Medical Policies/Clinical UM Guidelines 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, 2022

Dear Provider:

Anthem Blue Cross 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, 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.

NEW Medical Policy

• MED.00142 Gene Therapy for Adrenoleukodystrophy: This document addresses gene replacement therapy for cerebral adrenoleukodystrophy (CALD), a rare and life-threatening hereditary neurological disorder. o Outlines Medically Necessary and Investigational and Not Medically necessary criteria o Prior authorization required effective February 1, 2023

Prior Authorization will be required effective March 1, 2023, for members not eligible for AIM programs for the following (*SB535 exclusions apply where noted):

• GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer (SB535) • GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status • GENE.00016 Gene Expression Profiling for Colorectal Cancer (SB535) • GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site (SB535) • GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma • GENE.00025 Proteogenomic Testing for the Evaluation of Malignancies (SB535) • GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies • GENE.00037 Genetic Testing for Macular Degeneration • GENE.00038 Genetic Testing for Statin-Induced Myopathy • GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD) • GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens • GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) (*SB535) • GENE.00050 Gene Expression Profiling for Coronary Artery Disease • GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer • GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting • GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer • GENE.00056 Gene Expression Profiling for Bladder Cancer • GENE.00057 Gene Expression Profiling for Idiopathic Pulmonary Fibrosis • SURG.00008 Mechanized Spinal Distraction Therapy • SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures • SURG.00092 Implanted Devices for Spinal Stenosis

*Effective July 1, 2022, in compliance with California SB 535, Anthem Blue Cross and its delegated entities regulated by the California Department of Managed Health Care and the California Department of Insurance will no longer require prior authorization for biomarker testing, including biomarker testing for cancer progression and recurrence, for members with advanced or metastatic stage 3 or 4 cancer. Post service review of medical necessity for biomarker testing for advanced or metastatic stage 3 or 4 cancer members is not permitted, only confirmation of advanced or metastatic stage 3 or 4 cancer is permitted.

Clinical Guideline update

The September 1, 2022, update letter included the adoption of CG-MED-91 Remote Therapeutic and Physiologic Monitoring Services with prior authorization required effective January 1, 2023. Please note, we will not be adopting CG-MED-91 for our PPO business at this time.

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 and then selecting “For Providers”, then selecting “Policies, Guidelines & Manuals” under the Provider Resources column, select “Change State” and choose California, scrolling down to select “View Medical Policies & Clinical UM Guidelines”, then selecting ”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

Revised Medical Policies and Clinical Guidelines

Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance • Updated descriptor for E0438

SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting • Added A2014, A2015, A2016, A2017, A2018; updated descriptor for Q4128