MP/CG Update/Notice - March 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-078080-25 | March 2025

California | Anthem Blue Cross | Commercial

March 1, 2025

Subject: Medical Policies and Clinical Guidelines updates

Dear Provider:

Please refer to our website (cpvj go 0eqo 1ec1r tqxkf gt1r qnkekgu1enkpkecn/i wkf gnkpgu) for coding language, rationale updates, and changes that are not summarized below.

New Medical Policies with required preapproval effective June 1, 2025

DME.00053 Home Video-Assisted Robotic Rehabilitation Systems This policy addresses the home use of video-assisted robotic rehabilitation systems, which combine the use of robotic-assisted movement therapy with interactive video-assisted programs to complement physical rehabilitation programs for individuals with movement disorders:  Considered Investigational and Not Medically Necessary for all indications

MED.00151 Gene Therapy for Aromatic L-Amino Acid Decarboxylase Deficiency This policy addresses gene therapy for aromatic l-amino acid decarboxylase (AADC) deficiency, which is a genetic disease involving variations in the human dopa decarboxylase (DDC) gene that reduce an individual’s ability to synthesize dopamine and serotonin from their precursor molecules:  Considered Investigational and Not Medically Necessary for all indications

MED.00152 Outpatient Intravenous Insulin Therapy This policy addresses outpatient intravenous insulin therapy, also referred to as chronic intermittent intravenous insulin infusion therapy (CIIIT), hepatic activation, outpatient intravenous insulin therapy (OIVIT), metabolic activation therapy (MAT), physiologic insulin resensitization (PIR), pulsatile intravenous insulin therapy (PIVIT), or pulse insulin therapy (PIT):  Considered Investigational and Not Medically Necessary as a treatment for all indications, including diabetes

SURG.00165 Histotripsy This policy addresses the use of histotripsy to ablate tissue:  Considered Investigational and Not Medically Necessary for all indications

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Updated Medical Policies effective June 1, 2025

DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices This policy addresses certain types of electrical stimulation devices:  Revised Investigational and Not Medically Necessary statement, adding bimodal (acoustic and peripheral nerve electrical stimulation) neuromodulation therapy

LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) This policy addresses the use of serological testing for biomarkers to aid in the screening, diagnosis, and management of irritable bowel syndrome (IBS), including testing performed with ibs-smart® and IBSchek®:  Revised Investigational and Not Medically Necessary statement to remove proprietary names and “for all other indications”

TRANS.00033 Heart Transplantation This policy addresses cardiac transplantation, a therapeutic modality for individuals with end-stage heart disease, characterized by heart failure (HF; also known as cardiac failure) that does not respond to standard, optimal medical or surgical treatments:  Reformatted Medically Necessary statement  Revised Medically Necessary cardiopulmonary exercise testing criteria  Added Medically Necessary criteria related to history of malignancy  Added Note regarding 2024 International Society for Heart and Lung Transplantation listing guidelines  Added new Pediatric Medically Necessary criteria related to pulmonary vascular resistance (PVR)  Revised Relative Contraindications for Transplant Recipients related to PVR  Revised formatting in Absolute Contraindications for Transplant Recipients

Criteria revisions/conversions effective January 30, 2025:  MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease converted to CG-MED-98 (title unchanged)  MED.00132 Autologous Adipose-derived Regenerative Cell Therapy (previously titled Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures) revised to address autologous adipose-derived regenerative cell therapy, and content related to autologous fat grafting and injectable soft tissue fillers converted to CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers  SURG.00095 Viscocanalostomy and Canaloplasty converted to CG-SURG-124 Viscocanalostomy and CG-SURG-125 Canaloplasty

Clinical Guidelines de-adopted effective February 1, 2025 (unless otherwise noted):  CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output (effective January 1, 2025)  CG-DME-49 Standing Frames  CG-MED-90 Chelation Therapy  CG-MED-93 Navigational Bronchoscopy  CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)  CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis  CG-OR-PR-09 Microprocessor Controlled Knee-Ankle-Foot Orthosis  CG-SURG-108 Stereotactic Radiofrequency Pallidotomy  CG-SURG-111 Open Sacroiliac Joint Fusion

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Archivals effective January 30, 2025:  MED.00097 Neural Therapy  MED.00128 Insulin Potentiation Therapy  SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus

MCG Care Guidelines, 29th Edition Effective June 1, 2025, we will upgrade to the 29th edition of the MCG Care Guidelines for the following modules. Below is a high-level summary of the updates and is not intended to be all-inclusive:  Inpatient & Surgical Care (ISC):

• Five new observation care guidelines and a new mean arterial pressure (MAP) calculator were added.  General Recovery Care (GRG):
• A new Hospital-at-Home General Recovery Guideline was added.  Recovery Facility Care (RFC):
• The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.  Chronic Care (CCG):

• New guidelines to self-management and low-intensity disease management pediatric guidelines.

  For questions, call Provider Services at the number on the back of the member ID card.

  Transition to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Effective April 1, 2025, we will transition the following Clinical Criteria for medical necessity review of select procedures to Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These guidelines are located at https://guidelines.carelonmedicalbenefitsmanagement.com.

  Preapproval requirements remain the same. Requests for these services rendered on or after April 1, 2025, will be subject to review using the Carelon Medical Benefits Management criteria.

  Anthem criteria Title Carelon Medical Benefits Management guideline CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins Transcatheter Ablation for Management of Atrial Fibrillation CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Ambulatory Cardiac Rhythm Monitoring CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation Electrophysiological Studies, Transcatheter Ablation for Management of Atrial Fibrillation and Transcatheter Ablation for Management of Supraventricular and Ventricular Arrhythmias CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction Dialysis Access Evaluations SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing Cardiac Resynchronization Therapy THER-RAD.00008 Neutron Beam Radiotherapy Radiation Therapy (excludes Proton)

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Carelon Medical Benefits Management updates and expansion Effective March 1, 2025, Carelon Medical Benefits Management is performing medical necessity reviews for additional procedures for our members. Note that CG-ANC-04 Ambulance Services: Air and Water will not be included in their review.

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

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Af _l ecq CG-DME-31 Powered Wheeled Mobility Devices • Revised formatting in Medically Necessary Statement CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance • Removed Medically Necessary criteria requiring device clearance by the Food and Drug Administration (FDA) and documentation of need for airway clearance • Removed reasons for inability to use other airway clearance therapies • Removed Not Medically Necessary criterion for other indications CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins • Revised descriptor for 93656 effective February 1, 2025 CG-MED-81 Ultrasound Ablation for Oncologic Indications • Added new codes 51721, 55881, 55882 replacing 53899 for TULSA considered Not Medically Necessary effective February 1, 2025 CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift • Reformatted Clinical Indications section CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver • Added codes 60660, 60661 for radiofrequency ablation thyroid considered Not Medically Necessary (previously included in 60699) effective February 1, 2025 CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies • Removed Not Medically Necessary statement regarding histotripsy (now addressed in SURG.00165) CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity • Added endoluminal reoperative bariatric procedure to Not Medically Necessary statement CA-SURG-92 Paraesophageal Hernia Repair • Removed codes 43280, 43283, 43325, 43327, 43328, 43330, 43331, 43338 not specific to paraesophageal hernia effective February 1, 2025 CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention • Reformatted Clinical Indications section CG-SURG-120 Vagus Nerve Stimulation • Added codes 0908T, 0909T, 0910T, 0911T, 0912T for a stimulator (not yet FDA approved) for rheumatoid arthritis considered Not Medically Necessary effective February 1, 2025 ANC.00007 Cosmetic and Reconstructive Services: Skin Related • Added ICD-10-CM codes C4A.0-C4A.9 for dermabrasion and C49.A9 to end of range ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck • Removed code 15819 deleted as of February 1, 2025 LAB.00003 In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays • Added code 0525U for 3D Predict Ovarian test considered Not Medically Necessary and removed 0564T deleted effective February 1, 2025 LAB.00015 Detection of Circulating Tumor Cells • Clarified codes 86152 and 86153 are considered Investigational and Not Medically Necessary only for blood specimen; other specimens (e.g., CSF) not addressed

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LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions • Added Medically Necessary criteria for ArteraAI Prostate cancer risk stratification test • Revised Investigational and Not Medically Necessary statement to remove prostate cancer LAB.00028 Blood-based Biomarker Tests for Multiple Sclerosis • Added code 83884 for neurofilament light chain considered Investigational and Not Medically Necessary effective February 1, 2025 LAB.00035 Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis • Added code 0521U for rheumatoid arthritis panel considered Investigational and Not Medically Necessary effective February 1, 2025 LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia • Added code 0524U for sFlt-1/PlGF test considered Investigational and Not Medically Necessary effective February 1, 2025 LAB.00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy • Added code 81599 replacing code 0456U for PrismRA deleted as of February 1, 2025 LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease • Revised formatting and content of Medically Necessary statement • Added codes 0479U and 0503U effective October 1, 2024 • Added codes 82233, 82234, 84393, 84394 for Abeta and pTau considered Medically Necessary when criteria are met, code 83884 for neurofilament light chain considered Investigational and Not Medically Necessary, and removed code 0346U (deleted) effective February 1, 2025 MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications • Revised Investigational and Not Medically Necessary statement to include examples of bilateral staged focused ultrasound thalamotomy or pallidotomy, benign prostate hyperplasia (BPH) and uterine fibroids • Added new code 61715 replacing 0398T for intracranial magnetic resonance image guided high intensity focused ultrasound (MRgFUS) considered Medically Necessary when criteria are met effective February 1, 2025 MED.00135 Gene Therapy for Hemophilia • Added code J1414 for Beqvez replacing C9172 deleted as of February 1, 2025 MED.00137 Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion • Revised descriptor for 0615T effective February 1, 2025 MED.00140 Gene Therapy for Beta Thalassemia • Added code J3392 for Casgevy replacing codes C9399, J3490, J3590 effective February 1, 2025 MED.00146 Gene Therapy for Sickle Cell Disease • Added code J3392 for Casgevy replacing codes C9399, J3490, J3590 effective February 1, 2025 SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Added codes 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018 and C8002 for products considered Medically Necessary when criteria are met, and codes Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353 for products considered Investigational and Not Medically Necessary effective February 1, 2025 SURG.00099 Convection-Enhanced Delivery of Therapeutic Agents to the Brain • Revised title (previously titled Convection Enhanced Delivery of Therapeutic Agents to the Brain) SURG.00131 Lower Esophageal Sphincter Augmentation Devices • Revised title (previously titled Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease [GERD]) SURG.00135 Renal Sympathetic Nerve Ablation • Added codes C1735 and C1736 for renal denervation catheters considered Investigational and Not Medically Necessary effective February 1, 2025

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SURG.00155 Cryoneurolysis • Added codes C9808 and C9809 for cryoICE and Iovera devices considered Investigational and Not Medically Necessary effective February 1, 2025 SURG.00156 Implanted Artificial Iris Devices • Added code 66683 replacing codes 0616T-0618T deleted as of February 1, 2025 SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain • Added code C9807 for the Sprint device considered Investigational and Not Medically Necessary effective February 1, 2025 SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis • Added code C8003 for implantation MISHA knee system considered Investigational and Not Medically Necessary effective February 1, 2025 TRANS.00008 Liver Transplantation • Changed “patient” to “individual” and “noncompliance” to “nonadherence” in Position Statement TRANS.00009 Lung and Lobar Transplantation • Reformatted Investigational and Not Medically Necessary statement • Changed ”patient” to “ individual” and “noncompliance” to “ nonadherence” in Position Statement TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation • Revised Absolute Contraindications for Transplant Recipients in Position Statement TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias • Reformatted Position Statement section TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome • Reformatted Position Statement section TRANS.00026 Heart/Lung Transplantation • Revised contraindications list to replace “noncompliance” with “nonadherence” and “patient” with “individual” TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors • Added ICD-10-CM diagnosis code C49.3 as Medically Necessary when criteria are met TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias • Removed age requirements for hematopoietic stem cell transplantation for aplastic anemia, sickle cell disease, and thalassemia from Medically Necessary criteria