Indiana Medicaid Medical Policy Updates


December 2017 ~

In an update to a previously announced change on May 4th, the Medical Policy and Technology Assessment Committee (MPTAC) enacted final approval for the following Medical Policies applicable to Anthem.

Anthem notes that Existing precertification requirements have not changed. The following policies were developed or revised to support clinical coding edits:

New Medical Policies

  • 00099 Cerliponase Alfa (Brineura™) Effective May 18th
  • 00107 Avelumab (Bavencio®) Effective May 18th
  • 00109 Durvalumab (IMFINZI™) Effective May 18th
  • 00121 Implantable Interstitial Glucose Sensors Effective June 28th
  • 00122 Wilderness Programs Effective June 28th
  • 00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy Effective June 28th
  • 00149 Percutaneous Ultrasonic Ablation of Soft Tissue Effective June 28th
  • 00150 Leadless Pacemakers Effective June 28th

Revised Medical Policies

  • 00040 Automated Insulin Delivery Devices Effective May 18th
  • 00002 Tumor Necrosis Factor Antagonists Effective May 18th
  • 00038 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications Effective May 18th
  • 00041 Rituximab (Rituxan®) for Non-Oncologic Indications Effective May 18th
  • 00047 Brentuximab Vedotin (Adcetris®) Effective May 18th
  • 00062 Obinutuzumab (Gazyva®) Effective May 18th
  • 00066 Antihemophilic Factors and Clotting Factors Effective May 18th
  • 00071 Pembrolizumab (Keytruda®) Effective May 18th
  • 00075 Nivolumab (Opdivo®) Effective May 18th
  • 00083 Elotuzumab (Empliciti™) Effective May 18th
  • 00088 Atezolizumab (Tecentriq®) Effective May 18th
  • 00104 Nusinersen (SPINRAZA™) Effective May 18th
  • 00032 Molecular Marker Evaluation of Thyroid Nodules Effective May 18th
  • 00035 Genetic Testing for TP53 Mutations Effective May 18th
  • 00121 Transcatheter Heart Valves Effective June 28th
  • THER-RAD. 00004 External Beam Intraoperative Radiation Therapy Effective May 18th
  • 00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome Effective May 18th



Source(s): Anthem Blue Cross and Blue Shield Network Update;