CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines

A catalog/notice listing the Clinical Utilization Management Guidelines (CUMG) the health plan has adopted for New York Medicaid, indicating which guideline codes/titles are included and that some are newly adopted. It explains usage of MCG Care Guidelines and that Medical Policy/CUMG/contractual requirements supersede MCG guidance.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeListing/Informational

Effective Date

Next Review Date

Key ActionMake case-by-case medical necessity determinations following the Medicaid state contract, regulatory guidance, CMS requirements, or the plan's Medical Necessity Criteria Policy ADMIN.0O04; refer to a licensed physician reviewer if requests do not meet established guidelines.

POLICY UPDATE CHANGES

No material clinical/coverage changes.

200+Listed CUMG items

SomeItems indicated as New

Coverage Summary — Clinical Utilization Management Guidelines (CUMG) for NY Medicaid

A catalog/notice listing the Clinical Utilization Management Guidelines the plan has adopted for New York Medicaid, indicating which guideline codes and titles are included and that some items are new. The list is publicly available and was adopted for Medicaid members. MCG Care Guidelines are used in specific review contexts such as certain inpatient and outpatient reviews, but Medical Policy, Medicaid contracts, regulatory guidance and CMS requirements supersede MCG.

Use of MCG Care Guidelines and Medical Necessity Determinations

Guidance on when MCG Care Guidelines are used and hierarchy of guidance:

ALL of the following

MCG Care Guidelines are used for medical necessity review for medical and behavioral health inpatient review.
MCG Care Guidelines are used for inpatient site of service appropriateness.
MCG Care Guidelines are used for inpatient rehabilitation and skilled nursing facility review.
MCG Care Guidelines are used for outpatient based service or procedure where there is not an established Medical Policy or Clinical UM Guideline.
Level of Care for Alcohol and Drug Treatment Referral 3.0° is used for substance abuse services according to state requirements.
Medicaid state contracts, regulatory guidance, CMS requirements and the plan's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.
Medical necessity determinations are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements or the plan's Medical Necessity Criteria Policy ADMIN.0O04.
If a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise.

Adopted Clinical UM Guideline Codes and Titles

Adopted Clinical UM Guideline Codes and Titles (New items indicated where shown)mixed

CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ANC-03	Acupuncture
CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-05	Ambulance Services: Ground; Emergent
CG-ANC-06	Ambulance Services: Ground; Nonemergent
CG-ANC-07	Inpatient Interfacility Transfers
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04 D	Electrical Nerve Stimulation, Transcutaneous, Percutaneous
CG-DME-05 D	Cervical Traction Devices for Home Use

1–10 of 221

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Provider Actions and Documentation Expectations

Documentation Required

Medical necessity determinations follow state/CMS/plan criteria

Make case-by-case medical necessity determinations following the Medicaid state contract, regulatory guidance, CMS requirements, or the plan's Medical Necessity Criteria Policy ADMIN.0O04; documentation may be referred to a licensed physician reviewer if not meeting established guidelines.

Documentation Required

MCG guideline usage conditions

Use MCG Care Guidelines for inpatient and certain outpatient reviews only when no other Medical Policy or Clinical UM Guideline exists; ensure plan/contract/CMS rules supersede MCG guidance.

Operationally, if a request does not meet the established guideline criteria it will be referred/escalated to a licensed physician reviewer with appropriate clinical expertise; additionally, Medical Policy, Medicaid contracts, regulatory guidance and CMS requirements supersede MCG Care Guidelines.

Background

This document is a listing of Clinical Utilization Management Guidelines adopted by the plan for New York Medicaid and indicates which guideline codes/titles are included and which items are new. The full list of Medical Policies and Clinical UM Guidelines is publicly available on the plan's Medical Policy and Clinical UM Guideline website.

MCG Care Guidelines are used for medical necessity review for medical and behavioral health inpatient review, inpatient site of service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures where no established Medical Policy or Clinical UM Guideline exists. However, Medicaid state contracts, regulatory guidance, CMS requirements and the plan's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Medical necessity determinations are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or the plan's Medical Necessity Criteria Policy ADMIN.0O04.

MCG Care Guidelines: Care guidelines used by the plan for certain medical necessity and site-of-service determinations, subject to supersession by state/CMS/plan policies.