MP/CG Update/Notice - May 2025 Form

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Commercial coverage provided by Anthem Blue Cross, 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-080674-25 CABC-CM-084405-25 | May 2025 California | Anthem Blue Cross | Commercial May 1, 2025 Subject: Medical Policies and Clinical Guidelines updates Dear Provider: Please refer to our website (anthem.com/ca/provider/policies/clinical-guidelines) for coding language, rationale updates, and changes that are not summarized below. New Clinical Guideline with required preapproval effective August 1, 2025 CG-DME-06 Compression Devices for Lymphedema This policy addresses the use of devices that create compression for the treatment of lymphedema:  Outlines Medically Necessary and Not Medically Necessary indications Updated Medical Policy and Clinical Guideline effective August 1, 2025 SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational This policy addresses the use of soft tissue (such as skin, ligament, and cartilage) substitutes in wound healing and surgical procedures:  Revised title and scope (previously titled Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting)  Added plant based products as Investigational and Not Medically Necessary CG-SURG-119 Treatment of Varicose Veins (Lower Extremities) This policy addresses various modalities for the treatment of valvular incompetence (reflux) of the great saphenous vein (GSV), anterior accessory great saphenous vein (AAGSV), or small saphenous vein (SSV) (also known as greater saphenous vein or lesser saphenous vein, respectively) and associated varicose tributaries as well as telangiectatic dermal veins:  Revised the Clinical Indications to reflect current nomenclature for anterior accessory saphenous vein (AASV)/anterior saphenous vein (ASV)  Added Not Medically Necessary statement regarding VenoValve device

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Archivals effective April 16, 2025

CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury (converted to CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence and CG-SURG-126 Tibial Nerve Stimulation)

LAB.00039 Combined Pathogen Identification and Drug Resistance Testing

MED.00104 Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin

MED.00145 Digital Therapy Devices for Treatment of Amblyopia (converted to CG-MED-102 Dichoptic Digital Therapy for Amblyopia)

OR-PR.00008 Osseointegrated Limb Prosthesis (converted to CG-OR-PR-10 with same title)

SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses (converted to CG-SURG-128 with same title)

De-adoptions effective February 1, 2025

CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease CG-SURG-124 Viscocanalostomy

Carelon Medical Benefits Management, Inc. expansion

Updates to Carelon Medical Benefits Management programs apply to select 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. This notice does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program® (FEP®). For more information, please contact Provider Services via the number on the back of our member ID card.

Preservice review requirements

Effective August 1, 2025, Carelon Medical Benefits Management will expand the Additional Outpatient UM program to perform medical necessity reviews for CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue. For criteria, a list of services and codes, refer to the Clinical Guidelines and Medical Policies at anthem.com > For Providers > California > Commercial Provider Site > Review Policies > View Medical Policies & Clinical UM Guidelines.

To determine if prior authorization/preapproval is needed for a member on or after August 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on https://Availity.com to pre-certify an outpatient procedure will receive a message referring the provider to Carelon

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Medical Benefits Management. (Note: ICR cannot accept prior authorization/preapproval requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit preservice 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 to process requests in real-time using Clinical Criteria. Go to providerportal.com to register.

Behavioral health updates

AACAP and MCG notification for ABA As required by the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI), beginning August 1, 2025, California fully insured plans will use the following nonprofit criteria American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the assessment and treatment of children and adolescents with autism spectrum disorder for medical necessity determinations.

Beginning August 1, 2025, California self-funded accounts will use MCG B-806-T Behavioral Health Care Applied Behavioral Analysis for medical necessity determinations.

As a result of these changes, CAL-CB-BEH-02 will be retired August 1, 2025. Reminder, preapproval (prior authorization) continues to be required for these services.

If you have questions, contact Provider Services by calling the phone number on the back of the member's ID card.

CANMAT criteria notification for TMS CA FI plans (DMHC and CDI) As required by the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI), beginning August 1, 2025, California fully insured plans will use the nonprofit guideline Canadian Network for Mood and Anxiety Treatments (CANMAT) for medical necessity determinations for transcranial magnetic stimulation (TMS).

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality healthcare for Californians.

Sincerely,

David Pryor, MD, MPH Chief Medical Officer Anthem

Enclosure: Table: Revised Medical Policies and Clinical Guidelines effective April 16, 2025

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Commercial coverage provided by Anthem Blue Cross, 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-080674-25 | April 2025 Revised Medical Policies and Clinical Guidelines effective April 16, 2025 (unless otherwise noted) Policy/Guideline number Title Medical Policy/Clinical Guideline changes CG-DME-50 Automated Insulin Delivery Systems • Revised < symbol to the words less than in Medically Necessary statement CG-MED-59 (Carelon Surgical GI) Upper Gastrointestinal Endoscopy in Adults • Reformatted the Clinical Indications section • Added Medically Necessary criteria for screening esophagogastroduodenoscopy (EGD) for individuals with Lynch syndrome CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine • Moved content related to remote electrical neuromodulation (REN) and supraorbital transcutaneous neurostimulation from DME.00011 • Moved remote electrical neuromodulation (REN) from Investigational and Not Medically Necessary to Medically Necessary when criteria met • Moved content related to vagus nerve stimulation for migraines from CG-SURG-120 CG-MED-102 Dichoptic Digital Therapy for Amblyopia • Moved content from MED.00145 • Revised title (previously titled Digital Therapy Devices for Treatment of Amblyopia) • Considered Medically Necessary when criteria met • Revised criteria to address the initial use and continued use of dichoptic digital therapy in the treatment of amblyopia CG-OR-PR-10 Osseointegrated Limb Prostheses • Moved content from OR-PR.00008 CG-SURG-88 Mastectomy for Gynecomastia • Revised formatting of Medically Necessary section and Reconstructive criteria • Added Cosmetic and Not Medically Necessary criteria

CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence • Moved content for tibial nerve stimulation to new clinical UM guideline CG-SURG-126 and added content for sacral nerve stimulation from CG- SURG-08 • Revised title (previously titled Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention) CG-SURG-99 Panniculectomy and Abdominoplasty • Revised Clinical Indications section with gender neutral language

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Policy/Guideline number Title Medical Policy/Clinical Guideline changes CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone • Revised Medically Necessary criteria for congenital heart disease due to stenosis or hypoplasia of a pulmonary artery to remove the words in a child CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) • Revised Clinical Indications section CG-SURG-120 Vagus Nerve Stimulation • Moved content related to vagus nerve stimulation for migraines to new clinical UM guideline CG- MED-100 • Removed code E0735 for gammaCore now addressed in CG-MED-100 CG-SURG-123 (effective April 1, 2025) Autologous Fat Grafting and Injectable Soft Tissue Fillers • Added code D9914 for dermal fillers as Medically Necessary or Reconstructive when criteria met CG-SURG-126

Tibial Nerve Stimulation • Moved content for tibial nerve stimulation from CG-SURG-95 • Added Not Medically Necessary indication for transcutaneous tibial nerve stimulation CG-SURG-127 (effective April 1, 2025)

Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses • Moved Medically Necessary and not Medically Necessary criteria for breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications from SURG.00011 • Added NuSheild and Oasis Ultra Tri-Layer Wound Matrix as Medically Necessary for diabetic foot ulcers • Added Oasis Ultra Tri-Layer Wound Matrix as Medically Necessary for chronic wounds
• Removed limit of not more than 52 weeks from Diabetic Foot Ulcers and non-healing wound criteria • Revised ocular indications to be agnostic to specific product, as long as it is amnion-derived CG-SURG-128 (Carelon Surgical Program) Presbyopia and Astigmatism-Correcting Intraocular Lenses • Moved content from SURG.00061 • Removed The from Not Medically Necessary statements DME.00011
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices • Moved content related to remote electrical neuromodulation (REN) and supraorbital transcutaneous neurostimulation to new clinical UM guideline CG-MED-100 • Removed code A4540 for Nerivio now addressed in CG-MED-100

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Policy/Guideline number Title Medical Policy/Clinical Guideline changes DME.00038 (effective April 1, 2025) Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices • Added code E1832 for finger device considered Investigational and Not Medically Necessary • Updated descriptors LAB.00028 (effective April 1, 2025) Blood-based Biomarker Tests for Multiple Sclerosis • Added code 0547U for Neurofilament Light Blood Test, considered Investigational and Not Medically Necessary for multiple sclerosis LAB.00031 (effective April 1, 2025) Advanced Lipoprotein Testing • Added code 0541U for HDL Reverse Cholesterol Transport Panel with pCAD Score considered Investigational and Not Medically Necessary LAB.00033 (effective April 1, 2025) Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer • Added code 0550U for ClarityDx Prostate test considered Investigational and Not Medically Necessary LAB.00045 Selected Tests for the Evaluation and Management of Infertility • Removed information regarding endometrial receptivity testing from Position Statement • Removed code 0253U, criteria for this service has been transitioned to Carelon Medical Benefits Management Genetic Testing guidelines LAB.00046 (effective April 1, 2025) Testing for Biochemical Markers for Alzheimer's Disease • Added codes 0547U for Neurofilament Light Blood Test and 0551U for LucentAD p-Tau 217 test considered Investigational and Not Medically Necessary LAB.00050 (effective April 1, 2025) Metagenomic Sequencing for Infectious Diseases in the Outpatient Setting • Added code 0531U for NeXGen™ Fungal/AFB NGS Assay considered Investigational and Not Medically Necessary LAB.00051 (effective April 1, 2025) Per- and Polyfluoroalkyl Substances (PFAS) Testing • Added code 0535U for PFAS Testing and PFASure®FT considered Investigational and Not Medically Necessary MED.00112 Autonomic Testing • Removed codes 95922 and 95924, which include tilt testing (not applicable) MED.00120 Gene Therapy for Ocular Conditions • Added codes C9399, J3590 MED.00148 (effective April 1, 2025) Gene Therapy for Metachromatic Leukodystrophy • Added ICD-10-PCS codes XW133G8 and XW143G8 for Lenmeldy considered Medically Necessary when criteria met RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single- Photon Emission • Removed name of radiotracer from the Investigational and Not Medically Necessary statement • Removed code A9582 for radiotracer no longer addressed

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Policy/Guideline number Title Medical Policy/Clinical Guideline changes Computed Tomography (SPECT) SURG.00011 (effective April 1, 2025) Products for Wound Healing and Soft Tissue Grafting: Investigational • Moved content related to breast reconstruction, burns, complex abdominal wall wounds, dermal wounds, diabetic foot ulcers, venous stasis ulcers, and ocular indications to new clinical UM guideline CG-SURG-127 • Added codes A2030-A2035 and Q4354-Q4367, and deleted Q4231 SURG.00047 (effective April 1, 2025) Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis • Revised Position Statement to remove age criterion for peroral endoscopic myotomy (POEM) and requirement for no previous open surgery • Added Medically Necessary criteria for the transoral incisionless fundoplication (TIF) and gastric peroral endoscopic myotomy (G-POEM) procedures SURG.00155 Cryosurgery of Peripheral Nerves • Revised title (previously titled Cryoneurolysis) • Revised Position Statement to say, “Cryosurgical techniques (for example, cryoneurolysis and cryoablation) of peripheral nerves” • Added codes 0440T, 0441T, 0442T for cryoablation of peripheral nerves considered Investigational and Not Medically SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain • Added new Medically Necessary statement for ReActiv8 Implantable Neurostimulation System • Revised Investigational and Not Medically Necessary statement SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease • Removed injection code 67028, not specific to Susvimo TRANS.00008 Liver Transplantation • Revised formatting in Medically Necessary statement for Mass Occupying Lesions • Added new Medically Necessary criteria for unresectable colorectal cancer with liver metastases (UCLM) TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation • Revised Absolute Contradictions for Transplant Recipients section of Position Statement, changing noncompliance to nonadherence