Why Anthem BCBS Denies Colonoscopy
Screening interval not met
Prior authorization not obtained
Age does not meet screening criteria
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
Distinguish diagnostic from screening indication
Document symptoms warranting diagnostic colonoscopy
Reference family history or personal risk factors
Note positive screening test (FIT, Cologuard) requiring follow-up
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
- USPSTF Colorectal Cancer Screening Recommendations
- AGA Guidelines for Colonoscopy Surveillance
- NCCN High-Risk Screening Guidelines
Relevant CPT Codes
Specialty: Gastroenterology
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