ModifiedAnthemPolicy N/A

MCG Care Guidelines 25th Edition Update

Announces Anthem Blue Cross and Blue Shield upgrade to MCG Care Guidelines 25th Edition effective September 1, 2021 for multiple modules (inpatient & surgical care, general recovery care, chronic care, recovery facility care, behavioral health). Highlights changes to goal length of stay (GLOS) for numerous procedures, new behavioral health/recovery facility guidelines, and Anthem-specific customizations (notably Transcranial Magnetic Stimulation/TMS).

Policy Summary

PayerAnthem

PolicyMCG Care Guidelines 25th Edition Update

Policy CodePolicy N/A

Change TypeGuideline update & Anthem customizations

Effective DateSep 1, 2021

Next Review Date

Key ActionProviders should apply the updated MCG 25th Edition goal length of stay recommendations for utilization management and discharge planning, as these may be more restrictive for certain procedures.

SourceLink

POLICY UPDATE CHANGES

Anthem upgraded to MCG Care Guidelines 25th edition effective September 1, 2021 for ISC, GRC, CC, RFC, and BHC modules.

Multiple procedures have updated Goal Length of Stay (GLOS) in the 25th edition compared to 24th edition (examples provided).

New behavioral health and recovery facility care guidelines added (e.g., Withdrawal Management codes B-031-* and several medical condition guidelines).

Anthem customization for Transcranial Magnetic Stimulation (W0174) specifying covered indications and duration limits.

MultipleGLOS updates (procedures affected)

1Major Anthem customization (TMS)

10+New BHC/RFC guideline codes added

What is changing

Anthem Blue Cross and Blue Shield is adopting the independent MCG Health 25th Edition care guidelines effective September 1, 2021 for multiple modules: inpatient & surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC).

Key high-level changes include updated Goal Length Of Stay (GLOS) recommendations for numerous inpatient and surgical procedures (some shifts are more restrictive), the addition of new behavioral health and recovery facility care guidelines (including Withdrawal Management codes), and Anthem-specific customizations — most notably a customized policy for Transcranial Magnetic Stimulation (TMS, W0174) that defines covered indications and duration limits.

Thresholds & key stats

TMS — acute treatment durationup to six weeks

TMS — continuation of acute treatmentup to six months

GLOS updates (procedures affected)Multiple

Major Anthem customization (TMS)1

New BHC/RFC guideline codes added10+

Document-level changes

2021-09-01added

Anthem upgraded to MCG Care Guidelines 25th edition effective September 1, 2021 for ISC, GRC, CC, RFC, and BHC modules. (material change)

2021-09-01revised

Multiple procedures have updated Goal Length of Stay (GLOS) in the 25th edition compared to 24th edition (examples provided) — some GLOS changes may be more restrictive (e.g., shifts from inpatient postoperative day to Ambulatory). (material change)

2021-09-01added

New behavioral health and recovery facility care guidelines added, including Withdrawal Management codes (B-031-IP, B-031-IOP, B-031-AOP, B-031-PHP, B-031-RES) and additional medical condition guidelines (examples: M-5197, M-7087, M-7095, M-7100, M-5545). (material change)

Goal Length of Stay (GLOS) updates — examples

GLOS Changes Summary (Inpatient & Surgical Care)

Selected examples where 25th Edition GLOS differs from 24th Edition:

Aortic Coarctation, Angioplasty (MCG S-152): 24th = Ambulatory or postoperative day; 25th = Ambulatory

Cardiac Septal Defect: Atrial, Transcatheter Closure (MCG W0016): 24th = Ambulatory or postoperative day; 25th = Ambulatory

Esophageal Diverticulectomy, Endoscopic (MCG S-445): 24th = Ambulatory or postoperative day; 25th = Ambulatory

Gastrectomy, Partial Billroth I or II (MCG S-510): 24th = 4 or 6 postoperative days; 25th = 5 postoperative days

Hernia Repair (Non-Hiatal) (MCG S-1305): 24th = Ambulatory or postoperative day; 25th = Ambulatory

Behavioral health & recovery facility guideline additions

New Guidelines (Behavioral Health Care and Recovery Facility Care)

New MCG guideline codes added in 25th edition:

Withdrawal Management, Adult: Inpatient Care (B-031-IP)

Withdrawal Management, Adult: Intensive Outpatient Program (B-031-IOP)

Withdrawal Management, Adult: Outpatient Care (B-031-AOP)

Withdrawal Management, Adult: Partial Hospital Program (B-031-PHP)

Withdrawal Management, Adult: Residential Care (B-031-RES)

Transcranial Magnetic Stimulation (TMS) — Anthem customization

TMS (Transcranial Magnetic Stimulation) Coverage Customization

Anthem customization to MCG 25th edition for TMS (W0174):

ALL of the following

Acute treatment course indication (any of):
- Initial course of treatment for major depressive disorder (severe)
- Relapse of symptoms after remission
Need for acute TMS treatment; up to six weeks
Continuation of acute treatment; up to six months

Action required for providers

Documentation Required

Follow MCG GLOS expectations

Providers should apply the updated MCG 25th Edition goal length of stay recommendations for utilization management and discharge planning, as these may be more restrictive for certain procedures.

Effective 2021-09-01
Affected modules: ISC, GRC, CC, RFC, BHC

Prior Authorization

TMS authorization and indication limits

Authorize TMS (W0174) only for acute treatment (up to six weeks) and continuation up to six months when indicated for severe major depressive disorder or relapse after remission; maintenance TMS and other indications are considered not medically necessary.

Affected code: W0174

Definitions

GLOS: MCG-recommended expected length of stay for procedures/conditions used in utilization management and discharge planning.

TMS: Transcranial Magnetic Stimulation; Anthem customized coverage in the 25th edition specifies acute treatment up to six weeks, continuation of acute treatment up to six months, and limits indications to severe major depressive disorder or relapse after remission (all other indications and maintenance treatment are considered not medically necessary).

Revision & review dates

Document dates, status & scope

Effective Date2021-09-01

Last Review2021-04-01

Next Review

Policy statusMODIFIED

ScopeAnnounces Anthem upgrade to MCG Care Guidelines 25th Edition for multiple modules; highlights GLOS changes, new behavioral health/recovery facility guidelines, and Anthem customizations (notably TMS).

Policy Summary

PayerAnthem

PolicyMCG Care Guidelines 25th Edition Update

Policy CodePolicy N/A

Change TypeGuideline update & Anthem customizations

Effective DateSep 1, 2021

Next Review Date

SourceLink

On This Page

2021-09-01revisedLatest

Anthem customization for Transcranial Magnetic Stimulation (W0174) specifying covered indications and duration limits: authorize acute TMS up to six weeks and continuation up to six months for severe major depressive disorder or relapse; maintenance TMS and other indications are not medically necessary. (material change)

Pancreatectomy (MCG S-1200): 24th = 5 or postoperative days; 25th = postoperative days

Pyloroplasty and Vagotomy (MCG S-990): 24th = 4 or 6 postoperative days; 25th = postoperative days

Cervical Laminectomy: 24th = 2 postoperative days; 25th = Ambulatory or 2 postoperative days

Lumbar Diskectomy/Foraminotomy/Laminotomy: 24th = Ambulatory or postoperative day; 25th = Ambulatory

Removal of Posterior Spinal Instrumentation (MCG S-530): 24th = 1 postoperative day; 25th = Ambulatory or postoperative day

Shoulder Hemiarthroplasty (MCG W0138): 24th = postoperative day; 25th = Ambulatory or postoperative day

Spine, Scoliosis, Posterior Instrumentation, Pediatric (MCG W0156): 24th = 4 postoperative days; 25th = 3 postoperative days

Bladder Resection: Cystectomy with Urinary Diversion (MCG S-190): 24th = 5 or 6 postoperative days; 25th = 5 postoperative days

Prostatectomy, Transurethral Resection (TURP) (MCG S-970): 24th = Ambulatory or postoperative day; 25th = Ambulatory

Urethroplasty (MCG S-1172): 24th = Ambulatory or postoperative day; 25th = Ambulatory

MCG guideline codes referenced (examples)mixed

S-152	Aortic Coarctation, Angioplasty
W0016	Cardiac Septal Defect: Atrial, Transcatheter Closure
S-445	Esophageal Diverticulectomy, Endoscopic
S-510	Gastrectomy, Partial Billroth I or II
S-1305	Hernia Repair (Non-Hiatal)
S-1200	Pancreatectomy
S-990	Pyloroplasty and Vagotomy
S-530	Removal of Posterior Spinal Instrumentation
W0138	Shoulder Hemiarthroplasty
W0156	Spine, Scoliosis, Posterior Instrumentation, Pediatric

1–10 of 24

1/3

Cardiology: Hypertension (M-5197)

Cardiology: Peripheral Vascular Disease (M-7087)

Nephrology: Rhabdomyolysis (M-7095)

Nephrology: Encephalopathy (M-7100)

Thoracic Surgery: Rib Fracture (M-5545)

Scope note: The 25th edition adds new Withdrawal Management guideline codes for behavioral health and recovery facility care (e.g., B-031-IP, B-031-IOP, B-031-AOP, B-031-PHP, B-031-RES) and other new BHC/RFC modules; these are new guideline additions in the 25th edition.

These new behavioral health and recovery facility guidelines are part of the Anthem upgrade to MCG 25th Edition and are in-scope for utilization management under the listed modules.

Need for acute TMS treatment; up to six weeksup to six weeks

Continuation of acute treatment; up to six monthsup to six months

TMS Not Medically Necessary (Exclusions)

TMS is considered not medically necessary for all other indications not listed above, including but not limited to:

Maintenance TMS treatment

Continuation of acute TMS treatment for longer than six months

TMS treatment of conditions other than major depressive disorder (severe), including but not limited to: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome

Thresholds: acute treatment up to six weeks; continuation of acute treatment up to six months

Maintenance and other indications are not medically necessary

Documentation Required

Questions / provider contact

For questions, contact provider services at the number on the back of the member's ID card.

Contact provider services at number on back of member ID card.