Overview

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Anthem Medical Policies & Clinical UM Guidelines 
Welcome to Anthem’s Medical Policy & Clinical UM Guideline website. Our goal in creating this application is to provide you with ready access to electronic versions of medical policies and clinical UM guidelines. 
 
Finding Medical Policies & Clinical UM Guidelines
Anthem medical policies are listed by the following categories under the tabs noted above: 
All Medical Policies
Policies by Type
Anthem Clinical UM Guidelines are listed by the following categories under the tabs noted above: 
All UM Guidelines
Guidelines by Type
You can locate a medical policy or clinical UM guideline by clicking on a category, or by browsing all medical policies or all clinical UM guidelines, or by using the search function. 
 
Search for Medical Policies & Clinical UM Guidelines
 
Consumer Tools
Consumer Tools are a new group of documents that offer information on certain health services and procedures for which a review may occur based on Medically Necessary, Not Medically Necessary, Investigational, Cosmetic and Reconstructive criteria. Consumer Tools provide background information related to benefit decisions and also describe possible positive considerations and risks that will have to be weighed, to support care that is safe and appropriate. The documents also include questions that a doctor may wish to review with her/his patients, our members. We hope that these documents can help enhance the discussion between doctors and their patients (our members), to support informed health care choices related to some of our medical policies and clinical UM guidelines. To help find out if a health service and/or treatment will be covered, and to learn more about the member’s plan benefits, see the certificate of coverage or call the customer service number on the member ID card. 
Functional Endoscopic Sinus Surgery (FESS)
Weight Loss Surgery
 
Customizations to MCG™ Care Guidelines  
This document provides a summary of customizations to the MCGCare Guidelines 18th Edition (effective April 28, 2014). 
 
ICD-10 Coding (Effective October 1, 2014)  
In preparation for the implementation of ICD-10 CM and ICD-10 PCS, we are updating medical policies and clinical UM guidelines on a quarterly basis to include proposed ICD-10 coding. The ICD-10 coding is available through either a hyperlinked Appendix or a listing of applicable ICD-10 codes within the Coding section. Please note that at this time, the ICD-10 code list may not be all inclusive and is subject to change as Position Statements may be updated. Feel free to send comments regarding the ICD-10 coding using the Contact Us link below.  
 
Contact Us  
The following contact us e-mail address is for questions related to the research and development of medical policies and clinical Utilization Management (UM) guidelines found on this site. For those inquiries please use the following link: Contact Us 
Please direct inquiries related to benefit coverage, new ID cards, billing practices, prior authorization, pre-determination or reimbursement and any other inquiries unrelated to medical policy or clinical guidelines to the local plan provider representative, billing/reimbursement department or Customer Service, as applicable, by calling the number listed on the member ID card. We will not be able to respond to those inquiries. 

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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use