MP/CG Update/Notice - May 2023 Form

California | Commercial

P.O. Box 4330 Woodland Hills, CA 91365

• 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-020973-23-CPN20737 March 2023 May 1, 2023

  Dear Provider:

  Effective August 1, 2023, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross (Anthem) members as further 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 additional procedures related to the Carelon Medical Benefits Management cardiology, genetic testing and radiology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on July 17, 2023, for dates of service August 1, 2023, and after.

  Updates to Carelon Medical Benefits Management, Inc. (Carelon) 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 Carelon. 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.

  For procedures that are scheduled to begin on or after August 1, 2023, providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following nonemergency modalities. Please refer to the program microsite resource pages for complete code lists.

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

  Program Services Clinical guidelines Cardiology • Cardiac Resynchronization Therapy (Pacemakers/Defibrillator/Electrode 1) • Peripheral Revascularization • CG-SURG-49 • CG-SURG-63 • CG-SURG-97 • MCG: W0099 Genetic testing • Whole Genome sequencing
  • Gene Expression Profiling for Idiopathic Pulmonary Fibrosis • Genetic Testing to Confirm the Identify of Laboratory Specimens
  • Cell-free DNA testing to aid in monitoring of kidney transplants • Laboratory testing to aid in diagnosis of heart transplant rejection • GENE.00052 • GENE.00057 • GENE.00041 • LAB.00038 • TRANS.00025 Radiology • MRI Breast (OPPS-Codes) • Chest Imaging • Oncologic Imaging

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. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to https://providers.carelonmedicalbenefitsmanagement.com/ to register.

Visit the resources below to help your practice get started with the radiology, cardiology, and genetic testing programs.

Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQ.

Resources: Genetic Testing program: https://providers.carelonmedicalbenefitsmanagement.com/genetictesting Cardiology Program: https://providers.carelonmedicalbenefitsmanagement.com/cardiology Radiology Program: https://providers.carelonmedicalbenefitsmanagement.com/radiology

Specialty pharmacy updates

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem Medical Specialty Drug Review Team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Access our Clinical Criteria at https://www.anthem.com/ms/pharmacyinformation/clinicalcriteria.html to view the complete information for these updates.

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.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Clinical Criteria
Drug
HCPCS or CPT code(s)
CC-0230
Adstiladrin (nadofaragene firadenovec-vncg)
J9999
CC-0062
Idacio (adalimumab-aacf)
J3490, J3590
CC-0231
Lamzede (velmanase alfa-tycv)
C9399, J3490
CC-0232
Lunsumio (mosunetuzumab-axgb)
C9399, J3490, J3590, J9999
CC-0233
Rebyota (fecal microbiota, live – jslm)
C9399, J3490, J3590
CC-0234
Syfovre (pegcetacoplan)
C9399, J3490
CC-0116
Vivimusta (bendamustine)
J9999

• Oncology use is managed by Carelon Medical Benefits Management, Inc.

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

Site of care updates

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current Clinical Criteria documents will be included in our site of care review process.

Clinical Criteria
Drug
HCPCS or CPT code(s)
CC-0217
Amvuttra (vutrisiran)
J0225
CC-0194
Cabenuva (cabotegravir extended-release; rilpivirine extended-release)
J0741
CC-0003
Cutaquig (immune globulin)
J1551
CC-0210
Enjaymo (sutimlimab-jome)
J1302
CC-0018
Nexviazyme (avalglucosidase alfa-ngpt)
J0219
CC-0019
Reclast (zoledronic acid)
J3489
CC-0075
Riabni (rituximab-arrx)
Q5123
CC-0075
Ruxience (rituximab-pvvr)
Q5119
CC-0202
Saphnelo (anifrolumab-fnia)
J0491
CC-0212
Tezspire (tezepelumab-ekko)
J2356
CC-0075
Truxima (rituximab-abbs)
Q5115
CC-0207
Vyvgart (efgartigimod alfa-fcab)
J9332
CC-0220
Xenpozyme (olipudase alfa)
J0218

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current Clinical Criteria documents will be removed from our site of care review process.

Clinical Criteria
Drug
HCPCS or CPT code(s)
CC-0004
Acthar (corticotropin)
J0800
CC-0034
Berinert (C1 Esterase Inhibitor, Human)
J0597
CC-0034
Firazyr (icatibant)
J1744
CC-0154
Givlaari (givosiran)
J0223
CC-0034
Kalbitor (ecallantide)
J1290
CC-0013
Mepsevii (vestronidase alfa)
J3397
CC-0073
Prolastin-C (alpha-1 proteinase inhibitor)
J0256
CC-0156
Reblozyl (luspatercept)
J0896
CC-0034
Ruconest (C1 Esterase Inhibitor, Recombinant)
J0596

Quantity limit updates

Effective for dates of service on and after August 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug
HCPCS or CPT code(s)
CC-0230
Adstiladrin (nadofaragene firadenovec-vncg)
J9999
CC-0062
Idacio (adalimumab-aacf)
J3490, J3590
CC-0231
Lamzede (velmanase alfa-tycv)
C9399, J3490
CC-0233
Rebyota (fecal microbiota, live – jslm)
C9399, J3490, J3590
CC-0234
Syfovre (pegcetacoplan)
C9399, J3490

If you have any questions, call the number on the back of the patient’s member ID card.

MCG Care Guidelines 27th Edition

Effective September 1, 2023, we will upgrade to the 27th edition of MCG Care Guidelines for the following modules:
• Inpatient & Surgical Care (ISC) • General Recovery Care (GRG) • Recovery Facility Care (RFC) • Behavioral Health Care (BHG) • Chronic Care (CCG) The below tables highlight new guidelines and changes. Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Goal Length of Stay (GLOS) for Inpatient & Surgical Care (ISC)
Guideline MCG Code 26th Edition GLOS
27th Edition GLOS
Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion M157 [W0011] Ambulatory or 1 day postoperative Ambulatory Renal Failure, Acute M-326 3 days 2 days Paraplegia, Acute M-255 8 days 7 days Tetraplegia, Acute M-305 9 days 7 days Percutaneous Revascularization, Lower Extremity S-1310 [W0121] Ambulatory or 1 day postoperative Ambulatory Splenectomy by Laparoscopy S-1062 1 day postoperative Ambulatory or 1 day postoperative Elbow Arthroplasty S-420 Ambulatory or 1 day postoperative Ambulatory Elbow Fracture, Open Treatment S-424 Ambulatory or 1 day postoperative Ambulatory Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF) S-490 Ambulatory or 1 day postoperative Ambulatory Foot: Surgical Wound Care S-495 Ambulatory or 1 day postoperative Ambulatory Hip Resurfacing S-565 2 days postoperative Ambulatory or 1 day postoperative Knee Dislocation, Closed or Open Reduction S-675 Ambulatory or 1 day postoperative Ambulatory Shoulder Arthroplasty S-634 [W0137] 1 day postoperative Ambulatory or 1 day postoperative Appendectomy, without Abscess or Peritonitis, Pediatric P-25 Ambulatory or 1 day postoperative Ambulatory Hip: Congenital Dislocation, Open Reduction P-590 1 day postoperative Ambulatory or 1 day postoperative Renal Transplant, Pediatric P-1015 [W0126] 6 days postoperative 5 days postoperative Slipped Upper Femoral Epiphysis, Closed Reduction P-443 Ambulatory or 1 day postoperative Ambulatory Tibial Osteotomy, Child or Adolescent S-1131 Ambulatory or 1 day postoperative Ambulatory Bladder Incision: Cystotomy S-200 Ambulatory or 1 day postoperative Ambulatory Ureterotomy, Nontransurethral for Stone S-1150 1 day postoperative Ambulatory or 1 day postoperative

New Guidelines for Inpatient & Surgical Care (ISC) Body System Guideline Title MCG - Code Hospital-at-Home COVID-19: Hospital-at-Home M-281-HaH Hospital-at-Home Viral Illness, Acute: Hospital-at-Home M-280-HaH Observation Care Guidelines COVID-19: Observation Care OC-068 Pediatrics COVID-19, Pediatric P-281 Thoracic Surgery and Pulmonary Disease COVID-19 M-281

New Guidelines for Recovery Facility Care (RFC) Body System Guideline Title MCG - Code Cardiovascular Surgery Percutaneous Revascularization, Lower Extremity S-6310 Thoracic Surgery and Pulmonary Disease COVID-19 M-5281

New Guidelines for Chronic Care (CCG) Body System Guideline Title MCG - Code Social Determinants of Health Food Insecurity C-1164 Social Determinants of Health Housing Insecurity C-1165

Anthem Customizations to MCG Care Guideline 27th Edition
To view a detailed summary of customizations, visit https://www.anthem.com/ca/provider/policies/clinical-guidelines/, scroll down to other criteria section and select Customizations to MCG Care Guidelines 27th Edition. For questions, please contact the provider service number on the back of the member's ID card.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer