MP/CG Update/Notice - March 2024 Form

P.O. Box 4330 Woodland Hills, CA 91365 Carelon Medical Benefits Management, Inc. is an independent company providing utilization management 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.

March 1, 2024

Dear Provider:

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

In the February 1, 2024, letter, we notified you of the adoption of new Clinical UM Guidelines effective May 1, 2024. Upon further review, we have made the determination to not adopt the following criteria (no clinical review required):

• CG-DME-51 External Insulin Pumps • CG-DME-52 Continuous Passive Motion Devices in the Home Setting • CG-MED-94 Vestibular Function Testing

Wilderness Therapy clarification

Effective December 1, 2023, Anthem Medical Policy MED.00122 for Wilderness Programs was archived. Prior Authorization review for Wilderness Therapy Programs (T2036, T2037) will continue to be performed by Carelon Behavioral Health and will be based on clinical criteria from LOCUS/CALOCUS or other appropriate clinical references instead of MED.00122. If you have any questions, please contact the 800 number on the back of the member’s ID card for Behavioral Health or email CarelonBehavioralHealth@anthem.com.

Transition to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective June 1, 2024, Anthem Blue Cross will transition the following clinical criteria for medical necessity review of select procedures to Carelon Medical Benefits Management Clinical Appropriateness Guidelines. Applicable CPT code lists are included in each guideline listed below.

Anthem Criteria Title Carelon Guideline CG-SURG-52 Site of Care: Hospital-based Ambulatory Surgical Procedures and Endoscopic Services Surgical Appropriate Use Criteria: Site of Service CG-MED-55 Site of Care: Advanced Radiologic Imaging Advanced Imaging Appropriate Use Criteria: Site of Care CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Endovascular Revascularization CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure Cardiac Resynchronization Therapy CG-SURG-97 Cardioverter Defibrillators Implantable Cardioverter Defibrillators SURG.00150 Leadless Pacemaker Permanent Implantable Pacemakers

• Please note, these reviews do not apply to procedures performed on an emergent basis.

  Prior authorization requirements remain the same. The requested services received on or after June 1, 2024 will be reviewed with the new clinical criteria.

Carelon Medical Benefits Management, Inc. genetic testing code updates

Updates to Carelon Medical Benefits Management programs apply to local fully-insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. 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 for dates of service on and after July 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

CPT code Description 0262U Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE) , algorithm reported as gene pathway activity score 0403U Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch post-digital rectal examination urine (or processed first-catch urine), algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer 0405U Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected 0409U Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability 0410U Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected 0411U Psychiatry (for example, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 0413U Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow , report of clinically significant alterations 0414U Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1 , if performed, formalin- fixed paraffin-embedded (FFPE) tissue, reported as positive or negative for each biomarker 0417U Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder–associated genetic variants 0419U Neuropsychiatry (for example, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype

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 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 the Availity website at availity.com.

  If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com/.

Specialty Pharmacy updates

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

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.

Access our Clinical Criteria at anthem.com/ca/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these prior authorization updates.

Prior authorization updates

Effective for dates of service on and after June 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria will be included in our prior authorization review process.

Clinical Criteria Drug HCPCS or CPT code(s) CC-0107 Avzivi (bevacizumab-tnjn) J3490, J3590 CC-0255 Loqtorzi (toripalimab-tpzi) C9399, J3490, J3590 CC-0256 Rivfloza (nedosiran) J3490 CC-0002* Ryzneuta (efbemalenograstim alfa-vuxw) J3490, J3590 CC-0257 Wainua (eplontersen) C9399, J3490

• Oncology use is managed by Carelon Medical Benefits Management.

  Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

  Step therapy updates Effective for dates of service on and after June 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria will be included in our existing specialty pharmacy medical step therapy review process.

  Clinical Criteria Status Drug HCPCS or CPT code(s) CC-0107 Non-preferred Avzivi (bevacizumab-tnjn) J3490, J3590 CC-0002 Non-preferred Ryzneuta (efbemalenograstim alfa-vuxw) J3490, J3590

  Quality limit updates Effective for dates of service on and after June 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria will be included in our quantity limit review process.

  Clinical Criteria Drug HCPCS or CPT code(s) CC-0256 Rivfloza (nedosiran) J3490 CC-0002 Ryzneuta (efbemalenograstim alfa-vuxw) J3490, J3590 CC-0257 Wainua (eplontersen) C9399, J3490

  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