by AJ Riviezzo
Anthem Blue Cross and Blue Shield just came out with a new Clinical UM Guideline effective April 10, 2024. While you may not be in a state with Anthem, the odds are good that some Anthem patients will be seen by you. Noted below are some of the guidelines for this new policy (CG-SURG-119) and the changes from the old policy.
The only veins authorized for treatment by ablation are the GSV, ASV and SSV. The patient is subject to six weeks of conservative therapy which should include use of compression stockings, leg elevation, weight loss and exercise. Anthem does NOT have an ‘out clause’ from conservative therapy for higher CEAP scores. If the patient does not have ulceration secondary to stasis dermatitis or hemorrhage from a superficial varicosity, then the other symptoms must cause discomfort to the degree that employment or activities of daily living are compromised which should be well documented in the chart. None of this is a change from the old policy.
What has changed, and is a little confusing, is their sections regarding treatment of perforators. In the Ablation section III.D. it notes the patient should not have untreated incompetent perforators. However, in the Sclerotherapy section II.A and section III.D.1 perforators may be treated if they meet criteria and after an ablation of the GSV, ASV or SSV. Further section III.D.4. notes that sclerotherapy may not be the sole treatment of symptomatic tributary or perforator veins. “Sole” refers to sclerotherapy without concomitant or prior treatment of the great or small saphenous veins. Given the strong language in the sclerotherapy section, we believe it is pretty clear and defensible to perform ablations prior to the closer of perforators. American Physician will be sending a letter to Anthem requesting they delete the ablation section III.D. line.
Of note is the new policy has a Coding section. In the Coding section it strongly notes that the Varithena codes (36465 and 36466) can only be used for the treatment of truncal veins. This is in keeping with the AMA CPT guidelines. They also note that they expect to see it used as adjunctive to RF or laser ablation or follow-up treatment after ablation which is how many practices use Varithena, but it is the first policy I can recall that specifically notes its use as an adjunctive or follow-up treatment. Anthem is becoming more aggressive with its audits. It is important to ensure that your documentation is reflective of both the conservative therapy and the disease impact on the patient’s employment or activities of daily living. The key elements to the new policy is attached here: AnthemAbbPolicy