MP/CG Update/Notice - June 2021 Form

P.O. Box 4330 Woodland Hills, CA 91365 447-0621-DM-CA

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.

June 1, 2021

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

Dear Provider:

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

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®), please visit www.fepblue.org > Policies & Guidelines.

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 and 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 September 1, 2021, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our prior authorization review process.

Please note, 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 information is available at https://www.anthem.com/ca/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).

• Oncology use is managed by AIM.

  Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0167 C9399, J3590, J9999 Riabni (rituximab-arrx) ING-CC-0191 C9399, J3590, J9999 Pepaxto (melphalan flufenamide; melflufen) *ING-CC-0192 C9399, J3490 Cosela (trilaciclib) ING-CC-0193 C9399, J3490 Evkeeza (evinacumab) ING-CC-0194 J3490 Cabenuva (cabotegravir extended-release; rilpivirine extended-release)

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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 Insurance 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 July 1, 2021, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Inflectra is changing to preferred status effective July 1, 2021.

Clinical Criteria Status Drug(s) HCPCS Codes ING-CC-0062 Preferred Inflectra Q5103 ING-CC-0062 Preferred Remicade J1745 ING-CC-0062 Non-preferred Avsola Q5121 ING-CC-0062 Non-preferred Renflexis Q5104

Updates to AIM Clinical Appropriateness Guidelines

Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Advanced Imaging and AIM Musculoskeletal Program: Joint Surgery and Spine Surgery 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

Advanced Imaging of the Spine • Congenital vertebral defects o New requirement for additional evaluation with radiographs • Scoliosis o Defined criteria for which presurgical planning is indicated o Requirement for radiographs and new or progressive symptoms for postsurgical imaging • Spinal dysraphism and tethered cord o Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed o New requirement for ultrasound prior to advanced imaging for tethered cord in infants age 5 months or less • Multiple sclerosis (MS) o New criteria for imaging in initial diagnosis of MS • Spinal infection o New criteria for diagnosis and management aligned with Infectious Diseases Society of America and University of Michigan guidelines • Axial spondyloarthropathy o Defined inflammatory back pain o Diagnostic testing strategy outlining radiography requirements • Cervical injury o Aligned with American College of Radiology (ACR) position on pediatric cervical trauma • Thoracic or lumbar injury o Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture o Removed indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits • Syringomyelia o Removed indication for surveillance imaging • Non-specific low back pain o Aligned pediatric guidelines with ACR pediatric low back pain guidelines

Advanced Imaging of the Extremities • Osteomyelitis or septic arthritis; myositis o Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT • Epicondylitis and Tenosynovitis – long head of biceps

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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 Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

o Removed due to lack of evidence supporting imaging for this diagnosis • Plantar fasciitis and fibromatosis o Removed CT as a follow-up to nondiagnostic MRI due to lower diagnostic accuracy of CT o Added specific conservative management requirements • Brachial plexus mass o Added specific requirement for suspicious findings on clinical exam or prior imaging • Morton’s neuroma o Added requirements for focused steroid injection, orthoses, plan for surgery • Adhesive capsulitis o Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions) • Rotator cuff tear; Labral tear – shoulder; Labral tear - hip o Defined specific exam findings and duration of conservative management o Recurrent labral tear now requires same criteria as an initial tear (shoulder only) • Triangular fibrocartilage complex tear o Added requirement for radiographs and conservative management for chronic tear • Ligament tear – knee; meniscal tear o Added requirement for radiographs for specific scenarios o Increased duration of conservative management for chronic meniscal tears • Ligament and tendon injuries – foot and ankle o Defined required duration of conservative management • Chronic anterior knee pain including chondromalacia patella and patellofemoral pain syndrome o Lengthened duration of conservative management and specified requirement for chronic anterior knee pain • Intra-articular loose body o Requirement for mechanical symptoms • Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella) o New requirement for radiographs • Entrapment neuropathy o Exclude carpal and cubital tunnel • Persistent lower extremity pain o Defined duration of conservative management (6 weeks) o Exclude hip joint (addressed in other indications) • Upper extremity pain o Exclude shoulder joint (addressed in other indications) o Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is nondiagnostic • Knee arthroplasty, presurgical planning o Limited to MAKO and robotic assist arthroplasty cases • Perioperative imaging, not otherwise specified o Require radiographs or ultrasound prior to advanced imaging

Vascular Imaging - Alternative non-vascular modality imaging approaches, where applicable
• Hemorrhage, Intracranial
o Clinical scenario specification of subarachnoid hemorrhage indication o Addition of pediatric intracerebral hemorrhage indication • Horner’s syndrome; Pulsatile Tinnitus; Trigeminal neuralgia
o Removal of management scenario to limit continued vascular evaluation
• Stroke/TIA; Stenosis or Occlusion (Intracranial/Extracranial) o Acute and subacute time frame specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications o Sections separated anatomically into anterior/posterior circulation (Carotid artery and Vertebral or Basilar arteries, respectively) • Pulmonary Embolism
o Addition of non-diagnostic chest radiograph requirement for all indications o Addition of pregnancy-adjusted YEARS algorithm

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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 Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

• Peripheral Arterial Disease (PAD) o Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation

Joint Surgery
• Further defined criteria for home physical therapy • Removed cognitive behavioral therapy as a conservative care modality for extremity • Added indication for diagnostic arthroscopy • Standardized Radiographic criteria to align with lateral release criteria • Adhesive capsulitis o Added history of trauma or post-operative contracture as a requirement
• Tendinopathy o Removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for Superior Labrum Anterior and Posterior (SLAP) repair or have suggestive MRI findings • Hip arthroscopy o Removed complementary alternative medicine as not typically done for the hip • Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) o Removed age as an exclusion for FAIS but further defined radiographic exclusions • Unicompartmental Knee Arthroplasty/Partial Knee Replacement
o Added degenerative change of the patellofemoral joint as a contraindication • Arthroscopically assisted lysis of adhesions o Added ligamentous or joint reconstruction criteria • Added criteria for plica resection

Spine Surgery • Further defined criteria for home physical therapy • Added standard conservative management requirement for instability to align with spinal stenosis indications • Added new comprehensive indication for tethered cord syndrome

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. You may access and download a copy of the current and upcoming guidelines at aimspecialtyhealth.com/anthem185/.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem Blue Cross Web site at http://www.anthem.com/ca. Select “Providers”, choose “Policies, Guidelines & Manuals” under the Provider Resources column, scroll down to select “View Medical Policies & Clinical UM Guidelines”, then choose “Full List page” or by entering a keyword or code in the search box.

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