ModifiedAnthemPolicy N/A

Anthem_Medicare_Part_B_Preferred_Device_Update

Notifies that, effective for dates of service on and after 2020-01-17, specified Medicare Part B injectable/visco-supplement devices will be included in Anthem's preferred device precertification review process; describes criteria for approval of nonpreferred Part B devices and references the Clinical UM Guideline.

Policy Summary

PayerAnthem

PolicyAnthem_Medicare_Part_B_Preferred_Device_Update

Policy CodePolicy N/A

Change TypeAdded preferred Part B devices; referenced nonpreferred list

Effective DateJan 17, 2020

Next Review Date

Key ActionPreferred device review will apply upon precertification initiation for the listed Medicare Part B devices effective for dates of service on and after 2020-01-17; noncompliance with new requirements may result in denied claims.

SourceLink

POLICY UPDATE CHANGES

Supartz FX, Durolane, Euflexxa, and Gelsyn-3 included in preferred device precertification review process for Medicare Part B devices.

Reference to nonpreferred Part B device list code ING-CC-0005.

4Named preferred devices added

Summary of change

Notifies that, effective for dates of service on and after January 17, 2020, specified Medicare Part B injectable/viscosupplement devices will be included in Anthem's preferred device precertification review process. This change is a material modification to prior precertification handling and adds preferred device review in addition to the current medical necessity review.

Describes criteria for approval of nonpreferred Part B devices: approval may be granted when a member is actively receiving listed agents, has had a trial and inadequate response or intolerance to one preferred agent, or preferred agents are unacceptable due to contraindications including hypersensitivity/allergy. References the Clinical Utilization Management (UM) Guideline as the source for medical necessity review.

Key facts

Effective dateEffective for dates of service on and after January 17, 2020

Last review2019-12-01

Change type / statusModified – added Medicare Part B preferred devices; material change

Scope summarySpecifies that Supartz FX, Durolane, Euflexxa, and Gelsyn-3 will be included in Anthem's preferred device precertification review for Medicare Part B; describes criteria and documentation for approval of nonpreferred Part B devices and references the Clinical UM Guideline; federal/state law and CMS guidelines take precedence.

Precertification & approval criteria

Preferred device precertification and nonpreferred device approval

Preferred device review applies upon precertification initiation; nonpreferred devices may be approved when:

ANY of the following

Member is actively receiving agents listed below
Member has had a trial and inadequate response or intolerance to one preferred agent
Preferred agents are not acceptable due to contraindications including hypersensitivity/allergy

What providers must do

Prior Authorization

Precertification required for Medicare Part B devices

Preferred device review will apply upon precertification initiation for the listed Medicare Part B devices effective for dates of service on and after 2020-01-17; noncompliance with new requirements may result in denied claims.

Effective for dates of service on and after 2020-01-17
Noncompliance may result in denied claims

Documentation Required

Documentation for nonpreferred device approval

When requesting a nonpreferred Part B device, document active use of listed agents or trial and inadequate response/intolerance to one preferred agent, or contraindication/hypersensitivity to preferred agents.

Document active use of listed agents
Document trial and inadequate response or intolerance to one preferred agent
Document contraindication or hypersensitivity/allergy to preferred agents

Guidance & precedence

Anthem updated its Medicare Part B preferred device precertification process to include certain specialty viscosupplement and injectable devices; preferred device review will apply upon precertification initiation.

The Clinical UM Guideline remains the source for medical necessity review and is publicly available on Anthem's Clinical Criteria page.

Federal and state law, state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage.

Policy update changes

2020-01-17addedLatest

Supartz FX included in preferred device precertification review process for Medicare Part B devices.

2020-01-17addedLatest

Durolane included in preferred device precertification review process for Medicare Part B devices.

2020-01-17addedLatest

Euflexxa included in preferred device precertification review process for Medicare Part B devices.

2020-01-17addedLatest

Gelsyn-3 included in preferred device precertification review process for Medicare Part B devices.

2020-01-17addedLatest

Reference to nonpreferred Part B device list code ING-CC-0005.

Policy Summary

PayerAnthem

PolicyAnthem_Medicare_Part_B_Preferred_Device_Update

Policy CodePolicy N/A

Change TypeAdded preferred Part B devices; referenced nonpreferred list

Effective DateJan 17, 2020

Next Review Date

SourceLink

On This Page

OpenPayer

Anthem_Medicare_Part_B_Preferred_Device_Update

Summary of change

Affected devices and reference codes

Precertification & approval criteria

What providers must do

Guidance & precedence

Policy update changes

Supartz FX	Preferred Part B device (viscosupplement)
Durolane	Preferred Part B device (viscosupplement)
Euflexxa	Preferred Part B device (viscosupplement)
Gelsyn-3	Preferred Part B device (viscosupplement)