MP/CG Update/Notice - November 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 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.

November 1, 2021

Dear Provider:

Anthem Blue Cross is pleased to provide you with new and updated Clinical Criteria and Clinical Appropriateness Guidelines. Please refer to the specific policy for coding, language and rationale updates and changes that are not summarized below.

Updates to AIM Specialty Health® (AIM) 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 AIM.
They do 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.

Specialty Pharmacy updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our prior authorization (PA) review process.

Please note that 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.

Clinical Criteria is available at www.anthem.com/ms/pharmacyinformation/clinicalcriteria.html

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.

Clinical Criteria Drug HCPCS or CPT Code ING-CC-0096 Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) J3590 ING-CC-0167 Ruxience Q5119 ING-CC-0167* Truxima Q5115 ING-CC-0202 Saphnelo (anifrolumab-fnia) J3490, J3590 ING-CC-0203 Ryplazim (plasminogen, human-tvmh) J3490, J3590

  *Oncology use is managed by AIM

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insu rance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Step therapy updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Clinical Criteria Status Drug HCPCS or CPT Code(s) ING-CC-0075 Preferred
Rituxan J9312 Riabni Q5123 Non-preferred Ruxience Q5119 Truxima Q5115 ING-CC-0167* Preferred (no PA or step therapy required) Rituxan J9312 Riabni Q5123 Non-preferred Ruxience Q5119 Truxima Q5115

  *Oncology use is managed by AIM

Quantity limit updates

Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our quantity limit review process.

Clinical Criteria Drug HCPCS or CPT Code ING-CC-0081 Crysvita (burosumab-twza) J0584 ING-CC-0202 Saphnelo (anifrolumab-fnia) J3490, J3590

Updates to AIM Specialty Health Clinical Appropriateness Guideline

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Clinical Appropriateness Guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services

Updates by Guideline

Imaging of the Brain
• Acoustic neuroma – removed indication for CT brain and replaced with CT temporal bone • Meningioma – new guideline establishing follow-up intervals • Pituitary adenoma – removed allowance for CT following nondiagnostic MRI in macroadenoma • Tumor, not otherwise specified – added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

Imaging of the Head and Neck
• Parathyroid adenoma – specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines • Temporomandibular joint dysfunction – specified duration of required conservative management

Imaging of the Heart
• Coronary CT Angiography - removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

Imaging of the Chest
• Pneumonia – removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insu rance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

• Pulmonary nodule – aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT

Imaging of the Abdomen and Pelvis
• Uterine leiomyomata – new requirement for US prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures • Intussusception – removed as a standalone indication • Jaundice – added requirement for US prior to advanced imaging in pediatric patients • Sacroiliitis – defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs) • Azotemia – removed as a standalone indication • Hematuria – modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline • Diffuse liver disease – new indication for multiparametric MRI for fibrosis and hemochromatosis

Oncologic Imaging
• National Comprehensive Cancer Network (NCCN) recommendation alignments for Breast Cancer, Hodgkin & Non-Hodgkin Lymphoma, Neuroendocrine Tumor, Melanoma, Soft Tissue Sarcoma, Testicular Cancer, and Thyroid Cancers.
• Cancer Screening: new age parameters for Pancreatic Cancer screening; new content for Hepatocellular Carcinoma screening • Breast Cancer: clinical scenario clarifications for Diagnostic Breast MRI and PET/CT

Radiation Oncology • Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines.

Diagnostic coronary angiography
• Removed indications for asymptomatic patients (in alignment with the ISCHEMIA trial) • Facilitated coronary angiography with a view to intervention in non-culprit vessels following ST-segment elevation myocardial infarction (STEMI), (in alignment with the COMPLETE trial) • For patients undergoing preoperative evaluation for TAVR or other valve surgery, aligned criteria with the updated ACC/AHA Guideline for the management of patients with valvular heart disease

Percutaneous coronary intervention
• Revised criteria such that, for some cohorts, only those patients with persistent unacceptable symptoms and moderate or severe stress test abnormalities can proceed to revascularization (in alignment with the ISCHEMIA trial) • For non-left main percutaneous coronary intervention (PCI), expanded use to non-culprit vessels in patients following ST-segment elevation myocardial infarction (STEMI), and restricted use to those with moderate or severe stress test abnormalities who have failed medical therapy
• Left main PCI limited to situations where coronary artery bypass grafting (CABG) is contraindicated or refused (in alignment with NOBLE and EXCEL trials) • Clarified requirements for patients who have undergone CABG: at least 70% luminal narrowing qualifies as stenosis, symptomatic ventricular tachycardia is considered an ischemic symptom, and instant wave- free ratio fractional flow reserve (iFR) is considered in noninvasive testing

Interventional Pain Management Epidural Injection Procedures (ESI) and Diagnostic Selective Nerve Root Blocks (SNRB):
• Allow more frequent ESI in newly diagnosed patients
• Remove imaging requirement in certain circumstances • Require similar criteria as ESI for diagnostic SNRB
• Add epidural abscess as a contraindication • Limit multilevel and combination diagnostic SNRB

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932-1021-DM-CA

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insu rance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Paravertebral Facet Injection/Medial Branch Block (MBB)/Neurolysis:
• Limit indefinite use of diagnostic MBB • Add indication for diagnostic pars defect MBB • Expand exceptions allowed for intraarticular facet injections • Define MBB timing with respect to radiofrequency neurotomy, MBB limited to RFA candidacy
• Limit open surgical neurolysis, and limited multiple spinal injections Sacroiliac Joint Injections:
• Limit indefinite use of diagnostic intraarticular injections
• Disallow sacral lateral branch blocks
• Disallow sacroiliac joint therapeutic injections in a previously fused joint Spinal Cord and Nerve Root Stimulators:
• Allow minimally invasive pain procedures to satisfy conservative management definition • Specify timing of mental health evaluation • Define indications for repeat stimulator trial

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
• Access AIM’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 AIM via the Availity Web Portal at availity.com • Call the AIM Contact Center toll-free number: 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.
Current and upcoming guidelines are available at https://aimspecialtyhealth.com/anthem185/.

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