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Anthem Updates

Anthem National Accounts Pre-Certification List for 2021
On October 1, 2020, Anthem published their national accounts pre-certification list for 2021.  The list contains many procedures requiring pre-certification.  The entire list of pre-certification procedures can be found at the below link.  This is a national list.  The link below is for New Hampshire, but the list is the same for all states since it is a national list.  The diagnostic testing and Radiation Therapy/Radiology Services are key to note.  

Diagnostic Testing:
•    Cardiac Ion Channel Genetic Testing 
•    Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies 
•    Gene Expression Profiling for Managing Breast Cancer Treatment 
•    Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management 
•    Genetic Testing for Breast and/or Ovarian Cancer Syndrome 
•    Preimplantation Genetic Diagnosis Testing 
•    Prostate Saturation Biopsy 
•    Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders 

Radiation Therapy/ Radiology Services:
•    Intensity Modulated Radiation Therapy (IMRT) 
•    MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications 
•    Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications 
•    Proton Beam Therapy 
•    Radiofrequency Ablation to Treat Tumors Outside the Liver 
•    Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) 
•    Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for treating Primary or Metastatic Liver Tumors 
•    Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver- except CNS and Spinal Cord 
•    Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule 

For the full list, please visit: Anthem National Accounts Precertification List for 2021

Anthem Not Allowing 90 Modifier on POS 11 Beginning 1/1/2021
On October 1, 2020 Anthem announced for the professional laboratory and venipuncture reimbursement, beginning with dates of service on or after January 1, 2021, Anthem will update the policy language to indicate modifier 90 will not allow reimbursement when reported in a place of service office (11). Modifier 90 is defined as Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.  

For the full policy and other Anthem reimbursement policies, please follow the below link:
Anthem not allowing 90 modifier on POS 11 beginning 1/1/2021

Anthem Medical Policy Updates for Laboratory and Radiology:
Revised medical policy effective September 1, 2020
The following policy was revised to expand medical necessity indications or criteria.
•    GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling

Reviewed medical policy effective September 1, 2020
The following policy was reviewed and may have coding updates, but had no significant changes to the policy position or criteria.
•    GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies

Coding update effective September 1, 2020
The following policy was updated with new procedure and/or diagnosis codes.
•    GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
 
Coding updates effective October 1, 2020
The following policies were updated with new procedure and/or diagnosis codes.
•    GENE.00037 - Genetic Testing for Macular Degeneration

Reviewed medical policies effective October 7, 2020
The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.
•    GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site 
•    GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
•    GENE.00023 - Gene Expression Profiling of Melanomas
•    GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
•    GENE.00034 - SensiGene® Fetal RhD Genotyping Test
•    GENE.00046 - Prothrombin (Factor II) Mutation Testing
•    GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
•    LAB.00011 - Analysis of Proteomic Patterns
•    LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Patients with Chronic Liver Disease
•    LAB.00028 - Serum Biomarkers for Multiple Sclerosis
•    LAB.00029 - Rupture of Membranes Testing in Pregnancy
•    LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
•    LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
•    RAD.00037 - Whole Body Computed Tomography Scanning                    
•    RAD.00057 - Near-Infrared Coronary Imaging and Near- Infrared Intravascular Ultrasound Coronary Imaging
•    RAD.00061 - PET/MRI
•    RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single

Archived medical policy effective October 7, 2020
The following policy has been archived.
•    RAD.00062 - Intravascular Optical Coherence Tomography (OCT)

Revised medical policies effective January 1, 2021
The following policies listed below were revised and might result in services previously covered, but now being considered either not medically necessary and/or investigational.
•    GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
 
Revised clinical guidelines effective August 20, 2020
The following guidelines were revised to expand medical necessity indications or criteria.
•    CG-GENE-03 - BRAF Mutation Analysis

Coding updates effective October 1, 2020
The following guidelines were updated with new procedure and/or diagnosis codes.
•    CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

For the full list of Anthem Medical Policy Updates, please follow the below link.
Click link and learn more

Anthem Medicare Prior Authorization Required Effective 12/1/2020
Effective December 1, 2020 Anthem Medicare prior authorization requirements will change for the below codes.

Prior authorization requirements will be added for the following codes:

•    36514 - Therapeutic apheresis; plasma pheresis 
•    36522 - Photopheresis, extracorporeal 

For the full list of Anthem prior authorization changes, please follow the below link.
Anthem Medicare Prior Authorization required effective 12/1/2020

As always, APS will continue to monitor upcoming changes to all of the carrier requirements for submission to maximize our client’s revenue.  

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