CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (CUMG) adoption notice — Anthem HealthKeepers Plus (Medicaid)

List and adoption notice of Clinical Utilization Management Guidelines (CUMG) that Anthem HealthKeepers Plus has adopted for Medicaid members; indicates where full guidelines are available and intended use.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (CUMG) adoption notice — Anthem HealthKeepers Plus (Medicaid)

Policy CodePolicy N/A

Change TypeAdoption/listing notice (no material coverage changes)

Effective DateMar 28, 2024

Next Review DateN/A

Key ActionProvide documentation supporting medical necessity per the referenced CUMG when requesting DME; requests not meeting criteria may be referred for physician review and potentially denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG items listed in this announcement

PublicGuidelines available

Mar 28, 2024Adoption date

NCApplicable state

Adoption and Application of CUMGs

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General application of adopted CUMGs

Guidelines adoption and use

Use conditions: CUMGs listed are adopted for Anthem HealthKeepers Plus Medicaid members and are to be used for medical necessity and utilization management as described (medical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient services where there is not an established Coverage Guideline or Clinical UM Guideline).

Refer to individual CUMG documents for specific medical necessity criteria. Medical necessity determinations are made case-by-case per Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria ADMIN.0OO004; requests not meeting established criteria will be referred to a licensed physician reviewer.

Listed CUMG Codes and Coding Notes

Listed CUMG codes (partial list)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-BEH-14	Intensive In-Home Behavioral Health Services
CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy

1–10 of 14

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Additional listed CUMG codes (partial list)mixed

CG-DME-08	Infant Home Apnea Monitors
CG-DME-09	Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Postoperative Period
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 or Modifications for Individuals with Diabetes
CG-DME-20	Orthopedic Footwear

1–10 of 18

1/2

Further listed DME-related CUMG codes (partial list)mixed

CG-DME-33	Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
CG-DME-34	Wheeled Mobility Devices: 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 of the Appendicular Skeleton
CG-DME-41	Ultraviolet Light Therapy Delivery Devices for Home Use
CG-DME-42	Continuous Glucose Monitoring Devices
CG-DME-43	High Frequency Chest Compression Devices for Airway Clearance

1–10 of 17

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Remaining listed CUMG codes (partial list)mixed

CG-DME-51	External Insulin Pumps
CG-DME-52	Continuous Passive Motion Devices in the Home Setting
CG-DME-53	Biomechanical Footwear Therapy
CG-LAB-03	Tropism Testing for HIV Management
CG-LAB-09	Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
CG-LAB-10	Zika Virus Testing
CG-LAB-11	Screening for Vitamin D Deficiency in Average Risk Individuals
CG-LAB-12	Testing for Oral and Esophageal Cancer
CG-LAB-13	Skin Nerve Fiber Density Testing
CG-LAB-14	Respiratory Viral Panel Testing in the Outpatient Setting

1–10 of 23

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inv-07: N/A (placeholder key/value entry from inventory)

Inventory statusN/A (placeholder entry)

NotesThis entry is a catalog placeholder with no substantive threshold or code information in the adoption notice.

ActionRefer to specific CUMG documents listed in this communication for details.

What Providers Need to Know and Do

Documentation Required

Pre-payment review and use of guidelines

MCG Care Guidelines and other Clinical Utilization Management (CUMG) Guidelines are used for pre-payment medical necessity review and other utilization management activities. These guidelines support inpatient medical and behavioral health review, inpatient site-of-service appropriateness, inpatient rehabilitation and SNF review, and outpatient services/procedures when no established Coverage Guideline exists. Medicaid state contracts, regulatory guidance, CMS requirements, and our Coverage/Clinical UM Guidelines supersede MCG. Determinations of medical necessity are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or our Medical Necessity Criteria ADMIN.0OO004.

Used for pre-payment medical necessity review and utilization management activities
Applies to inpatient medical/behavioral health, inpatient site-of-service, rehab/SNF, outpatient services without established guideline
Medicaid/CMS guidance and Anthem Coverage Guidelines supersede MCG
Medical necessity determinations made case-by-case

Prior Authorization

Prior authorization notice

The Clinical Utilization Management Guidelines listed (CUMG) were adopted for Anthem HealthKeepers Plus members on March 28, 2024. Many items are listed as new or updated in the CUMG inventory. This notice is informational and indicates which CUMG titles are newly adopted or updated; it does not, by itself, specify the exact prior authorization requirements or individual coverage rules—providers should consult the full Coverage Guidelines/Clinical UM Guidelines for any prior authorization or utilization management requirements.

CUMG titles (selected examples) shown as New/Updated include: CG-SURG-89 through CG-SURG-121 and others (see full guideline list)
Listing indicates adoption date: March 28, 2024
This excerpt does not specify exact prior authorization triggers—refer to full guidelines for PA requirements

Denial Risk

Referral/Denial risk when criteria not met

If a request does not meet the established guideline criteria, the request will be referred to a licensed physician reviewer with appropriate clinical expertise. If medical necessity is not met after review, the request may be denied. Providers should ensure documentation supports medical necessity to reduce risk of referral or denial.

Requests not meeting criteria will be referred to licensed physician reviewer
Potential denial if medical necessity is not met
Ensure complete clinical documentation to support medical necessity

Note

Not specified in this excerpt

Some provider action items are not fully specified in the excerpted CUMG listing (for example, exact prior authorization steps, step-therapy rules, or specific documentation checklists). Providers must consult the full Coverage Guidelines/Clinical UM Guidelines or contact Provider Services for specific authorization instructions.

Exact authorization steps and documentation checklists not specified in this excerpt
Step therapy rules are not stated here — consult full guidelines
Contact Provider Services at 800-901-0020 with questions

Note

Provider communication

To receive updates and communications (including some sent in lieu of fax or mail), providers are encouraged to sign up for email notifications via the QR code or online form.

Sign up for email updates via QR code or: http://anthem.ly/signup-abcbs-va
Email is the quickest and most direct way to receive important information

Document Purpose and Scope

This document is an adoption notice listing the Clinical Utilization Management Guidelines (CUMGs) that HealthKeepers, Inc. has adopted for Anthem HealthKeepers Plus Medicaid members. The announcement states the CUMG items were adopted by the Medical Operations Committee effective March 28, 2024 and that the full list of Coverage Guidelines and Clinical UM Guidelines is publicly available via Anthem’s Coverage Guidelines and Clinical UM Guideline website.

The notice also explains intended uses: CUMGs and, where applicable, MCG Care Guidelines are used to support pre‑payment medical necessity review and other utilization management activities for inpatient reviews, site‑of‑service decisions, inpatient rehabilitation and SNF review, and for outpatient procedures when no Coverage Guideline exists. ASAM criteria are referenced for substance use services as required by state rules, and providers are directed to the public policy search for full guideline details.

Key Terms and Sources

inv-17: MCG Care Guidelines — clinical guidance used for medical necessity reviews for inpatient care and other settings

DefinitionMCG Care Guidelines are clinical guidance used for medical necessity reviews for inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services where no Coverage Guideline exists.

Primary useMedical necessity review for medical and behavioral health inpatient care and site-of-service appropriateness.

Secondary useOutpatient services or 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.

inv-18: ASAM criteria — American Society of Addiction Medicine criteria used for substance abuse services

DefinitionASAM criteria (American Society of Addiction Medicine) — criteria used for substance abuse services according to state requirements.

ApplicationUsed where state requirements mandate ASAM criteria for substance abuse service determinations.

Relation to CUMGsReferenced as the standard for substance abuse services alongside adopted CUMGs in this notice.

inv-19: CUMG item definition — Clinical Utilization Management Guideline entry; many entries marked as 'New item' in the excerpt

DefinitionCUMG item — a Clinical Utilization Management Guideline entry titled with a procedure or therapy; many items in this adoption notice are marked as 'New item' indicating newly added or updated guidelines.

ScopeThis adoption notice lists numerous CUMG items (surgical, DME, lab, medical, rehab, etc.) but does not contain individual medical necessity criteria.

Next stepRefer to each named CUMG document (e.g., CG-DME-08, CG-SURG-89) on the Anthem provider policy search for full guideline content and criteria.

Where to Find DME-Specific Medical Necessity Criteria

DME-specific criteria location

See individual DME CUMG documents for specific medical necessity criteria for each equipment type.

See individual policies: Medical necessity criteria for durable medical equipment are defined within each listed DME CUMG (for example: 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, etc.).

This listing notice does not contain the specific DME medical necessity criteria; consult each referenced CUMG via Anthem Provider Medical Policy Search for detailed requirements, documentation, and any rental/purchase or replacement rules.

Topic	Rule / Guidance
Durable Medical Equipment (general)	Rental vs purchase rules are determined by the specific DME CUMG documents and applicable Medicaid/coverage rules; refer to individual CUMG documents (e.g., CG-DME-10 and related DME CUMGs) for the equipment‑specific rental versus purchase policy.

Documentation and Communication

Documentation Required

Provide documentation to support medical necessity for DME requests

When requesting durable medical equipment, providers should supply documentation that supports medical necessity in accordance with the referenced criteria in the applicable CUMG.

Prepare clinical records demonstrating how the request meets the specific CUMG medical necessity criteria.
Be available to respond to requests for additional information; determinations are case‑by‑case per Medicaid/CMS/Anthem requirements.

Documentation Required

Subscribe to Anthem email updates for notifications

Providers should subscribe to Anthem email updates via the QR code or the provided URL to receive important information and notifications (including administrative or authorization updates).

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (CUMG) adoption notice — Anthem HealthKeepers Plus (Medicaid)

Policy CodePolicy N/A

Change TypeAdoption/listing notice (no material coverage changes)

Effective DateMar 28, 2024

Next Review DateN/A

Key ActionProvide documentation supporting medical necessity per the referenced CUMG when requesting DME; requests not meeting criteria may be referred for physician review and potentially denied.

SourceLink

On This Page

OpenPayer

Clinical Utilization Management Guidelines (CUMG) adoption notice — Anthem HealthKeepers Plus (Medicaid)

Adoption and Application of CUMGs

Listed CUMG Codes and Coding Notes

What Providers Need to Know and Do

Document Purpose and Scope

Key Terms and Sources

Where to Find DME-Specific Medical Necessity Criteria

DME Rental vs Purchase Guidance

Replacement Rules

Documentation and Communication

Exclusions and Non-Covered Items

Policy Revision History