State: Virginia. Clinical Guidelines Applicable for Virginia

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1 State: Virginia Clinical Guidelines Applicable for Virginia NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete a ASO group-specific review requirement will be considered Adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider s claims when a provider s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are Adopted for those purposes. Virginia Implementation Dates for Clinical Guidelines Posted on this Site As of 7/01/2018, Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc. (Anthem-Virginia) will implement the following Clinical Guidelines currently posted on this web site on the dates indicated below. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Medicare-Medicaid Plan (Dual Integration product). VA CG-DRUG-51 Romidepsin (Istodax ) 11/1/2018 VA CG-DRUG-89 Implantable and Extended-Release Buprenorphine- 9/1/2018 Containing Products VA CG-MED-26 Neonatal Levels of Care 9/1/2018 VA CG-SURG-36 Adenoidectomy 11/1/2018 THIRD PARTY CRITERIA ADOPTED: The health plan may use guidelines developed by third parties to perform utilization management services of some procedures for certain health plan members. Effective 04/01/2011, Anthem-Virginia retired its Clinical Guidelines for advanced imaging services. In lieu of these guidelines, Anthem-Virginia began utilizing Diagnostic Imaging Utilization Management Program Guidelines developed by and proprietary to AIM Specialty HealthSM (AIM.) Effective 07/01/2018, Anthem-Virginia uses: AIM Radiation Oncology Clinical Appropriateness Guidelines: Radiation Oncology includes brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS) developed by AIM Specialty Health (AIM). These guidelines are available at: By clicking on the link above, you will be linked to sites created and/or maintained by another, separate entity ( External Site ). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. State CG number CG title Date adopted by - VA Date - Current Version Implementation Special Notes VA CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for 8/18/2016 3/29/2018 Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists VA CG-ANC-04 Ambulance Services: Air and Water 4/21/2010 2/28/2018 VA CG-ANC-06 Ambulance Services: Ground; Non-Emergent 11/1/2014 8/17/2017 VA CG-BEH-02 Applied Behavioral Analysis for Autism Spectrum 4/1/2014 4/25/2018 Disorder VA CG-BEH-03 Psychiatric Disorder Treatment 10/8/2013 4/25/2018 VA CG-BEH-04 Substance-Related and Addictive Disorder 10/8/2013 3/29/2018 Treatment VA CG-BEH-05 Eating and Feeding Disorder Treatment 10/8/2013 2/28/2018 VA CG-BEH-14 Intensive In-Home Behavioral Health Services 1/1/2017 9/27/2017 VA CG-DME-01 External (Portable) Continuous Insulin Infusion Pump 7/15/2009 6/28/2017 Recategorized to CG-DME-42 4/30/18 VA CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) 10/21/2009 9/27/2017 VA CG-DME-10 Durable Medical Equipment 4/22/2009 3/29/2018 VA CG-DME-30 Prothrombin Time Self-Monitoring Devices 7/1/2015 4/5/2016 Va. archived 2/17/2017 VA CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized with or without Power Seating Systems and Power Operated Vehicles (POVs) 7/15/2009 3/15/2018 Revised: March 15, 2016 (SKJ) Page 1 of 5

2 VA CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs- 10/1/2010 3/29/2018 Ultra Lightweight VA CG-DME-36 Pediatric Gait Trainers 1/1/ /4/2016 Va. archived 8/1/2017 VA CG-DME-40 Electrical Bone Growth Stimulation 12/27/ /27/2017 VA CG-DME-43 Oscillatory Devices for Airway Clearance (High Frequency Chest Compression) 5/1/2018 5/1/2018 Contents previously addressed in DME VA CG-DME-44 Electric Tumor Treatment Field (TTF) 6/28/2018 6/28/2018 Previously DME VA CG-DRUG-01 Off-label Drug and Approved Orphan Drug Use 1/14/2009 3/29/2018 VA CG-DRUG-03 Beta Interferons and Glatiramer Acetate for 5/1/ /27/2017 Treatment of Multiple Sclerosis VA CG-DRUG-05 Recombinant Erythropoietin Products 7/15/2009 6/6/2018 VA CG-DRUG-08 Enzyme Replacement Therapy for Gaucher 7/15/2009 6/6/2018 Disease VA CG-DRUG-09 Immune Globulin (Ig) Therapy 10/1/2010 6/6/2018 VA CG-DRUG-11 Infertility Drugs 12/1/2009 9/27/2017 VA CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy 10/21/2009 9/27/2017 Archived 4/25/18 VA CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for 7/1/2015 4/5/2016 Va. archived 2/17/2017 the Treatment of Migraine or Cluster Headaches in Adults VA CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) 7/15/2009 6/28/2016 Archived 12/28/2016 Analogs VA CG-DRUG-16 White Blood Cell Growth Factors 11/1/2015 6/28/2018 VA CG-DRUG-20 Enfuvirtide (Fuzeon ) 4/7/2015 3/29/2017 Va. archived 2/21/2018 VA CG-DRUG-21 Naltrexane (Vivitrol ) Injections for the Treatment 7/1/2015 9/27/2017 Va. archived 11/17/2017 of Alcohol and Opiod Dependence VA CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar Gel) 7/15/2009 9/27/2017 VA CG-DRUG-25 IV vs. Oral Drug Administration in the Outpatient 7/15/2009 6/28/2016 Va. archived 5/12/2017 and Home Setting VA CG-DRUG-27 Clostridial Collagenase Histolyticum Injection 10/13/2010 4/25/2018 VA CG-DRUG-28 Alglucosidase alfa (Lumizyme ) 1/1/2011 2/28/2018 VA CG-DRUG-29 Hyaluronan Injections in the Knee 12/1/2017 5/1/2018 VA CG-DRUG-34 Docetaxel (Docefrez,Taxotere ) 7/7/2015 6/28/2016 Va. archived 2/17/2017 VA CG-DRUG-38 Pemetrexed (Alimta ) 5/1/ /27/2017 VA CG-DRUG-41 Zoledronic acid 7/7/2015 6/28/2016 Va. archived 2/17/2017 VA CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase) 4/1/ /27/2017 VA CG-DRUG-43 Natalizumab (Tysabri ) 7/1/2015 3/29/2018 VA CG-DRUG-44 Pegloticase (Krystexxa ) 7/1/2015 3/29/2018 VA CG-DRUG-45 Octreotide acetate (Sandostatin ; Sandostatin 11/1/ /27/2017 LAR Depot VA CG-DRUG-47 Level of Care: Specialty Pharmaceuticals 11/1/2015 9/27/2017 VA CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection 1/1/2017 6/6/2018 VA CG-DRUG-50 Paclitaxel, protein-bound (Abraxane ) 1/1/2017 5/10/2018 VA CG-DRUG-51 Romidepsin (Istodax ) 1/1/2017 1/1/2017 Va. archived 5/12/2017 VA CG-DRUG-53 Drug Dosage, Frequency, and Route of 9/1/2017 6/6/2018 Administration VA CG-DRUG-54 Agalsidase beta (Fabrazyme ) 5/1/2017 2/28/2018 VA CG-DRUG-55 Elosulfase alfa (Vimizim ) 5/1/ /27/2017 VA CG-DRUG-56 Galsulfase (Naglazyme ) 5/1/2017 9/27/2017 VA CG-DRUG-57 Idursulfase (Elaprase ) 5/1/2017 4/25/2018 VA CG-DRUG-58 Laronidase (Aldurazyme 5/1/ /27/2017 VA CG-DRUG-61 Gonadotropin Releasing Hormone (GnRH) 12/28/ /27/2017 Analogs for the Treatment of Non-Oncologic VA CG-DRUG-62 Fulvestrant (FASLODEX ) 5/1/2017 6/6/2018 VA CG-DRUG-63 Levoleucovorin calcium (Fusilev ) 5/1/ /27/2017 VA CG-DRUG-64 FDA-Approved Biosimilar Products 11/17/2016 6/28/2018 VA CG-DRUG-65 Tumor Necrosis Factor Antagonists 12/27/2017 6/28/2018 Previously DRUG VA CG-DRUG-66 Panitumumab (Vectibix ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-67 Cetuximab (Erbitux ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-68 Bevacizumab (Avastin ) for Non-Ophthalmologic 12/27/ /27/2017 Previously DRUG VA CG-DRUG-69 Ustekinumab (Stelara ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-70 Eribulin mesylate (Halaven ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-71 Ziv-aflibercept (Zaltrap ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-72 Pertuzumab (Perjeta ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-73 Denosumab (Prolia, Xgeva ) 12/27/2017 6/6/2018 Previously DRUG Revised: March 15, 2016 (SKJ) Page 2 of 5

3 VA CG-DRUG-74 Canakinumab (Ilaris) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-75 Romiplostim (Nplate ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-76 Plerixafor Injection (Mozobil ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo ) 7/1/2018 7/1/2018 VA CG-DRUG-78 Antihemophilic Factor and Clotting Factors 5/1/2018 7/1/2018 Previously DRUG VA CG-DRUG-79 Siltuximab (Sylvant ) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-80 Cabazitaxel (Jevtana) 12/27/ /27/2017 Previously DRUG VA CG-DRUG-81 Tocilizumab y (Actemra ) y 12/27/ /27/2017 Previously DRUG VA CG-DRUG-82 Therapy for Treatment of Pulmonary Arterial 5/1/2018 5/1/2018 Previously DRUG Hypertension VA CG-DRUG-83 Growth Hormone 5/1/2018 5/1/2018 Previously DRUG VA CG-DRUG-84 Belimumab (Benlysta ) 5/1/2018 5/1/2018 Previously DRUG VA CG-DRUG-85 Tesamorelin (Egrifta ) 5/1/2018 5/1/2018 Previously DRUG VA CG-DRUG-86 Ocriplasmin (Jetrea ) Intravitreal Injection 5/1/2018 5/1/2018 Previously DRUG Treatment VA CG-DRUG-87 Vedolizumab (Entyvio ) 5/1/2018 5/1/2018 Previously DRUG VA CG-DRUG-88 Dupilumab (Dupixent ) 5/1/2018 5/1/2018 Previously DRUG VA CG-DRUG-90 Intravitreal Treatment for Retinal Vascular 6/28/2018 6/28/2018 Previously DRUG Conditions VA CG-DRUG-91 Intravitreal Corticosteroid Implants 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-92 Alpha-1 Proteinase Inhibitor Therapy 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-93 Sarilumab (Kevzara ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-94 Rituximab (Rituxan ) for Non-Oncologic 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-95 Belatacept (Nulojix ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-97 Rilonacept (Arcalyst ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-98 Bendamustine Hydrochloride 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-99 Elotuzumab (Empliciti ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-100 Interferon gamma-1b (Actimmune ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-101 Ixabepilone (Ixempra ) 6/28/2018 6/28/2018 Previously DRUG VA CG-DRUG-102 Olaratumab (Lartruvo ) 6/28/2018 6/28/2018 Previously DRUG VA CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation 12/27/ /27/2017 Previously GENE Assay VA CG-GENE-02 Analysis of KRAS Status 12/27/ /27/2017 Previously GENE VA CG-GENE-03 BRAF Mutation Analysis 12/27/ /27/2017 Previously GENE VA CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules 12/27/ /27/2017 Previously GENE VA CG-LAB-13 Skin Nerve Fiber Density Testing 6/28/2018 6/28/2018 Previously LAB VA CG-MED-05 Ketogenic Diet for Treatment of Intractable 10/21/2009 9/27/2017 Seizures VA CG-MED-19 Custodial Care 4/22/2009 3/29/2018 VA CG-MED-23 Home Health 1/1/2018 3/29/2018 VA CG-MED-28 Iontophoresis for Medical 7/1/2015 4/5/2016 Va. archived 2/17/2017 VA CG-MED-31 Skilled Nursing Facility Services 10/21/2009 6/28/2017 Va. archived 1/1/2018 VA CG-MED-32 Ancillary Services for Pregnancy Complications 4/22/2009 4/5/2016 Va. archived 2/17/2017 VA CG-MED-38 Inpatient Admission for Radiation Therapy for 4/22/2009 4/5/2016 Va. archived 2/17/2017 Cervical or Thyroid Cancer VA CG-MED-40 External Ambulatory Event Monitors to Detect 12/1/2012 9/27/2017 Cardiac Arrhythmias VA CG-MED-46 Ambulatory Electroencephalography 12/1/2013 5/1/2018 VA CG-MED-55 Level of Care: Advanced Radiologic Imaging 3/1/2018 4/25/2018 VA CG-MED-58 9/15/2017 9/15/2017 Previously RAD Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI VA CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation) 12/27/ /27/2017 Previously MED VA CG-MED-67 Melanoma Vaccines 12/27/ /27/2017 Previously MED VA CG-MED-68 Therapeutic Apheresis 12/27/2017 4/25/2018 Previously MED VA CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule 6/28/2018 6/28/2018 Previously RAD VA CG-MED-72 Hyperthermia for Cancer Therapy 6/28/2018 6/28/2018 Previously MED VA CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices 9/1/2011 3/29/2018 VA CG-REHAB-08 Private Duty Nursing in the Home Setting 4/22/2009 9/27/2017 Revised: March 15, 2016 (SKJ) Page 3 of 5

4 VA CG-REHAB-09 Acute Inpatient Rehabilitation 10/21/ /4/2016 Va. archived 1/1/18 VA CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow 7/15/2009 3/29/2018 Lift VA CG-SURG-05 Maze Procedure 10/21/2009 9/27/2017 VA CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib 10/21/ /4/2016 Va. archived 8/1/2017 (VEPTR) VA CG-SURG-08 Sacral Nerve Stimulation as a Treatment of 9/1/2011 9/27/2017 Neurogenic Bladder Secondary to Spinal Cord Injury VA CG-SURG-09 Temporomandibular Disorders 1/14/2009 4/25/2018 VA CG-SURG-12 Penile Prosthesis Implantation 9/1/2011 9/27/2017 VA CG-SURG-18 Septoplasty 3/1/2012 6/6/2018 VA CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) 11/1/2010 9/27/2017 VA CG-SURG-27 Sex Reassignment Surgery 1/1/2010 4/25/2018 VA CG-SURG-28 Transcatheter Uterine Artery Embolization 3/1/ /27/2017 VA CG-SURG-30 Tonsillectomy with or without Adenoidectomy for 8/1/2012 6/28/2017 Va. archived 5/8/18 Children VA CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral 5/13/2013 2/28/2018 Disc (LAID) VA CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, 1/1/ /27/2017 Laminotomy and/or Discectomy VA CG-SURG-42 Cervical Fusion 5/1/ /27/2017 VA CG-SURG-43 Knee Arthroscopy 5/1/ /27/2017 VA CG-SURG-47 Surgical Interventions for Scoliosis and Spinal 11/1/ /27/2017 Deformity VA CG-SURG-49 Endovascular Techniques (Percutaneous or Open 5/1/2016 4/25/2018 Exposure) for Arterial Revascularization of the Lower Extremities VA CG-SURG-53 Elective Total Hip Arthroplasty 9/1/ /27/2017 VA CG-SURG-54 Elective Total Knee Arthroplasty 9/1/ /27/2017 VA CG-SURG-59 Vena Cava Filters 7/1/2018 7/1/2018 VA CG-SURG-60 Cervical Total Disc Arthroplasty 9/15/2017 3/29/2018 Previously SURG VA CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the 12/27/ /27/2017 Previously SURG Liver VA CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside 12/27/ /27/2017 Previously SURG the Liver VA CG-SURG-63 12/27/ /27/2017 Previously SURG Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure VA CG-SURG-65 12/27/ /27/2017 Previously SURG Recombinant Human Bone Morphogenetic Protein VA CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal 12/27/ /27/2017 Previously SURG Cord Stimulators (SCS) VA CG-SURG-67 Treatment of Osteochondral Defects 12/27/ /27/2017 Previously SURG VA CG-SURG-68 Surgical Treatment of Femoroacetabular 12/27/ /27/2017 Previously SURG Impingement Syndrome VA CG-SURG-69 Meniscal Allograft Transplantation of the Knee 12/27/ /27/2017 Previously TRANS VA CG-SURG-70 Gastric Electrical Stimulation 5/1/2018 5/1/2018 Previously SURG VA CG-SURG-71 Reduction Mammoplasty 5/1/2018 5/1/2018 Previously SURG VA CG-SURG-72 Endothelial Keratoplasty 5/1/2018 5/1/2018 Previously SURG VA CG-SURG-74 Total Ankle Replacement 6/28/2018 6/28/2018 Previously SURG VA CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) 6/28/2018 6/28/2018 Previously SURG Excision of Rectal Lesions VA CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent 6/28/2018 6/28/2018 Previously SURG Placement with or without Angioplasty VA CG-SURG-77 Refractive Surgery 6/28/2018 6/28/2018 Previously SURG VA CG-SURG-78 Locally Ablative Techniques for Treating Primary 6/28/2018 6/28/2018 Previously SURG and Metastatic Liver Malignancies VA CG-SURG-79 Implantable Infusion Pumps 6/28/2018 6/28/2018 Previously SURG VA CG-SURG-80 6/28/2018 6/28/2018 Previously RAD Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors VA CG-THER-RAD-01 Fractionation and Radiation Therapy: Bone 3/1/2016 6/28/2017 Transitioned to AIM 07/01/18 Mestastases and Whole-Breast Irradiation Following Breast Conserving Surgery VA CG-THER-RAD-02 RT special physics consult; RT Special Treatment Procedures 3/1/ /27/2017 Transitioned to AIM 07/01/18 Revised: March 15, 2016 (SKJ) Page 4 of 5

5 VA CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor 5/1/2018 7/1/2018 Previously THER-RAD Targeted Radiotherapy VA CG-THER-RAD-04 Selective Internal Radiation Therapy (SIRT) of 5/1/2018 7/1/2018 Previously THER-RAD Primary or Metastatic Liver Tumors VA CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and 6/28/2018 6/28/2018 Previously THER-RAD Noncoronary) VA CG-TRANS-02 Kidney Transplantation 11/19/2009 4/25/2018 Revised: March 15, 2016 (SKJ) Page 5 of 5