — Added indications for symptomatic os acromiale and for symptomatic mechanical impingement due to tumor or malunited fracture.  Shoulder debridement — extended required conservative management to 12 weeks.  Biceps tenodesis/tenotomy — Broadened criteria to allow when criteria are met for any shoulder procedure, or when patient has an acute proximal biceps tear.  Added exclusion for subacromial balloon spacer and for shoulder resurfacing. o Hip:  Added indications for primary partial hip arthroplasty and partial or total hip resurfacing.  Revision total hip arthroplasty — Added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant.  Acetabuloplasty — Added indications for arthritis, hip instability, and FAIS.  Diagnostic arthroscopy — Added exclusion for non intra-articular hip procedures.

Anthem Blue Cross New Medical Policy Page 4 of 10

 Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty.  Labral tear — Added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis.  Added exclusion for debridement/chondroplasty when done solely for osteoarthritis, and for labral repair in untreated severe hip dysplasia. o Knee:  Total knee arthroplasty — added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage.  Unicompartmental knee arthroplasty — Modified requirements related to conservative management and varus/valgus deformities; allow concurrent ACL reconstruction in some scenarios.  Revision knee arthroplasty — Added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to 6 weeks for revision attributable to prior implants.  Abrasion arthroplasty/microfracture — Aligned with osteochondral grafts criteria regarding the size of defect that can be treated.  Debridement/drainage/lavage (knee) — Reduced conservative management requirement to 6 weeks for consistency with lysis of adhesions criteria.  Anterolateral ligament reconstruction or extra-articular tenodesis – Added indications.  ACL reconstruction and PCL repair/reconstruction — Excluded patients with advanced knee arthritis (Kellgren-Lawrence 4).  Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury.  Patellar compression syndrome — Added exclusion for central or medial tracking of the patella.  Medial patellofemoral ligament reconstruction — Waived requirement for conservative management when function is limited due to pain. o Osteochondral grafts:  Patient selection requirements — Specified that conservative management duration must be 6 weeks; waived this requirement when a symptomatic loose body is present.  Osteochondritis dissecans — Added indications for surgical treatment.  Osteochondral allograft transplantation — Decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee.  Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement.  Added HCPCS code S2118.

o Small Joint Surgery:  Hallux rigidus procedures; hallux valgus and bunionette procedures; lesser toe deformities — Removed poor wound healing as a contraindication.  Hallux valgus surgery — Added allowance for pre-ulcer (Wagner grade 0-1 lesion); added criterion for simple exostectomy/resection medial eminence. Separated bunionette surgery indications from hallux valgus surgery.  First MTP joint arthrodesis for hallux valgus — Added indication.  Metatarsal osteotomy — Separated criteria into standalone indication; added exclusion for improved cosmesis.  Ankle arthritis — Added indication for revision total ankle arthroplasty.

Anthem Blue Cross New Medical Policy Page 5 of 10

 Ankle arthroplasty — Removed severe ankle deformity and peripheral neuropathy as contraindications.

• Level of Care for Musculoskeletal Surgery: o Added total or partial primary shoulder arthroplasty to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty.
o Added CPT® codes 23470 and 23472 to level of care review.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:
• Access Carelon Medical Benefits Management’s ProviderPortalSM directly at www.providerportal.com:
o Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. • Access Carelon Medical Benefits Management via Availity Essentials at availity.com.

The complete list of our Medical Policies and Clinical Utilization Management Guidelines may be accessed on the Anthem website at http://www.anthem.com/ca. Then, select For Providers, then select Policies, Guidelines & Manuals under the Provider Resources column, select Change State and choose California. Scroll down to select View Medical Policies & Clinical UM Guidelines, then select Full List page or enter 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 healthcare for Californians.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer Anthem Blue Cross

California | Commercial

• Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan. 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.
  CABC-CM-028232-23 June 2023

  Attachment A — Revised Medical Policies and Clinical Guidelines

  Policy/guideline number Title Medical Policy/Clinical Guideline changes CG-GENE-10 (Carelon Genetic Testing) Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies • Removed aCGH and replaced it with CMA in the

• notation in the Clinical Indications section. CG-GENE-13 (Carelon Genetic Testing) Genetic Testing for Inherited Diseases • For Tier 2 code 81404, gene SOD1 was changed to review for Medically Necessary criteria (was Not Medically Necessary). CG-GENE-16 (Carelon Genetic Testing) BRCA Genetic Testing • Revised Clinical Indications to include homologous recombination deficiency pathways to poly-ADP ribose polymerase (PARP) inhibitor criteria. CG-GENE-22 (Carelon Genetic Testing) Gene Expression Profiling for Managing Breast Cancer Treatment • Revised criterion to simplify tumor size. CG-DME-31 Powered Wheeled Mobility Devices • Revised hierarchy and formatting in the Medically Necessary statement addressing power seating systems. • Added new Medically Necessary and Not Medically Necessary criteria to address power seat elevation systems when individuals meet criteria for (uneven) transfers. CG-LAB-27 Human Chorionic Gonadotropin Testing • Revised term serum to blood for hCG testing in the Medically Necessary and Not Medically Necessary criteria. CG-MED-59 (Carelon Surgical GI) Upper Gastrointestinal Endoscopy in Adults • Revised Clinical Indications section to remove references to life-limiting comorbidities. CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) • Added continuation criteria to each section on chronic non-healing wounds in Medically Necessary statement . • Revised formatting and hierarchy in the Clinical Indications sections. • Removed continuation criteria from the Not Medically Necessary statement. • Added Stroke to Not Medically Necessary statement.

Anthem Blue Cross New Medical Policy Page 7 of 10

CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver • Removed criteria that individual must a be high renal or surgical risk from the cryoablation and radiofrequency ablation criteria for clinically localized, suspected renal malignancies. CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies • Revised title (previously titled Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies). • Revised criteria to remove references to surgical resection. • Removed requirements 1) 3 or less lesions to be treated and 2) 6 months have elapsed prior to repeat procedure under locally ablative techniques statement. • Removed requirements 1) 3 or few encapsulated nodules and each nodule is less than or equal to 5 centimeters 2) no evidence of severe renal function 3) no evidence or portal vein impairment under arterially directed techniques to treat unresectable primary hepatocellular carcinoma statement. • Revised criteria no evidence of extrahepatic metastases to no or minimal extrahepatic metastases under arterially directed techniques to treat unresectable primary hepatocellular carcinoma (as noted) and to the locally ablative techniques Medically Necessary criteria. • Added Medically Necessary indication for selective internal radiation therapy (SIRT)/transarterial radioembolization (TARE) as a treatment of liver only metastasis from uveal (ocular) melanoma. • Added Medically Necessary indication for SIRT/TARE as a treatment of colorectal cancer when criteria are met . • Removed requirement of no evidence of severe renal function impairment from bridge to liver transplantation criteria. • Revised Not Medically Necessary statements. • Reformatted all locally ablative and arterially directed technique criteria. • Added in transcatheter arterial chemoembolization (TACE) Medically Necessary section, added Note referring to Not Medically Necessary section regarding chemotherapy loaded microspheres or immunoembolization. CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants • Reformatted the Medically Necessary criteria for cochlear implants. • Revised cochlear implantation criteria to include unilateral sensorineural deafness.

Anthem Blue Cross New Medical Policy Page 8 of 10

CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity • Added HCPCS code C9784 for endoscopic sleeve gastroplasty and C9785 for transoral outlet reduction (TORE) effective July 1, 2023 for considered Not Medically Necessary. CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery • Revised hierarchy formatting in the Clinical Indications section. CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention • Revised title (previously titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention). • Added Medically Necessary criteria for the temporary sacral nerve stimulation (SNS) for urinary and fecal conditions. • Reformatted the Medically Necessary criteria for permanent SNS for urinary and fecal conditions. • Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices. CG-SURG-97 Cardioverter Defibrillators • Revised formatting and hierarchy in Medically Necessary section. CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus • Revised formatting and hierarchy in the Clinical Indications section. • Removed 1 year life expectancy from the Clinical Indications section . • Removed requirement for absence of comorbid conditions from the Medically Necessary statement. ANC.00007 Cosmetic and Reconstructive Services: Skin Related • Updated term port wine stain to port wine birthmark in the Position Statement. DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices • Added HCPCS code E0761 for electromagnetic treatment device considered Investigational and Not Medically Necessary. DME.00047 Rehabilitative Devices with Remote Monitoring • Removed list of examples in the Position Statement section. DME.00048 Virtual Reality-Assisted Therapy Systems • Removed list of examples in the Position Statement section. GENE.00010 Panel and other Multi- Gene Testing for Polymorphisms to Determine Drug- Metabolizer Status • Added CPT PLA code 0392U effective July 1, 2023 for panel test considered Investigational and Not Medically Necessary. GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling • Reformatted hierarchy for gene panel testing for inherited diseases, testing for cancer susceptibility, testing for cancer management,

Anthem Blue Cross New Medical Policy Page 9 of 10

and molecular profiling for the evaluation of malignancies. • Revised panel testing criteria to remove 5-50 gene parameter. • Revised acute myeloid leukemia Medically Necessary statement to include newly diagnosed or relapsed. • Added circulating tumor DNA to scope of document (moved content from GENE.00049 into this document and added new criteria for prostate cancer and advance non-small cell lung cancer). • Revised molecular profiling criteria to remove progressed following prior treatment language • Revised Not Medically Necessary statement for Whole Exome Sequencing to address repeat testing. • Added CPT PLA codes effective July 1, 2023: 0391U, 0388U, and 0397U with Medically Necessary criteria; 0400U considered Not Medically Necessary; and 0401U risk panel considered Investigational and Not Medically Necessary. LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders • Revised hierarchy formatting in the second Investigational and Not Medically statement. LAB.00031 Advanced Lipoprotein Testing • Reformatted Position Statement. MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease • Revised Medically Necessary criteria for PR interval for myocarditis. • Updated Rationale, References, and Websites sections. MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders • Revised hierarchy formatting in the Investigational and Not Medically statement. MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures • Revised formatting and hierarchy of Position Statement section. • Revised Cosmetic and Not Medically Necessary statements for injectable soft tissue fillers. SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Added HCPCS codes Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284 effective July 1, 2023, for products considered Investigational and Not Medically Necessary.

Anthem Blue Cross New Medical Policy Page 10 of 10

SURG.00037 Treatment of Varicose Veins (Lower Extremities) • Revised hierarchy and formatting in the Position Statement. SURG.00121 Transcatheter Heart Valve Procedures • Revised text and formatting in the Medically Necessary statement for Transcatheter Aortic Valve Replacement (TAVR). • Revised Medically Necessary statement for Transcatheter Pulmonary Valves to remove right ventricular outflow tract (RVOT) conduit diameter criteria and added criteria for native and patched RVOT. • Added a new Investigational and Not Medically Necessary statement addressing TAVR cerebral protection devices. • Revised the Investigational and Not Medically Necessary statement regarding valve-in-valve repair to address replacement instead of repair. • Added CPT code 33370 for cerebral embolic protection considered Investigational and Not Medically Necessary. SURG.00150 Leadless Pacemaker • Added category 3 codes 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T and 0804T effective July 1, 2023 for dual chamber leadless pacemaker considered Investigational and Not Medically Necessary. • Added ICD-10-PCS code 02PA3NZ for removal considered Investigational and Not Medically Necessary. TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection • Revised the timing for the Medically Necessary criteria for doing AlloMap testing post heart transplant from between 1 year and 5 years to between 6 months and 5 years. • Removed the word, Noninvasive from the Investigational and Not Medically statement about AlloSure Heart, AlloSeq cell-free DNA, MMDx Heart and myTAIHeart. TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors • Revised Medically Necessary statement to correct spelling of ocrelizumab. TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products • Revised descriptors for HCPCS codes G0460, G0465 effective July 1, 2023.