Anthem Policy on Remote Therapeutic Monitoring (RTM) - October 1, 2024

Remote therapeutic monitoring (RTM) is a healthcare service that enables the monitoring of a patient's condition outside of traditional healthcare settings, typically through digital health tools. Anthem has outlined specific guidelines under which RTM in a non-healthcare setting is considered medically necessary. According to Anthem’s policy, RTM is deemed medically necessary when clinical records document the rationale for monitoring, meeting the following criteria:

1. Clinical Appropriateness of RTM

RTM is clinically appropriate, in terms of type, quantity, frequency, extent, site, and duration, and is considered effective for the individual’s illness, injury, or disease and in accordance with generally accepted standards of medical practice.

2. Regular Assessment of RTM Data

RTM data is being regularly assessed to detect acute changes in clinical status and prompt intervention. The purpose of this is to allow healthcare providers to respond promptly to any significant changes, preventing further complications.

3. Not Primarily for Convenience

RTM is not primarily for the convenience of the individual, physician, caregiver, or other healthcare provider. This ensures that the use of RTM is medically justified and not simply used as an alternative to in-person care for convenience reasons.

4. Risk of Clinically Significant Changes

The individual is at risk of clinically significant changes in medical status which warrant enhanced monitoring based on current status and instability of the underlying clinical condition. RTM is particularly useful in situations where a patient's condition may fluctuate, requiring constant monitoring to detect changes.

5. Inability to Access Outpatient Care

The individual is unable to access regularly scheduled outpatient clinical care, or therapeutic monitoring is required between visits due to potential changes in medical status. RTM serves as an essential tool for individuals who may face barriers to accessing in-person care or require frequent monitoring between visits.

6. Prevention of Deterioration

Monitoring is reasonably likely to prevent avoidable deterioration in the clinical condition and/or other adverse events relating to the underlying clinical condition. The goal of RTM is to intervene early to prevent the patient's condition from worsening, reducing the likelihood of adverse events or hospitalization.

Anthem’s policy on remote therapeutic monitoring outlines clear criteria for when RTM is considered medically necessary. The policy emphasizes that RTM must be clinically appropriate, regularly assessed, and not used for convenience. It is intended for individuals who are at risk of significant changes in their condition, cannot access regular outpatient care, or need continuous monitoring to prevent deterioration. By adhering to these guidelines, Anthem ensures that RTM is applied effectively to improve patient outcomes and reduce unnecessary healthcare utilization.