Why Anthem BCBS Denies Chemotherapy / Infusion Therapy
Regimen not first-line per NCCN guidelines
Off-label use without compendia support
Continuation after disease progression not justified
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Building Your Medical Necessity Argument
Cite specific NCCN guideline category and recommendation level
Document prior treatment lines and responses
Reference tumor molecular markers guiding treatment selection
If off-label, cite peer-reviewed evidence or compendia listing
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- NCCN Clinical Practice Guidelines by cancer type
- CMS Anticancer Chemotherapy NCD
Relevant CPT Codes
Specialty: Oncology
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