CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (New York | Medicaid)

List of Clinical Utilization Management (CUMG) Guidelines adopted by Anthem for New York Medicaid, used to guide medical necessity and utilization review for DME and other services.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (New York | Medicaid)

Policy CodePolicy N/A

Change TypeInformational — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders should consult the individual listed CUMG on the Anthem provider site for documentation and coverage criteria for each equipment type.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG items listed

MultipleDME-related guidelines enumerated

NYState-specific applicability

NCapplicable state

Coverage Criteria Overview

This section serves as an index of Anthem’s adopted Clinical Utilization Management Guidelines (CUMG). It does not itself state coverage, exclusion, or not medically necessary determinations; instead, it points providers to the individual CUMG documents available on the Anthem Provider Medical Policies website for the specific criteria that govern medical necessity and coverage decisions.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (New York | Medicaid)

Policy CodePolicy N/A

Change TypeInformational — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders should consult the individual listed CUMG on the Anthem provider site for documentation and coverage criteria for each equipment type.

SourceLink

On This Page

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What Providers Need To Do

Prior Authorization

Use of MCG and pre-payment review

MCG Care Guidelines are used for medical necessity and pre-payment review activities, including inpatient and behavioral health inpatient reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures when no Anthem Medical Policy or Clinical Utilization Management Guideline (CUMG) exists. Level of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance use disorder services as required by state rules. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/CUMGs supersede MCG when applicable. Providers should document care consistent with the Medicaid contract, CMS requirements, and Anthem's Medical Necessity framework. If a request does not meet established criteria or MCG guidance, it will be referred to a licensed physician reviewer with appropriate clinical expertise for determination.

Note

Refer to CUMG on Anthem provider site

Providers must consult the Clinical Utilization Management Guidelines (CUMG) posted on the Anthem Provider Medical Policies site for specific, guideline-level criteria and operational details. The CUMG library contains the individual guidelines (for example: CG-SURG-76, CG-SURG-77 Refractive Surgery, CG-SURG-78 Cryosurgical/ablation for liver tumors, CG-SURG-79 Implantable Infusion Pumps) and any items newly adopted by the Medical Operations Committee for Medicaid members. Visit Provider Medical Policies | AnthemBlueCross.com to view these guidelines.

Denial Risk

Referral and denial process

If MCG or CUMG criteria are not met, the case will be referred to a licensed physician reviewer with the appropriate clinical expertise. The reviewer will assess medical necessity on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, and Anthem’s Medical Necessity Criteria. Denial determinations follow Anthem’s standard clinical review and notification processes.

Note

No explicit authorization or denial trigger

These sections do not, by themselves, establish automatic prior authorization triggers or guarantee coverage. Providers should not assume authorization or denial solely from the presence or absence of a CUMG entry; instead, consult the Anthem Provider site and the applicable CUMG or Medical Policy for any explicit prior authorization requirements or billing instructions.

Note

Provider site guidance

Providers are directed to view full guidelines, policy details, and any operational instructions on the Anthem Provider Medical Policies site. Use the posted CUMGs and Medical Policies for required documentation, submission instructions, and to confirm whether prior authorization is needed for a specific service.

Documentation Required

Documentation and review references

Documentation and review references: follow Medicaid state contracts, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines. Ensure documentation supports medical necessity determinations; inadequate documentation may result in referral for physician review or denial.

Defined Terms

MCG Care Guidelines

DefinitionMCG Care Guidelines are an external clinical guideline set used by Anthem for medical necessity review and site-of-service decisions (medical and behavioral health inpatient review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services when no Anthem Medical Policy or Clinical UM Guideline exists).

Superseding authoritiesMedicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Use in utilization reviewApplied for inpatient and certain outpatient reviews; requests not meeting criteria are referred to a licensed physician reviewer for case‑by‑case medical necessity determinations.

Related toolLevel of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance use disorder services according to state requirements.

How to access guidanceProviders are directed to view specific guidelines on Anthem’s Provider Medical Policies website for details and application.

CUMG (Clinical Utilization Management Guideline)

DefinitionClinical Utilization Management Guideline (CUMG) refers to Anthem’s named clinical guideline documents (CUMG titles) adopted by the Medical Operations Committee and listed on the Provider Medical Policies site (examples include Cochlear Implants, Bone‑Anchored Hearing Aids, Bariatric Surgery, and many others).

AccessTo view any CUMG, visit Provider Medical Policies | AnthemBlueCross.com where individual guideline titles and details are posted.

AdoptionCUMG items indicated as ‘new’ were adopted by the Medical Operations Committee for Medicaid members.

ScopeCUMGs provide the equipment/service‑specific clinical criteria and documentation expectations used for utilization review and medical necessity determinations across inpatient, outpatient, and home settings as specified per guideline.

OpenPayer

Clinical Utilization Management Guidelines (New York | Medicaid)

Coverage Criteria Overview

What Providers Need To Do

Documentation and Consulted Guidelines

Background and Purpose

Defined Terms