Anthem – Medical Policy and Clinical UM Guidelines (MAC)
April 5, 2022The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below. New Medical Policies effective for service dates on and after July 1, 2022:
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LAB.00043 Immune Biomarker Tests for Cancer: This document addresses immune response algorithmic tests for oncologic disease management. At least one test, Immunoscore® (Veracyte Inc.), which has been investigated for management of colon cancer, is commercially available. The test, which is performed on tissue samples, assesses immune response at the tumor site. o Considered investigational and not medically necessary for all indications. o Prior authorization required effective July 1, 2022.
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LAB.00044 Saliva-based Testing to Determine Drug-Metabolizer Status: This document addresses the use of saliva-based testing to determine drug-metabolizer status. o Considered investigational and not medically necessary for all indications. o Prior authorization required effective July 1, 2022.
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LAB00045 Selected Tests for the Evaluation and Management of Infertility: This document addresses selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment. o The following tests or procedures are considered investigational and not medically necessary for diagnosing or managing infertility: ▪ Endometrial receptivity analysis; ▪ Sperm-capacitation test; ▪ Sperm deoxyribonucleic acid (DNA) fragmentation test; ▪ Sperm penetration assay; and ▪ Uterine natural killer (uNK) cells test. o Prior authorization required effective July 1, 2022.
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RAD.00067 Quantitative Ultrasound for Tissue Characterization: This document addresses quantitative ultrasound to evaluate visceral organs and other anatomic structures by using imaging data and software to analyze tissue characteristics. This technology is being explored as a noninvasive means to identify tissue traits without performing biopsies or using contrast agents. o Considered investigational and not medically necessary for all indications. o Prior authorization required effective July 1, 2022.
Source: https://providernews.anthem.com/colorado/article/medical-policy-and-clinical-um-guidelines-mac