MP/CG Update/Notice - December 2018 Form

Blue Cross Of California Commercial Clinical Policy

Effective Date

Last Reviewed

Original Document

December 15, 2018

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

Dear Provider:

Anthem Blue Cross (Anthem) is pleased to provide you with our new 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, Imaging, Radiation Oncology, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy and Musculoskeletal Surgery and Interventional Pain Management program(s) in italics below apply to local and ASO Anthem members who have these services medically managed by AIM Specialty Health® (AIM), a separate company administering the program on behalf of Anthem. Providers should continue to verify eligibility and benefits for all members prior to rendering services. For further information, please contact the Provider Service number on the back of the member ID card. For more information go to http://www.aimprovider.com/specialtyrx/FAQ.html to view the FAQs.

New Medical Policy and Clinical Guidelines effective March 15, 2019

• CG-MED-71 Wound Care in the Home Setting: This document addresses wound care in the home setting for a variety of wounds such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy.

• MED.00125 Biofeedback and Neurofeedback: This document addresses biofeedback, a treatment method where an individual is given information, via an electronic monitor, about physiological processes that are normally involuntary, such as blood pressure, muscle tension, heart rate, and other bodily functions.

• MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders: This document addresses the measurement of exhaled nitric oxide and exhaled breath condensate for the diagnosis and monitoring of asthma and other respiratory disorders.

New MCG guideline effective March 15, 2019

Effective March 15, 2019, prior authorization review will be required for myomectomy surgery using MCG guidelines Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy (ORG: W0025 ), and Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy (ORG: W0026). The codes that will require review are 58140, 58145, 58146, 58545, 58546.

Updated Medical Policies and Clinical Guidelines effective March 15, 2019

• CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems: This document addresses diaphragmatic/phrenic (D/P) nerve stimulation and diaphragm pacing systems with devices that have obtained clearance from the U.S. Food and Drug Administration (FDA). o Convert from MED.00100 effective January 1, 2019 o Add C1823 (Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads) as Not Medically Necessary

• CG-SURG-27 Sex Reassignment Surgery: This document addresses sex reassignment surgery (also known as gender reassignment surgery and gender confirmation surgery), which is one treatment option for extreme cases of gender dysphoria, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in their own gender.

• SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting: This document addresses the use of soft tissue (e.g., skin, ligament, cartilage, etc.) substitutes in wound healing and surgical procedures. o Add Surgigraft (Q4183), Cellesta (Q4184), Cellesta flowable amnion (Q4185), Epifix (Q4186), Epicord (Q4187), Amnioarmor (Q4188), Artacent ac (Q4189), Artacent ac (Q4190), Restorigin (Q4191), Restorigin (Q4192), Coll-e-derm (Q4193), Novachor (Q4194), Puraply (Q4195), Puraply am (Q4196), Puraply xt (Q4197), Genesis amniotic membrane (Q4198), Skin te (Q4200), Matrion (Q4201), Keroxx (Q4202), Derma-gide ) Q4203), Xwrap (Q4204) as Investigational & Not Medically Necessary o Add V2790 ocular amniotic membrane Not Medically Necessary o Delete Q4131 and Q4172

• SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions: This document addresses various surgical and minimally invasive procedures used in the treatment of benign prostatic hyperplasia, and the use of these procedures for other genitourinary conditions. o Add 53854 (Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy) as Investigational & Not Medically Necessary; remove 55899

• SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis: This document addresses the use of extraosseous subtalar joint implantation and subtalar arthroereisis. o Add 0510T and 0511T as Investigational & Not Medically Necessary

Medical Policies converted to New Clinical Guidelines effective January 3, 2019

MP Number Title CG Number DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®) CG-THER-RAD-03 MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems CG-MED-79 RAD.00002
Positron Emission Tomography (PET) and PET/CT Fusion CG-MED-80

Medical Policy and Clinical Guidelines being archived and replaced by AIM MSK Clinical Appropriateness Guidelines

Effective January 1, 2019, the following Medical Policy and Clinical Guideline are being archived and replaced by AIM MSK Clinical Appropriateness Guidelines: • SURG.00066 Percutaneous Neurolysis for Chronic Neck and Back Pain • CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy

Updates to AIM Clinical Appropriateness Guidelines

Reviews for the programs below are administered by AIM, a separate company, on behalf of Anthem. These updates apply to local fully-insured and ASO Anthem members, with services managed by AIM. These do not apply to HMO, BlueCard®, Medicaid, Medicare Advantage, Medicare Supplement, Federal Employee Program® (FEP®). Providers should continue to verify eligibility and benefits for all members prior to rendering services. For further information, please contact the Provider Service number on the back of the member ID card.

New prior authorization requirement for Physical Therapy, Occupational Therapy and Speech Therapy Services begins March 15, 2019

Beginning with dates of service on and after March 15, 2019, Anthem will require prior authorization for rehabilitative (restoring function) and habilitative (enhancing function) services. AIM, a separate company, will manage these Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews using Anthem Clinical Guidelines (CG-REHAB-04 Physical Therapy, CG-REHAB-05 Occupational Therapy, CG-REHAB-06 Speech-Language Pathology Services). Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis. A complete list of these CPT codes requiring prior authorization is available on the Anthem Blue Cross website (https://www.anthem.com/wps/portal/ca/culdesac?content_path=provider/f3/s2/t0/pw_a111730.htm&label=By%20

The Rehabilitation ProviderPortalSM Experience Webinar Training Details for Anthem providers

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to www.providerportal.com to register. If you have previously registered for other services managed by AIM, there is no need to register again. View the recorded training at a time convenient for you! Take advantage of this opportunity to learn more about how the AIM ProviderPortal can benefit you!

Dates and times • Option A: Thursday, January 24, 2019 @ 8:00 am PST • Option B: Wednesday, January 30, 2019 @ 12:00 pm PST • Option C: Wednesday, February 6, 2019 @ 12:00 pm PST

Updates to AIM Musculoskeletal Clinical Appropriateness Guidelines

Beginning with dates of review on and after January 1, 2019, the following updates will apply to AIM Musculoskeletal Spine Surgery Clinical Appropriateness Guidelines as indicated by section below:
• Cervical Decompression with or without Fusion o Added criteria for the appropriate use of laminectomy for cordotomy and biopsy, excision, or evacuation o Added indications for non-traumatic atlantoaxial instability • Lumbar Laminectomy o Added criteria for the appropriate use of laminectomy for biopsy, excision, or evacuation o Added indication of Dorsal Rhizotomy

Beginning with dates of review on and after January 1, 2019, the following updates will apply to AIM Musculoskeletal Interventional Pain Management Clinical Appropriateness Guidelines as indicated by section below:
• Paravertebral Facet Injection/Nerve Block/Neurolysis
o Exclusions: Radiofrequency neurolysis for sacroiliac (SI) joint pain is considered not medically necessary

These services or procedures were previously reviewed by Anthem, but will now be reviewed by AIM as part of the Musculoskeletal program.

AIM Radiology Clinical Appropriateness Guidelines • Restructure of AIM guidelines, organized by the following body areas: o Abdomen and Pelvis Imaging o Brain Imaging o Chest Imaging o Extremity Imaging o Head & Neck Imaging o Spine Imaging o Oncologic Imaging − Covers all imaging (CT, MRI, MRS, PET) for staging, management and surveillance of established malignancy − Organized by tumor type with relevant literature summaries in each section − Includes all cancer screening indications (breast, lung, colon)
− Retains existing indications for PET in which tumor is suspected but not confirmed (lymphoma, prostate, paraneoplastic syndrome) o Vascular Imaging − Includes vascular indications from all body areas − Due to overlap between MRI/CT and MRA/CTA for indications like aneurysm, and PE, those indications are included in vascular only, but are referenced in the other documents so that the user knows where they appear. In these cases, the modality section will include non-vascular imaging as well as CTA/MRA o Organized by indication rather than CPT

Ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways: • Access AIM 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: 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT. For questions related to guidelines, please email aim.guidelines@aimspecialtyhealth.com. You may also access and download the current guidelines at http://www.aimspecialtyhealth.com/marketing/guidelines/185/index.html. Anthem’s 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 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’s 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 Anthem’s
web site at http://www.anthem.com/ca, then hover over “Providers” then select “Policies and Guidelines”, scroll down and select “View Medical Policies & UM Guidelines”, select “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,

Jo Ann Nishimoto, MD Medical Director

Attachment A – 6th Meeting 2018 Updates Revised Medical Policies, Clinical Guidelines and MCG Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes ADMIN.00001 Medical Policy Formation • Updated Description/Scope section concerning MPTAC membership to include behavioral health (BH) specialists • Updated text regarding subspecialty committees, including removal of BH subcommittee CG-DME-06 Pneumatic Compression Devices for Lymphedema • Added note to Description section clarifying that gradient compression stockings/sleeves for post breast surgery upper extremity lymphedema are not addressed in this document CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton • Revised title (previous title: Electrical Bone Growth Stimulation) • Revised scope of document to only address noninvasive electrical bone growth stimulation of the appendicular skeleton • Removed information related to invasive and semi-invasive electrical bone growth stimulation for all conditions and noninvasive bone growth stimulation for spinal conditions CG-DRUG-16 White Blood Cell Growth Factors • Added Q5111 for Udencya (pegfilgrastim-cbqv) effective January 1, 2019 CG-DRUG-29 Hyaluronan Injections • Added J7318 for Durolane (hyaluronan derivative), J7329 for TriVisc (hyaluronan derivative) effective January 1, 2019 • Removed C9465 for Durolane effective December 31, 2018 CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot) • Removed abbreviations from Clinical Indication statements CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications • Added J3316 for Triptodur (Triptorelin pamoate extended release) replacing J3490 effective January 1, 2019 CG-DRUG-62 Fulvestrant (FASLODEX®) • Replaced specific brand name drugs (palbociclib and abemaciclib) with the general term of “CDK4/6 inhibitor” in
Medically Necessary criteria CG-DRUG-63 Levoleucovorin Products • Revised title (Previously titled: Levoleucovorin Calcium (Fusilev®) • Revised scope to include all available FDA-approved levoleucovorin agents (Fusilev and Khapzory) • Added NCCN 2A indications to the Medically Necessary clinical indications statements CG-DRUG-64 FDA-Approved Biosimilar Products • Added J3590 for Hyrimoz (adalimumab-adaz) FDA approved October 31, 2018 • Added Q5107 for Mvasi (bevacizumab-awwb), Q5109 for Ifixi (infliximab-qbtx), and Q5111 for Udencya (pegfilgrastim-cbqv effective January 1, 2019 CG-DRUG-65 Tumor Necrosis Factor Antagonists • Revised Medically Necessary statement for use of adalimumab (Humira) for individuals with hidradenitis suppurativa lowering the age from 18 to 12 years of age or older • Added J3590 for Hyrimoz (adalimumab-adaz) FDA approved October 31, 2018 CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo®) • Added the use of Radium Ra 223 in combination with abiraterone acetate plus prednisone/prednisolone as Not
Medically Necessary

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-78 Antihemophilic Factors and Clotting Factors • Added Medically Necessary and Not Medically Necessary
criteria for antihemophilic factor (Factor VIII) damoctocog alfa pegol (Jivi) • Expanded Medically Necessary criteria for emicizumab (Hemlibra) • Expanded Medically Necessary criteria for coagulation Factor X, Human plasma-derived (Coagadex) CG-DRUG-81 Tocilizumab (Actemra®) • Updated Discussion and References sections to include September, 2018 FDA expanded approval of the subcutaneous formulation of tocilizumab in SJIA CG-DRUG-88 Dupilumab (Dupixent®) • Added the treatment of moderate to severe asthma as Medically Necessary when criteria are met • Added Medically Necessary criteria for continuation of therapy CG-DRUG-94 Rituximab (Rituxan®) for Non- Oncologic Indications • Added J9312 replacing J9310 for Rituxan effective January 1, 2019 CG-DRUG-107 Pharmacotherapy for Hereditary Angioedema • Added Takhzyro as Medically Necessary when criteria are met • Updated Not Medically Necessary criteria to include Takhzyro CG-GENE-01 Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays • Revised title (previous title: Janus Kinase 2 (JAK2) V617F Gene Mutation Assay • Added Medically Necessary and Not Medically Necessary
criteria for Janus Kinase 2 exon 12 gene mutation testing
• Removed select abbreviations from Clinical Indications section CG-GENE-03 BRAF Mutation Analysis • Changed “vemurafenib (Zelboraf®)” to “an FDA-approved BRAF inhibitor” in the Medically Necessary statement addressing individuals with non-small cell lung cancer (NSCLC) • Added new indication which reads: “BRAF V600E mutation analysis is considered Medically Necessary in individuals with Erdheim-Chester Disease to identify those who would benefit from treatment with vemurafenib (Zelboraf®)” CG-MED-26 Neonatal Levels of Care • Clarified Medically Necessary criteria for: 1) General Nursery or Well-Baby Nursery; 2) Level I Surveillance Special Care Nursery; 3) Level II Neonatal Intensive Care; and 4) Level III Neonatal Intensive Care CG-MED-65 Manipulation Under Anesthesia • Revised title (previous title: Manipulation Under Anesthesia of the Spine and Joints other than the Knee) • Removed manipulation of shoulder from scope of document • Updated Clinical Indications CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry • Added 33285 (Insertion, subcutaneous cardiac rhythm monitor, including programming) replacing 33282 effective January 1, 2019 • Description revision for 93285 effective January 1, 2019
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) • Clarified description of provider of outpatient skilled rehabilitation services in Clinical Indications section CG-SURG-60 Cervical Total Disc Arthroplasty • Revised clinical indications to note that Secure-C cervical artificial disc is considered Medically Necessary at a single level when criteria are met CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy • Moved content of DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®); added A9513 replacing C9031 effective, January 1, 2019 • Effective January 1, 2019, adding Medically Necessary and Not Medically Necessary criteria for iobenguane I 131 (Azedra), a newly FDA approved radiolabeled norepinephrine analog t t d th (C9408) DME.00037 Cooling Devices and Combined Cooling/Heating Devices • Revised descriptor for E0218 (Fluid circulating cold pad with pump, any type)

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. DRUG.00046 Ipilimumab (Yervoy®) • Added Medically Necessary criteria for ipilimumab as primary treatment when used in combination with nivolumab for unresectable metachronous colorectal cancer metastases when criteria are met • Clarified Medically Necessary criteria for ipilimumab when used in combination with nivolumab as subsequent therapy for unresectable advanced or metastatic colorectal cancer DRUG.00062 Obinutuzumab (Gazyva®) • Reformatted Medically Necessary criteria • Added obinutuzumab as Medically Necessary for the treatment of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) in the first-line of therapy in combination with bendamustine and as a single agent when criteria are met DRUG.00071 Pembrolizumab (Keytruda®) • Added the use of pembrolizumab for the first-line treatment of metastatic squamous NSCLC as Medically Necessary when criteria are met • Added the use of pembrolizumab for the treatment of small cell lung cancer (SCLC) as subsequent therapy as Medically Necessary when criteria are met • Removed "Presence of human immunodeficiency virus (HIV) infection, hepatitis B infection and hepatitis C infection" from Investigational & Not Medically Necessary statement • Added "Treatment used as first-line therapy, except as described in Medically Necessary criteria" to Investigational & Not Medically Necessary statement DRUG.00075 Nivolumab (Opdivo®) • Revised Medically Necessary criteria for nivolumab as primary treatment to include in combination with ipilimumab for unresectable metachronous colorectal cancer metastases when criteria are met • Clarified Medically Necessary criteria for nivolumab when used in combination with ipilimumab as subsequent therapy for unresectable advanced or metastatic colorectal cancer • Removed "Presence of human immunodeficiency virus (HIV) infection, hepatitis B infection and hepatitis C infection" from Investigational & Not Medically Necessary statement DRUG.00090 Bezlotoxumab (ZINPLAVA™) • Clarified Medically Necessary criteria for individuals at high risk of Clostridium difficile infection recurrence DRUG.00099 Cerliponase Alfa (Brineura™) • Added new HCPCS code J0567 replacing C9014 and J3490 effective January 1, 2019 DRUG.00110 Inotuzumab ozogamicin (Besponsa®) • Added new HCPCS code J9229 replacing C9028, J3590 and J9999 effective January 1, 2019 DRUG.00111 Monoclonal Antibodies to Interleukin-23 • Add new HCPCS codes J1628 (Tremfya) and J3245 (Ilumya) replacing C9029, J3490 and J3590 effective January 1, 2019 DRUG.00112 Gemtuzumab Ozogamicin (Mylotarg®) • Add diagnosis codes C92.A0-C92.A2, C93.00-C93.02, C94.00- C94.02, C94.20-C94.22 to pend for medical necessity review DRUG.00116 Vestronidase alfa (Mepsevii™) • Add new HCPCS code J3397 replacing J3490 effective January 1, 2019 DRUG.00118 Copanlisib (Aliqopa®) • Add new HCPCS code J9057 replacing C9030, J3490 and J9999 effective January 1, 2019 GENE.00006 Epidermal Growth Factor Receptor (EGFR) Testing • Simplified Medically Necessary and Investigational & Not
Medically Necessary statements LAB.00029 Rupture of Membranes Testing in Pregnancy • Revise title (previous title: Rupture of Membranes [ROM] Testing in Pregnancy) • Remove acronym from position statement

MED.00109 Corneal Collagen Cross-Linking • Add Medically Necessary statements with clinical criteria • Investigational & Not Medically Necessary statement changed to all “other” indications • Added J2787 for Photrexa (riboflavin 5’-phosphate ophthalmic solution) effective January 1, 2019 SURG.00007 Vagus Nerve Stimulation • Added 95976 replacing 95974, and 95977 replacing 95975 effective January 1, 2019 SURG.00090 Mechanical Embolectomy for Treatment of Acute Stroke • Made minor wording clarification to Medically Necessary statement SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke • Made minor wording clarification to Medically Necessary statement SURG.00111 Axial Lumbar Interbody Fusion • Removed codes 0195T and 0196T effective December 31, 2018 SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) • Added the implantation of Hydrus Microstent as Medically Necessary when criteria are met
• Added Hydrus Microstent to Investigational & Not Medically Necessary statement for all other indications not listed as Medically Necessary
• Added Hydrus Microstent to Investigational & Not Medically Necessary statement for anterior segment aqueous drainage SURG.00120 Internal Rib Fixation Systems • Add the use of an internal rib fixation system as Medically Necessary for the treatment of flail chest resulting in the inability to discontinue mechanical ventilation in the absence of other causes of ventilator dependency such as severe brain injury SURG.00121 Transcatheter Heart Valve Procedures • Revised Medically Necessary statements for Transcatheter aortic valve replacement, removing “end stage renal disease requiring chronic dialysis or creatinine clearance” from list of comorbid conditions or contraindications that would preclude the expected benefit from aortic stenosis correction SURG.00132 Treatment of Varicose Veins (Lower Extremity) • Removed C1874, 0406T and 0407T effective December 31, 2018 • Added C2625 effective January 1, 2019 TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome • Added minimal residual disease (MRD) positivity following induction as a "high risk" factor to acute lymphoblastic leukemia (ALL) Medically Necessary criteria • Revised Medically Necessary statement addressing allogeneic stem cell transplantation for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) to state: "Allogeneic (ablative or non-myeloablative stem cell transplantation is considered Medically Necessary for individuals with CLL or SLL who are refractory to small molecule inhibitor therapy" (removed all other current criteria) W0152 Medication-Assisted Opioid Withdrawal • Removed prior customizations from the Clinical Indications • Reinstated original MCG criteria for medication-assisted treatment for patients with an opioid use disorder W0154 Neonatal Abstinence Syndrome • Added "Note" under both Clinical Indications for Admission to Inpatient Care and Goal Length of Stay (GLOS):
• NOTE: For neonatal levels of care, see CG-MED-26 Neonatal Levels of Care W0155 Ankle Arthroscopy • Removed MCG Clinical Indications for Procedure for ankle arthroscopy due to osteochondral lesions
• Updated note under Clinical Indications for Procedure, Operative Status Criteria, and Goal Length of Stay (GLOS):
• NOTE: For ankle arthroscopy for osteochondral lesions, see Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

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MP/CG Update/Notice - December 2018 Form

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