MP/CG Update/Notice - December 2017 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.

December 1, 2017

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

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, and rationale updates and changes that are not summarized below.

NOTE: The expanded Specialty Pharmacy drug program in italics below applies to local Anthem members who have these services medically managed by AIM Specialty Health® (AIM), a separate company administering the program on behalf of Anthem. For more information go to http://www.aimprovider.com/specialtyrx/FAQ.html to view the FAQs.

NEW Medical Policies

• DRUG.00012 Gemtuzumab Ozogamicin (Mylotarg®): This document addresses gemtuzumab ozogamicin (Mylotarg), a humanized anti-CD33 monoclonal antibody for the treatment of acute myeloid leukemia (AML).

• DRUG.00018 Copanlisib (Aliqopa®): This document addresses the use of copanlisib, a P13K kinase inhibitor administered intravenously for the treatment of follicular lymphoma.

• MED.00123 Axicabtagene ciloleucel (Yescarta™): This document addresses the uses of axicabtagene ciloleucel autologous chimeric antigen receptor (CAR) T-cell, CD3/CD28-based therapy, that targets the CD19 surface antigen expressed in B cell malignancies, in particular, non-Hodgkin’s lymphoma (NHL).

UPDATED Medical Policies and Clinical Guidelines

• CG-DRUG-05 Recombinant Erythropoietin Products: This document addresses recombinant, or man- made, erythropoietin products. o Added Not Medically Necessary statement for use of epoetin alfa or darbepoetin alfa to treat anemia in individuals with cancer receiving myelosuppressive chemotherapy in whom the anemia can be managed by transfusion

• DRUG.00017 Hyaluronan Injections in Joints Other Than the Knee: This document addresses the use of hyaluronan injections for the replacement or supplementation of naturally occurring intra-articular lubricants in individuals with musculoskeletal conditions in joints other than the knee, including osteoarthritis and temporomandibular joint disease. o Revised position statement from Medically Necessary to Investigational and Not Medically Necessary for hyaluronan injections for the treatment of temporomandibular joint disorders

• MED.00124 Tisagenlecleucel (Kymriah™): This document addresses uses of tisagenlecleucel, an autologous chimeric antigen receptor (CAR) T-cell immunotherapy that targets the CD19 surface antigen expressed in B cell malignancies.
o Added code Q2040 replacing NOC J3490 and J3590 o Added indication for CAR-T cell therapy and lymphapheresis related to CAR-T cell therapy

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. Medical Policies converted to New Clinical Guidelines – no changes to clinical indications

MP Number Title CG Number DME.00004 Electrical Bone Growth Stimulation CG-DME-40 DME.00036 Ultraviolet Light Therapy Delivery Devices for Home Use CG-DME-41 DRUG.00048 Eribulin mesylate (Halaven®) CG-DRUG-70 DRUG.00051 Ziv-aflibercept (Zaltrap®) CG-DRUG-71 DRUG.00052 Pertuzumab (Perjeta®) CG-DRUG-72 DRUG.00055 Denosumab (Prolia®, Xgeva®) CG-DRUG-73 DRUG.00060 Plerixafor injection (Mozobil™) CG-DRUG-76 DRUG.00061 Radium Ra 223 Dichloride (Xofigo®) CG-DRUG-77 DRUG.00070 Siltuximab (Sylvant®) CG-DRUG-79 DRUG.00102 Cabazitaxel (Jevtana®) CG-DRUG-80 GENE.00004 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay CG-GENE-01 GENE.00014 Analysis of KRAS Status CG-GENE.02 GENE.00019 BRAF Mutation Analysis CG-GENE-03 MED.00032 Treatment of Hyperhidrosis CG-MED-63 MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) CG-MED-64 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee CG-MED-65 MED.00080 Cryopreservation of Oocytes or Ovarian Tissue CG-MED-66 MED.00083 Melanoma Vaccines CG-MED-67 SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver CG-SURG-61 SURG.00050 Radiofrequency Ablation of Solid Tumors Outside the Liver CG-SURG-62 SURG.00059
Recombinant Human Bone Morphogenetic Protein CG-SURG-65 SURG.00060
Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) CG-SURG-66 SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure CG-SURG-63 SURG.00093 Treatment of Osteochondral Defects CG-SURG-67 SURG.00109 Surgical Treatment of Femoroacetabular Impingement Syndrome CG-SURG-68 TRANS.00015 Meniscal Allograft Transplantation of the Knee CG-SURG-69

Medical Policies converted to New Clinical Guidelines (Changes noted in Attachment A)

MP Number Title CG Number DRUG.00002 Tumor Necrosis Factor Antagonists CG-DRUG-65 DRUG.00035 Panitumumab (Vectibix®) CG-DRUG-66 DRUG.00038 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications CG-DRUG-68 DRUG.00042 Ustekinumab (Stelara®) CG-DRUG-69 DRUG.00043 Tocilizumab (Actemra®) CG-DRUG-81 DRUG.00056 Antihemophilic Factors and Clotting Factors
CG-DRUG-78 DRUG.00057 Canakinumab (Ilaris®) CG-DRUG-74 DRUG.00059 Romiplostim (Nplate®) CG-DRUG-75 DRUG.00066 Antihemophilic Factors and Clotting Factors CG-DRUG-78 GENE.00032 Molecular Marker Evaluation of Thyroid Nodules CG-GENE-04 MED.00113 Therapeutic Apheresis CG-MED-68

Effective for dates of service on and after March 1, 2018, the following specialty pharmacy codes from current medical policy will be included in our existing Specialty Pharmacy level of care review process (CG-DRUG-47).

Medical Policy Drug Code DRUG.00080 Cinqair J2786 DRUG.00080 Nucala J2182

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. Effective for dates of service on and after March 1, 2018, the following specialty pharmacy codes from current medical policies will be included in our existing FDA Approved Biosimilar Products (CG-DRUG-64) review process.

Effective December 1, 2017, Prior authorization will no longer be required for the following drug administration codes:

Code Medical Policy Description 46505 DRUG.00006 Botulinum Toxin Chemodenervation of internal anal sphincter [for diagnosis of anal fissure] 64612 DRUG.00006 Botulinum Toxin Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm or hemifacial spasm)
67345 DRUG.00006 Botulinum Toxin Chemodenervation of extraocular muscle

Specialty Pharmacy Prior Authorization Requirements

Effective for dates of service on and after March 1, 2018, prior authorization reviews for CG-DRUG-09 Immune Globulin (Ig) Therapy will be managed by AIM Specialty Health® (AIM), a separate company. Codes included on this Clinical Guidelines are as follows:

J1459 J1557 J1561 J1569 J1599 J1460 J1559 J1566 J1572 J3490 J1556 J1560 J1568 J1575 S9338

Update to AIM Diagnostic Imaging Clinical Appropriateness Guidelines

Beginning with dates of service on and after March 9, 2018, the following updates will apply to the AIM Diagnostic Imaging Clinical Appropriateness Guidelines:

Criteria for imaging of suspicion for pulmonary embolism
• The evaluation for pulmonary embolism requires the use of well validated clinical prediction rules. • The addition of the use D Dimer to identify patients where imagining for pulmonary embolism is appropriate. For questions related to guideline updates, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.

Important information regarding post-service reviews using AIM Specialty Health®

Anthem Blue Cross (Anthem) uses AIM Specialty Health® (AIM), a separate company, to administer pre-service clinical reviews for services noted below. AIM reviews requests in real time against evidence-based clinical guidelines and Anthem medical policy.

Effective January 1, 2018, providers will be notified via letter or remit message when claims are submitted without the appropriate pre-service review by AIM. As a result, providers will need to obtain a post-service clinical review for the service via the AIM ProviderPortalSM.

To help prevent delays in claim processing and post-service reviews, ordering providers submit pre-service requests to AIM in one of the following ways: • Access AIM ProviderPortalSM directly at www.providerportal.com, available 24/7 to process orders in real-time
• Access AIM via the Availity Web Portal at www.availity.com Medical Policy Code Drug Comments DRUG.00110 J3490, J3590 Besponsa New Drug Addition to Policy

DRUG.00002
J3590 Cyltezo New Drug to Existing Policy

DRUG.00028 and DRUG.00038 J3590 Mvasi New Drug to Existing Policy

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.

As a reminder, AIM reviews the following services for clinical appropriateness: • Advanced diagnostic imaging (e.g. CT, MRI/MRA) • Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization) • Medical oncology treatments through the Cancer Care Quality Program • Radiation oncology treatments (e.g. IMRT, brachytherapy) • Sleep testing, treatment, and supplies • Specialty pharmacy • Genetic testing
Services performed in an emergency or inpatient setting are excluded from AIM programs.

This update applies to local fully-insured Anthem Blue Cross members, with services medically managed by AIM. It does not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®), members who are covered under a self-insured (ASO) benefit plan. For more information, please contact the phone number of the back of the member ID card.

Anthem Blue Cross Medical Policies and Clinical UM Guidelines are developed by our Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.
Medical Policies and Clinical UM Guidelines are subject to the approval of the Physician Relations Committee.

All coverage written or administered by Anthem Blue Cross excludes from coverage services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set forth in Anthem Blue Cross’ Medical Policies. Review procedures have been refined to facilitate claim investigation.

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 “Tools for Providers” near the bottom of the page, the click “Enter” under Welcome to Anthem Blue Cross, then click “Services described in the Medical Policies, UM Clinical Guidelines and/or Pre-certification Requirements” under Learn More, then click “Medical Policies and Clinical UM Guidelines (for Local Plan members)”, then click “Continue” at the bottom of the page.

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,

Jacob Asher, MD Vice President and Chief Medical Officer

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. Attachme nt A – 4th Quarter 2017 Updates Revised Medical Policies and Clinical Guidelines Policy Number Title Medical Policy / Clinical Guideline Changes CG-ANC-04 Ambulance Services: Air and Water • Clarified Not Medically Necessary statement for excess mileage when transport is Medically Necessary, but destination facility is not the nearest facility to the origination site CG-DME-31 Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) • Removed cross reference to CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories from clinical indications CG-DRUG-09 Immune Globulin (Ig) Therapy • Added code J1555 for Cuvitru replacing NOC code CG-DRUG-38 Pemetrexed Disodium (Alimta®) • Added "and beyond" to clinical indication for use "as second line therapy and beyond, as a single agent for metastatic urothelial carcinoma" CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot) • Clarified Medically Necessary statement for use in the treatment of acromegaly
• Clarified Medically Necessary criteria for Zollinger-Ellison syndrome to specify “hypergastrinemic” CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®) • Clarified Medically Necessary statement that ovarian cancer is persistent or recurrent ovarian cancer
• Added Medically Necessary criteria for combination therapy when criteria are met in the treatment of persistent or recurrent ovarian cancer
CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications • Added triptodur (triptorelin pamoate) to the Medically Necessary statement for central precocious puberty
• Updated Not Medically Necessary statement
• Updated header for Gender Dysphoria to include "Incongruence" CG-DRUG-65

Tumor Necrosis Factor Antagonists • Content moved from DRUG.00002 • Added Medically Necessary statements for golimumab (Simponi Aria) use in the treatment of adults with ankylosing spondylitis and psoriatic arthritis when criteria are met CG-DRUG-65

Panitumumab (Vectibix®) • Content moved from DRUG.00035 • Clarified Medically Necessary statement from "KRAS gene mutation testing" to "Extended RAS gene mutation testing with an FDA approved test" for RAS wild type which includes KRAS, NRAS, and BRAF gene mutations • Updated "Notes" following Medically Necessary criteria • Added Not Medically Necessary statement for RAS-mutant metastatic colorectal cancer, small bowel or anal adenocarcinoma or when RAS mutation status unknown CG-DRUG-68

Bevacizumab (Avastin®) for Non-Ophthalmologic Indications • Content moved from DRUG.00038 • Added Medically Necessary criteria for non-clear cell renal cell carcinoma CG-DRUG-69

Ustekinumab (Stelara®) • Content moved from DRUG.00042 • Revised Medically Necessary statement for use in plaque psoriasis for individuals 18 years of age or older to "12 years of age or older" • Added code J3358 replacing Q9989 for Stelara IV for Crohn's disease

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. CG-DRUG-75 Romiplostim (Nplate®) • Content moved from DRUG.00059
• Added Medically Necessary indication for treatment of
myelodysplastic syndrome (MDS) when criteria are met • Updated Not Medically Necessary statement CG-DRUG-78 Antihemophilic Factors and Clotting Factors • Content moved from DRUG.00066 • Added criteria for recombinant coagulation factor IX, GlycoPEGylated (Rebinyn) and human fibrinogen (Fibryna) • Added Not Medically Necessary statement for prophylactic use in prevention or reduction of frequency of bleeding episodes for recombinant coagulation factor IX, GlycoPEGylated (Rebinyn)
• Updated Not Medically Necessary statements • Added code J7210 replacing C9140 for Afstyla; new code J7211 for Kovaltry CG-DRUG-81 Tocilizumab (Actemra®) • Content moved from DRUG.00043 • Clarified Not Medically Necessary statement for latent tuberculosis testing CG-GENE-02 Analysis of KRAS Status • Content moved from GENE.00014 • Added 81479 NOC code for extended RAS panel (e.g. Praxis test) CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules • Content moved from GENE.00032 • Clarified name of gene expression classifier as "Afirma" in the Medically Necessary statement
• Updated Not Medically Necessary statements CG-MED-24 Electromyography and Nerve Conduction Studies • Added Not Medically Necessary statement for needle EMG or NCS for all other conditions, including but not limited to, back pain without radiculopathy, or headaches when there is no suspicion of an underlying disorder of the cranial nerves CG-MED-68

Therapeutic Apheresis • Content moved from MED.00113 • Added Medically Necessary indications for N-methyl D- aspartate receptor antibody encephalitis, progressive multifocal leukoencephalopathy and apheresis as a component of CAR-T therapy • Added Medically Necessary indication for lymphapheresis when used to collect autologous T-cells for CAR-T cell therapy when the criteria within the specific CAR-T therapy document are met
• Revised Medically Necessary indications for polyneuropathy, glomerulonephritis, neuromyelitis optica disorders and paraproteinemic demyelinating neuropathies • Updated Medically Necessary and Not Medically Necessary statement for plasmapheresis or plasma exchange • Descriptor change for 36516 includes service coded as 36515 which is deleted 12/31/17; added diagnosis codes for plasma- pheresis and leukapheresis to Medically Necessary criteria CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver • Content moved from MED.00113 • New code 32994 replacing 0340T for cryoablation of pulmonary tumors DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices • Updated Investigational and Not Medically Necessary statement for supraorbital transcutaneous neurostimulation to include "treatment of acute migraine headaches, with or without aura"

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. DME.00040 Automated Insulin Delivery Devices • Revised position statement from Investigational and Not Medically Necessary to Medically Necessary for a hybrid closed-loop device when criteria are met • Updated Not Medically Necessary and Investigational and Not Medically Necessary statements DRUG.00050 Eculizumab (Soliris®) • Added Medically Necessary statement for use in initial therapy and for continuation of treatment in generalized myasthenia gravis when criteria are met • Reformatted and made changes to abbreviations and acronyms in Medically Necessary and Investigational and Not Medically Necessary statements DRUG.00062 Obinutuzumab (Gazyva®) • Clarified Medically Necessary criteria for follicular lymphoma for combination chemotherapy and monotherapy DRUG.00071 Pembrolizumab (Keytruda®) • Added Medically Necessary statement for treatment of gastric or gastroesophageal junction adenocarcinoma when criteria are met • Added Medically Necessary statement for treatment of malignant pleural mesothelioma when criteria are met DRUG.00075 Nivolumab (Opdivo®) • Added Medically Necessary statement for − hepatocellular carcinoma when criteria are met
− Merkel cell carcinoma when criteria are met
− malignant pleural mesothelioma when criteria are met − adjuvant therapy for resected advanced melanoma when criteria are met DRUG.00081 Eteplirsen (Exondys 51™) • Revised position statement from Investigational and Not Medically Necessary to Medically Necessary for the use of eteplirsen for Duchenne muscular dystrophy when criteria met • Updated Investigational and Not Medically Necessary
statement • Added code J1428 replacing C9484 and NOC codes DRUG.00089 Daclizumab (Zinbryta®) • Revised title; changed ™ to ® • Clarified Medically Necessary statement for daclizumab use as single-agent treatment
• Updated Investigational and Not Medically Necessary statement DRUG.00109 Durvalumab (Imfinzi™)
• Revised title; changed to upper and lower case
• Added Medically Necessary statement for non-small cell lung cancer when criteria are met • Added header for urothelial carcinoma GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment • Revised criteria for gene expression profiling as a technique for management breast cancer treatment from "Chemotherapy is a therapeutic option being considered and will be supervised by the practitioner ordering the gene expression profile" to "chemotherapy is a therapeutic option being considered by the individual and their practitioner"
• Added Medically Necessary statement for use of gene expression profiling as a genetic index used to assist in decisions of extending adjuvant hormonal therapy beyond 5 years of treatment when criteria are met • Reformatted and made changes to abbreviations and acronyms throughout position statement • Updated Investigational and Not Medically Necessary statement • Added code 81520 replacing 0008M for Prosigna Breast Cancer Assay; 81521 for MammaPrint

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.

GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies • Added code 81448 for panel test as Investigational and Not Medically Necessary RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion • Added code 0482T for PET quantitation of blood flow, deleted HCPCS code A9599 RAD.00036 MRI of the Breast • Added additional genetic variants to Medically Necessary statement
SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions • Removed abbreviations from and added definitions to Medically Necessary, Not Medically Necessary, and Investigational and Not Medically Necessary statements • Added C9748 for convective water vapor thermal ablation (Investigational and Not Medically Necessary) SURG.00089 Balloon and Self-Expanding Absorptive Sinus Ostial Dilation • Revised position statement from Investigational and Not Medically Necessary to Medically Necessary for the use of balloon sinus ostial dilation when criteria are met • Updated Investigational and Not Medically Necessary
statements • Added code 31298 for balloon dilation of frontal and sphenoid sinus ostia SURG.00128 Implantable Left Atrial Hemodynamic Monitor • Deleted codes 0293T, 0294T effective 12/31/17; replaced by
code 93799 SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy • Added code 55874 replacing 0438T SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts) • Clarified Medically Necessary statement for VADs when used in accordance with FDA approval when criteria are met • Added "Note" to position statement to refer to Background section for a list of FDA approved VADs • Updated Investigational and Not Medically Necessary statement to include Impella RP as an example of a pVad • Added codes 33927, 33928, 33929 replacing 0051T, 0052T, 0053T for artificial heart systems
THER-RAD.00008 Neutron Beam Radiotherapy • Removed 77422 deleted 12/31/17 TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias • Removed Individual Selection Criteria section TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome • Removed Individual Selection Criteria section
• Revised category title for MDS, AML, and CML • Revised category CMML, MDS, JMML, and MPN to "MDS including MDS/MPN" TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors • Removed Individual Selection Criteria section TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma • Removed Individual Selection Criteria section TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias • Removed Individual Selection Criteria section TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors • Removed Individual Selection Criteria section

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.

RE: New Musculoskeletal Program Effective March 1, 2018

At Anthem Blue Cross we’re always looking for ways to create value for all our stakeholders. With that in mind, we are pleased to announce a musculoskeletal and pain management program. Beginning March 1, 2018, AIM Specialty Health® (AIM), a separate company, will perform medical necessity review of certain elective surgeries of the spine and joints, as well as interventional pain treatment for Anthem Blue Cross fully insured members, as further outlined below, and subject to Department of Managed Health Care approval. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable.

The new musculoskeletal program reviews certain spine and joint surgeries, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. Many of the spine and joint procedures are currently reviewed by Anthem today. AIM will be utilizing their guidelines to apply the review. In addition, AIM will also utilize related Anthem Medical Policies. To determine if precertification is needed for an Anthem member, please check online at www.anthem.com > Providers > select “California” > Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements or call the precertification number located on the back of the member’s ID card. The clinical guidelines that have been adopted by Anthem to review for medical necessity are also located on anthem.com.

Additionally, the program includes a member engagement initiative, designed to educate your patients about the surgeries and treatments your practice recommends for them, prior to the scheduled procedure. AIM’s member engagement initiative supports your efforts to reinforce important information about the surgeries and treatments you recommend. This initiative is designed to reduce anxiety, drive adherence to care plans, motivate preventive action, and improve appropriate use of care for our members. Members are contacted by email or telephone and are provided a link to review educational multimedia programs, based on the order requests you submit to AIM for the procedures and treatments noted. As they view these multimedia programs, members will have an opportunity to note and submit any questions and concerns. Member input will be sent to your practice, giving you the opportunity to follow up and provide any additional education and information required.

Members included in the new program All members in your area are included except for the following groups: Medicare Advantage, Medicaid, Medicare, Medicare supplement, and Federal Employee Program® (FEP®).

The program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of July 1, 2018.

Pre-service review requirements For surgeries and pain treatment that are scheduled to begin on or after March 1, 2018, all providers must contact AIM to obtain pre-service review for the following non-emergency modalities:

For self-funded accounts (ASO), current pre-service review requirements will continue, using AIM guidelines and Anthem Medical Policies until their new benefit package is offered to them at the time of their renewal beginning July 1, 2018.

Spinal surgeries – Cervical, thoracic, lumbar, and sacral (including all concurrent spinal procedures and all associated revision surgeries):
• Fusion surgery • Decompression • Disc replacement • Surgical treatment of scoliosis • Sacroiliac joint fusion • Total disc arthroplasty • Vertobroplasty/kyphoplasty

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. Joint replacement (including all associated revision surgeries) • Total knee arthroplasty • Partial knee replacement • Total hip arthroplasty • Hip resurfacing • Total shoulder arthroplasty • Total elbow arthroplasty • Total ankle arthroplasty

Interventional pain management
• Spinal cord stimulators • Facet injections • Epidural steroid injections • Percutaneous neurolysis • Peripheral nerve blocks for treatment of neuropathic pain • Pain management devices • Implantable pain pumps • Radio ablations • Sacroiliac joint

Surgeries and pain treatments performed as part of an inpatient admission are included.

How to place a review request:

Online
Get fast, convenient online service via the AIM ProviderPortalSM. ProviderPortal is available twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria. Go to www.aimspecialtyhealth.com/goweb to register. Registration opens February 19, 2018.

By phone Call AIM Specialty Health toll-free at 1-877-291-0360, Monday through Friday 8:00 a.m. – 5:00 p.m. Registration opens February 19, 2018.

For more information: Go to www.aimprovider.com/msk for resources to help your practice get started with the musculoskeletal and pain management program. Our special website helps you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, FAQs.