CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines — New York Medicaid (CUMG Index)

List and index of Anthem's Clinical Utilization Management guidelines adopted for New York Medicaid; provides titles and identifiers of many CUMG entries and directs providers to individual guideline pages for device-level medical necessity, prior authorization, and documentation requirements.

Policy Summary

PayerAnthem (Medicaid, NY)

PolicyClinical Utilization Management Guidelines (CUMG) index — DME and other topics

Policy CodePolicy N/A

Change TypeInformational / Index

Effective DateN/A

Next Review DateN/A

Key ActionRefer to the individual CUMG page for specific medical necessity, documentation, and prior-authorization requirements for each DME item.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40listed guideline items

100+total CUMG entries shown

Medicaid (NY)payer/program

multipleDME-specific titles

Coverage Criteria Overview

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MCG Care Guidelines may be used for medical necessity review (including inpatient and behavioral health inpatient reviews), inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures where no Anthem Medical Policy or Clinical UM Guideline exists. However, Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Medical necessity determinations are made on a case-by-case basis in accordance with the definition of medical necessity contained in the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy (ADMIN.00004).

This section functions as an index of adopted Clinical Utilization Management Guidelines and does not itself contain individual medical necessity criteria or explicit coverage/exclusion statements for specific services. Providers and reviewers should consult the individual guideline pages (via Search Medical Policies and Clinical Guidelines) for the specific medical necessity criteria, documentation requirements, and any code- or service-level coverage determinations.

CUMG Identifiers and Guideline Titles

CUMG identifiers listedmixed

No codes listed

Guideline identifiers and titlesmixed

CG-SURG-73	Balloon Sinus Ostial Dilation
CG-SURG-75	Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
CG-SURG-77	Refractive Surgery
CG-SURG-78	Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver
CG-SURG-79	Implantable Infusion Pumps
CG-SURG-81	Cochlear Implants and Auditory Brainstem Implants
CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids
CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity
CG-SURG-84	Mandibular/Maxillary (Orthognathic) Surgery

1–10 of 49

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Provider Actions and Pre-Payment Review

Note

Pre-Payment Review Guidelines and Next Steps

The Clinical Utilization Management Guidelines (CUMG) listed below are used for pre-payment review and medical necessity determinations when no other Medical Policy or Clinical UM Guideline exists. Providers must consult the individual guideline for code-specific prior authorization requirements, documentation expectations, and any stated authorization or denial criteria. These guideline pages are available via the 'Search Medical Policies and Clinical Guidelines' tool.

Provider action: Pre-Payment Review Guidelines — The document lists CUMG items adopted for pre-payment review and medical necessity determinations; individual guideline pages contain the clinical criteria used for decisions.
Provider action: Consult individual guideline — This section does not specify prior authorization requirements; providers must consult each listed guideline (via Search Medical Policies and Clinical Guidelines) for code-specific prior authorization and documentation requirements.
Provider action: No explicit authorization or denial criteria stated here — The section only lists guideline identifiers and titles; authorization/denial criteria are on the individual guideline pages.
Provider action: Access guideline details — Providers are directed to 'Search Medical Policies and Clinical Guidelines' to view individual guideline details and requirements.

Document Background

This document lists the Clinical Utilization Management Guidelines (CUMG) Anthem has adopted for New York Medicaid to guide medical necessity reviews and site-of-service decisions. It provides guideline identifiers and titles (for example, CG-SURG-73 = Balloon Sinus Ostial Dilation) and points providers to the online guideline repository to view the full guideline text and any pre-payment review or prior authorization requirements. Where no Anthem guideline exists, MCG Care Guidelines may be used, except that Medicaid contracts, regulatory guidance and CMS requirements supersede both MCG and Anthem guidelines.

Key Definitions

Medical necessity

DefinitionMedical necessity determinations are made case-by-case in accordance with the definition contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy (ADMIN.00004).

Decision processIf a request does not meet established criteria/guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make the determination.

Hierarchy of guidanceMedicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Scope of applicationMCG Care Guidelines may be used for medical necessity review inpatient, inpatient site-of-service appropriateness, inpatient rehabilitation/skilled nursing facility review, and outpatient services where no Anthem policy exists.

Related policy referenceSee Anthem Medical Necessity Criteria Policy ADMIN.00004 for the operative definition and additional process details.

CUMG title

DefinitionCUMG title refers to the consolidated/Clinical Utilization Management Guideline title associated with each CG- identifier (for example: CG-SURG-101 = Ablative Techniques as a Treatment for Barrett's Esophagus).

How to viewTo view a guideline and its CUMG title, visit 'Search Medical Policies and Clinical Guidelines'.

Identifier linkageEach CG- identifier is listed with its corresponding CUMG title in the guideline index (e.g., CG-SURG-102 = Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy).

Use for providersProviders should use the CG- identifier and CUMG title to locate the specific guideline page for device- or procedure-level medical necessity and documentation requirements.

Medical Necessity Process

General DME medical necessity process

Covered when ALL of the following are met:

General process: Medical necessity determinations and pre-payment review follow Anthem Clinical Utilization Management Guidelines (CUMG) and applicable Medicaid state contract, regulatory guidance, and CMS requirements.

See individual CUMG pages for device- or service-specific criteria and documentation requirements.

Decision-making and referral: Determinations of medical necessity are made on a case-by-case basis per the definition contained in the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem Medical Necessity Criteria Policy (ADMIN.00004); if a request does not meet established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise.

Provider action: Providers must consult the specific CUMG linked via 'Search Medical Policies and Clinical Guidelines' for the complete, device-level medical necessity criteria, prior authorization requirements, and documentation expectations.

This document is an index; it does not itself list device-level coverage rules.

Documentation Requirements

Documentation Required

Refer to the individual CUMG page for documentation and criteria

Providers should refer to each individual CUMG page for the specific documentation elements and medical necessity criteria required for that device or service.

The CUMG pages for DME topics (e.g., hospital beds, oxygen therapy, wheelchairs, orthoses) contain the documentation checklist and clinical thresholds to support coverage.
Failure to submit the documentation specified on the individual guideline may result in delay or denial.