MP/CG Update/Notice - April 2019 Form

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Rev 4/19 AIM Specialty Health® Updates

April 1, 2019

[Provider Name] [Contact Title] [Address] [City], [State] [Zip]

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with the following updates. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below. Anthem expands specialty pharmacy prior authorization list
Effective for dates of service on and after July 1, 2019, the following specialty pharmacy codes from new or current clinical criteria and clinical guidelines will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization clinical review of this specialty pharmacy drug will be managed by AIM Specialty Health® (AIM), a separate company. Clinical Criteria/Guideline HCPCS or CPT Code(s) NDC Code(s) Drug CG-THER-RAD-03 A9699, C9408 71258-0015-02 71258-0015-22 Azedra®

Clinical criteria information is available at www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

Update to AIM Clinical Appropriateness Guidelines

These updates apply to local fully-insured Anthem members and select members who are covered under self- insured (ASO) benefit plans with services medically managed by AIM. It does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

Update to AIM Advanced Imaging of the Heart Clinical Appropriateness Guideline

Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart and AIM Clinical Appropriateness Guidelines for Arterial Ultrasound.

Advanced Imaging of the Heart • Resting Transthoracic Echocardiography (TTE)
o Changes made to address frequency of surveillance of LV function for cardio-oncology.
• TTE o Changes made to address frequency of surveillance echocardiography following transcatheter mitral valve repair. These recommendations follow CMS guidelines.

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Rev 4/19 AIM Specialty Health® Updates

Arterial ultrasound • Upper extremity arterial duplex o Indication added for creation of arteriovenous (AV) fistulae for dialysis • Lower extremity arterial duplex o ACC guideline for management of peripheral arterial disease (2016) indicates that Duplex imaging should be performed only after the decision to revascularize has been made. There is no role for duplex imaging in the initial diagnosis of peripheral arterial disease. The current AIM guideline is not aligned with this position and the proposed changes address that malalignment.
o Language changed to account for the fact that critical limb ischemia should include patients with non- healing ulcers and gangrene Update to AIM Advanced Imaging of the Head and Neck Clinical Appropriateness Guidelines

Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Advanced Imaging of the Head and Neck Clinical Appropriateness Guidelines.
• Sinusitis/rhinosinusitis o Expanded the scope of complicated sinusitis
o Defined a minimal treatment requirement for uncomplicated sinusitis
o Identified reasons for repeat sinus imaging, aligned with Choosing Wisely
o Subacute sinusitis to be treated as more like acute or chronic rhinosinusitis based on the AAO-HNS acute sinusitis guideline o Defined indications for preoperative planning for image navigation following a clinical policy statement on appropriate use from the AAO-HNS o Removed CT screening for immunocompromised patients
• Infectious disease – not otherwise specified o Added MRI TMJ to this indication
• Inflammatory conditions – not otherwise specified o Allow MRI TMJ for suspected inflammatory arthritis following radiographs • Trauma o Radiograph requirement for suspected mandibular trauma
o MRI TMJ in trauma for suspected internal derangement in surgical candidates • Neck mass(including lymphadenopathy) o Align adult neck imaging guideline with AAO-HNS guideline o Expand definition of neck mass beyond palpable (seen on laryngoscopy) o Allow imaging for pediatric neck masses when initial ultrasound is not diagnostic • Parathyroid adenoma o Further defined the patient population that needs evaluation
o Removed the requirement for aberrant anatomy in preoperative planning
o Position CT as a diagnostic test after both ultrasound and parathyroid scintigraphy o Remove MRI as a modality to evaluate based on lack of evidence • Temporomandibular joint dysfunction o Removed standalone “frozen jaw” indication o Allow ultrasound in addition to radiographs as preliminary imaging o Allow advanced imaging without preliminary radiographs or US in the setting of mechanical signs or symptoms
o Changed “Panorex” to “Radiographs” to allow for TMJ radiographs
o Added requirement for conservative treatment and planned intervention for suspected osteoarthritis • Cerebrospinal fluid (CSF) leak of the skull base o Added modalities and criteria to evaluate for CSF leak

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Rev 4/19 AIM Specialty Health® Updates

• Dizziness or vertigo o Add Tullio’s phenomenon for lateral semicircular canal dehiscence
o Expand definition of abnormal vestibular function testing • Hearing loss o Added indication for sudden onset hearing loss in adult patients o More clearly delineated appropriate modalities based on types of hearing loss in pediatric patients o Allow either CT or MRI for mixed hearing loss

Update to AIM Musculoskeletal Joint Surgery Clinical Appropriateness Guidelines

Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Joint Surgery Clinical Appropriateness Guidelines.
• General Requirements o Conservative management: For joint arthroplasty, clarification of conservative management options provide allowance for conservative management exception. Add intraarticular corticosteroid injections as an option. Remove ice or heat given that it is commonly performed in all patients and hence does not meet the threshold for a non-operative management modality as intended. Addition of physical therapy or home therapy requirement for all non-arthroplasty joint procedures based on preponderance of benefit over harm to conservative care. Remove MOON protocol conservative care requirement throughout the document based on feasibility and standards of practice o Reporting of symptom severity: Inability felt too restrictive to allow for difficulty performing o Tobacco Cessation: removed nicotine-free documentation requirement • Subacromial Impingement Syndrome (without Rotator Cuff Tear)Cervical Decompression with or without Fusion o Drop Arm Test removed due to lack of diagnostic accuracy for subacromial impingement
• Synovectomy/Debridement o New indication for synovectomy/debridement based on review of the evidence and common clinical scenarios • Tendinopathy of the Long Head of the Biceps – Tenodesis or Tenotomy o Allows both techniques based on no evidence for net benefit of one over the other o Allow a broader range of clinical symptoms and a lower threshold for imaging evidence of tendinopathy , no requirement for MR evidence as tendinopathy can be a clinical diagnosis • Primary Total Hip Arthroplasty o Addition of fracture management and hip arthrodesis • Revision Total Hip Arthroplasty o Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature • Resection Arthroplasty of the Hip, Femoral Head Ostectomy, or Girdlestone Resection Arthroplasty o Addition of appropriate clinical scenarios based on clinical practice experience (limited evidence) • Hip Arthroscopy o Expanded appropriate techniques for FAI surgery to include acetabuloplasty and femoroplasty • Arthroscopic Treatment of FAIS o Radiographic and clinical criteria added to include symptoms related to FAI and the likelihood that surgery will be successful • Elective Patellofemoral Arthroplasty o New guideline for patellofemoral arthroplasty, a unicompartmental procedure based on evidence and standards of practice • Revision of Prior Knee Arthroplasty o Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature

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. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Rev 4/19 AIM Specialty Health® Updates

• Meniscal Repair or Meniscectomy
o Conservative requirement for degenerative meniscus tears o Definition of acute meniscal tear and symptomatology
o More restrictive use of partial meniscectomy associated with osteoarthritis and degenerative tears • Arthroscopically assisted lysis of adhesions o New guideline based on evidence and clinical consensus • Manipulation under anesthesia o New guideline based on evidence and clinical consensus • In-Office Diagnostic Arthroscopy (mi-eye 2™) o Not medically necessary based on lack of evidence for net benefit • Meniscal Allograft Transplantation of the Knee o Collagen meniscal implants are considered not medically necessary • Treatment of Osteochondral Defects o New criteria for talar OCD based on lesion size and prior procedures • Autologous chondrocyte implantation (ACI) o Allow patellar surface ACI based on evidence for non-inferiority relative to trochlear surface lesions • CPT Code additions o CPT codes 27120, 27122, 27437, 27445, 27488, 29871, G0428, 28446, and 29892 As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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 AIM via the Availity Web Portal at availity.com • Call the AIM Contact Center toll-free number: 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines at http://www.aimspecialtyhealth.com.

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 Senior Clinical Officer