CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (Anthem HealthKeepers Plus Medicaid)

A catalog of Clinical Utilization Management (UM) Guidelines adopted for Anthem HealthKeepers Plus Medicaid members, listing many topic-specific guidelines and noting use of MCG and other criteria for medical necessity and review processes; intended for providers and internal reviewers caring for Anthem HealthKeepers Plus members in Virginia.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Anthem HealthKeepers Plus Medicaid)

Policy CodePolicy N/A

Change TypeInformational listing of Clinical UM Guidelines

Effective DateN/A

Next Review DateN/A

Key ActionConsult the specific CG-DME guideline for medical necessity criteria and documentation when requesting durable medical equipment for Anthem HealthKeepers Plus members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed Clinical UM Guidelines and Coverage Guidelines

Anthem HKPproduct to which this communication applies

~40clinical guideline items listed

1item explicitly marked NEW

Coverage / Medical Necessity Criteria

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Medical Necessity Determination

Determinations are made case-by-case according to governing contracts, regulations, and the payer's medical necessity criteria.

Medical necessity determination: Determinations are made on a case-by-case basis in accordance with the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria ADMIN.00004.

If the request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise.

DME medical necessity by device guideline

Specific medical necessity criteria are defined within the listed device-specific CG-DME guidelines; providers must reference the applicable CG-DME-## guideline for the detailed requirements for each equipment type.

Reference-specific DME criteria: Individual CG-DME guidelines (for example: CG-DME-07, CG-DME-08, CG-DME-10, CG-DME-12, CG-DME-13, CG-DME-15, CG-DME-16, CG-DME-18, CG-DME-19, CG-DME-20, CG-DME-21, CG-DME-22, CG-DME-23, CG-DME-24, CG-DME-25, CG-DME-26, CG-DME-30, CG-DME-31, CG-DME-33, CG-DME-34, CG-DME-35, CG-DME-36, CG-DME-37, CG-DME-39, CG-DME-40, CG-DME-41, CG-DME-42, CG-DME-43, CG-DME-44, CG-DME-45, CG-DME-46, CG-DME-47, CG-DME-48) contain the specific medical necessity criteria for each durable medical equipment category.

This summary references the existence of those CG-DME guidelines but does not reproduce their detailed criteria; consult the named CG-DME-## document for clinical criteria, documentation requirements, and rental/purchase or replacement rules.

Listed Clinical UM Guideline Identifiers / Coding Index

Listed Clinical UM Guideline identifiersmixed

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-BEH-02	Adaptive Behavioral Treatment
CG-BEH-14	Intensive In-Home Behavioral Health Services
CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

1–10 of 93

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Provider Actions, Authorization & Denial Notes

Note

CUMG/CG Policy Index & New-Item Notices

The listed Clinical Utilization Management (CUMG/CG) Guidelines are adopted and publicly available; providers should review the CUMG/CG policy index for the full list and note any entries flagged as new items. Visit the Anthem provider site (https://providers.anthem.com/va) or the Medical policies and clinical UM guidelines page to view guideline details and the new-item notices.

CUMG/CG policy index and new-item notices available on Anthem provider site
Examples of guideline entries: CG-ADMIN-01, CG-ANC-03, CG-SURG-114 (marked NEW)

Denial Risk

Denial Risk for Unmet Criteria

Requests that do not meet the established guideline criteria may be referred to a licensed physician reviewer with appropriate clinical expertise and are subject to denial if medical necessity is not demonstrated.

Case-by-case medical necessity determinations per Medicaid state contract, regulatory guidance, CMS requirements, and Anthem Medical Necessity Criteria ADMIN.00004
Requests not meeting criteria will be referred to a physician reviewer and may be denied

Prior Authorization

Authorization/Denial Triggers Not Explicit

The CUMG/CG listing and new-item indicators shown in this section do not explicitly state the operational triggers for authorization or denial; providers must consult the specific guideline text on the Anthem site for authorization requirements or prior authorization triggers.

Guideline titles and new-item flags are listed without explicit authorization/denial triggers in these excerpts
Consult each guideline page for specific prior authorization or medical necessity trigger language

Documentation Required

Documentation Requirements Not Specified

There are no explicit documentation requirements specified in the guideline index excerpts included here. Providers should reference the individual Clinical UM Guideline or Coverage Guideline for documentation expectations and any state/Medicaid-specific requirements.

Documentation requirements are not specified in these index entries
Follow guideline-specific and state Medicaid/CMS documentation rules when submitting requests

Note

Provider action: review the full Clinical UM Guidelines and Coverage Guidelines on the Anthem provider site, confirm whether prior authorization is required for the requested service, ensure documentation meets guideline and Medicaid/CMS criteria, and be aware that failure to meet criteria may result in referral to a physician reviewer and possible denial.

Visit https://providers.anthem.com/va and the Medical policies and clinical UM guidelines page to view full guideline text
Confirm prior authorization requirements for the specific guideline before submitting claims
Ensure documentation aligns with guideline and Medicaid/CMS medical necessity definitions
Anthem HealthKeepers Plus Provider Services: 800-901-0020 for questions

DME-Specific Medical Necessity

DME medical necessity by device guideline (device-specific index)

See the device-specific Clinical UM Guidelines (CG-DME-##) listed below for the medical necessity criteria that govern coverage decisions for each equipment type.

Device-specific guideline index: CG-DME-07 Devices with Digitized or Synthesized Speech Output; CG-DME-08 Infant Home Apnea Monitors; CG-DME-09 Elastomeric Infusion Pumps; CG-DME-10 Durable Medical Equipment; CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia; CG-DME-13 Lower Limb Prosthesis; CG-DME-15 Hospital Beds and Accessories; CG-DME-16 Pressure Reducing Support Systems Groups 1, 2 and 3; CG-DME-18 Home Oxygen Therapy; CG-DME-19 Therapeutic Shoes/Inserts for Diabetes; CG-DME-20 Orthopedic Footwear; CG-DME-21 External Infusion Pumps for Home Use; CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses; CG-DME-23 Lifting Devices for Home Use; CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight; CG-DME-25 Seat Lift Mechanisms; CG-DME-26 Back-Up Ventilators in the Home Setting; CG-DME-30 Prothrombin Time Self-Monitoring Devices; CG-DME-31 Wheeled Mobility Devices: Powered Wheelchairs/Power Seating/POVs; CG-DME-33 Wheeled Mobility Devices: Ultra Lightweight Manual Wheelchairs; CG-DME-34 Wheelchair Accessories; CG-DME-35 Electric Breast Pumps; CG-DME-36 Pediatric Gait Trainers; CG-DME-37 Air Conduction Hearing Aids; CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices; CG-DME-40 Noninvasive Electrical Bone Growth Stimulation (Appendicular); CG-DME-41 Ultraviolet Light Therapy Devices for Home Use; CG-DME-42 Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices; CG-DME-43 High Frequency Chest Compression Devices; CG-DME-44 Electric Tumor Treatment Field (TTF); CG-DME-45 Ultrasound Bone Growth Stimulation; CG-DME-46 Pneumatic Compression Devices for DVT Prevention in the Home; CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure; CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting.

For coverage, clinical criteria, required documentation, and any rental/purchase or replacement rules, reference the individual CG-DME-## guideline listed above on the payer's provider website.

Rental, Purchase and Replacement

Topic	Rule / Guidance
Rental vs. Purchase determinations for listed DME items (CG-DME series)	Not specified in this listing; consult the individual CG‑DME‑## guideline for rental vs. purchase rules and criteria.
Scope of guidance	This document provides a catalog of CG‑DME guidelines (e.g., CG‑DME‑07, ‑08, ‑10, ‑12, ‑13, ‑15, ‑16, ‑18, ‑19, ‑20, ‑21, ‑22, ‑23, ‑24, ‑25, ‑26, ‑30, ‑31, ‑33, ‑34, etc.); rental/purchase rules are defined within each specific guideline.
Action for providers	Refer to the applicable CG‑DME guideline cited for the specific equipment type to determine rental versus purchase, applicable documentation, and any state/CMS rule considerations.

Replacement key facts — replacement rules summary

Replacement intervalsNot specified in this summary; replacement intervals for DME items are defined in each specific CG-DME guideline and must be consulted there.

Where to find interval rulesRefer to the applicable CG-DME-## document listed on the Anthem provider site (e.g., CG-DME-10, CG-DME-15, CG-DME-16, etc.) for equipment-specific replacement policy.

Replacement triggersReplacement requests that do not meet the established criteria in the specific CG-DME guideline will be referred to a licensed physician reviewer and may be denied.

Documentation sourceReplacement and frequency guidance are contained within the individual Clinical UM Guidelines (CG-DME series) referenced in the guideline index.

Documentation & Recordkeeping

Documentation Required

Consult CG-DME guideline for required documentation

Refer to the specific CG-DME guideline (e.g., CG-DME-03 through CG-DME-49) for required documentation elements to support medical necessity determinations for DME; the guideline list indicates which device-specific documents must be consulted.

The guideline list includes numerous CG-DME topics; each CG-DME-## contains the documentation expectations for that equipment type.
Access the full guideline on the Anthem provider site to obtain exact documentation requirements.

Background and Definitions

MCG Care Guidelines are used by Anthem HealthKeepers Plus for several targeted review activities when no other internal guideline applies. Specifically, MCG Care Guidelines are applied for medical necessity review of medical and behavioral health inpatient care, assessments of inpatient site-of-service appropriateness, review of inpatient rehabilitation and skilled nursing facility stays, and for outpatient services or procedures when there is not an established Coverage Guideline or Clinical UM Guideline.

These external MCG recommendations are supplemental: state Medicaid contracts, regulatory guidance, CMS requirements, and Anthem's own Coverage Guidelines/Clinical UM Guidelines supersede MCG Care Guidelines. Medical necessity determinations remain case-by-case and are made in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria (ADMIN.00004). If a request does not meet the applicable criteria, it will be referred to a licensed physician reviewer with the appropriate clinical expertise.

MCG Care Guidelines definition — external clinical guidance used for reviews

MCG Care Guidelines — use casesUsed for medical necessity review of medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no established Coverage Guideline or Clinical UM Guideline exists.

HierarchyMedicaid state contracts, regulatory guidance, CMS requirements, and Anthem Coverage Guidelines/Clinical UM Guidelines supersede MCG Care Guidelines.

Role in reviewsMCG Care Guidelines serve as external clinical guidance to support medical necessity determinations and site-of-service appropriateness assessments when applicable.

ASAM criteria definition — standards used for substance abuse services

ASAM criteria — purposeASAM criteria are used for substance abuse services according to state requirements.

Use in determinationsASAM criteria provide standardized standards referenced when evaluating medical necessity for substance use disorder treatment services.

Superseding rulesState Medicaid contracts, regulatory guidance, CMS requirements, and Anthem Coverage Guidelines/Clinical UM Guidelines take precedence over ASAM when applicable.