CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines — California Medi‑Cal Managed Care (CUMG)

Lists the Clinical Utilization Management Guidelines Anthem has adopted for California Medi‑Cal Managed Care members and describes their use for medical necessity and utilization review across services, including numerous DME-related guidelines. Affects providers serving Anthem Blue Cross Medi‑Cal members in California.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — California Medi‑Cal Managed Care (CUMG)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders should reference Anthem’s publicly available Medical Policies and Clinical UM Guidelines when submitting requests and follow the specific DME CUMG for medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG items listed

MultipleDME-related titles

CAGeographic scope

~40MCG guideline items referenced

4Document chunks

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Coverage Criteria Overview

Anthem’s Clinical Utilization Management Guidelines (MCG Care Guidelines) are used to support medical necessity and utilization management determinations across settings. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Determinations of medical necessity are made on a case‑by‑case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem’s Medical Necessity Criteria Policy (ADMIN.00004).

This section functions as a mapping/index of MCG Care Guideline identifiers and titles and does not itself provide explicit coverage criteria or exclusions. Providers should refer to the individual CUMG documents listed (by CG code and title) for the specific medical necessity criteria, documentation requirements, and coverage guidance applicable to each service.

Codes and Guideline Identifiers

CUMG identifiers listed (no billing codes provided in this section)mixed

No codes listed

Referenced Anthem guideline codes and titlesmixed

CG-SURG-120	Vagus Nerve Stimulation
CG-SURG-121	Fetal Surgery for Prenatally Diagnosed Malformations
CG-SURG-122	Lingual Frenotomy for Ankyloglossia-Related Feeding Difficulties
CG-SURG-123	Autologous Fat Grafting and Injectable Soft Tissue Fillers
CG-SURG-124	Viscocanalostomy
CG-SURG-125	Canaloplasty
CG-SURG-126	Tibial Nerve Stimulation
CG-SURG-127	Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
CG-SURG-128	Presbyopia and Astigmatism-Correcting Intraocular Lenses
CG-SURG-129	Internal Rib Fixation Systems

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Additional referenced Anthem guideline codes and titlesmixed

CG-SURG-84	unspecified in excerpt
CG-SURG-87	Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
CG-SURG-88	Mastectomy for Gynecomastia
CG-SURG-89	Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
CG-SURG-90	Mohs Micrographic Surgery
CG-SURG-91	Minimally Invasive Ablative Procedures for Epilepsy
CG-SURG-92	Paraesophageal Hernia Repair
CG-SURG-94	Keratoprosthesis
CG-SURG-95	Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
CG-SURG-96	Intraocular Telescope

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Provider Actions and Authorization

Note

MCG Care Guidelines — Index and Use

MCG Care Guidelines are used as a reference for Anthem prior authorization and medical necessity determinations when an applicable Anthem Medical Policy or Clinical UM Guideline is not available. They support medical necessity review for medical and behavioral health inpatient services, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures lacking an established Anthem Medical Policy or Clinical UM Guideline. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Providers should reference Anthem's publicly available Medical Policies and Clinical UM Guidelines and the applicable medical necessity definition in the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy (ADMIN.00004) when submitting requests.

MCG used for inpatient and outpatient medical necessity review when no Anthem policy exists
Anthem Medical Policy/Clinical UM Guidelines and state/CMS rules supersede MCG
Determinations made case-by-case per applicable medical necessity definition (see ADMIN.00004)

Background and Scope

Anthem has adopted the Clinical Utilization Management Guidelines to help promote quality care and reduce inappropriate use of medical resources. The MCG Care Guidelines are applied for medical necessity review across inpatient and outpatient settings — including inpatient site‑of‑service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services when no established Medical Policy or Clinical UM Guideline exists. Requests that do not meet the established guideline criteria are referred to a licensed physician reviewer with appropriate clinical expertise for final determination.

Definitions

MCG Care Guidelines — definition and role

Primary useMCG 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 outpatient services or procedures when no established Medical Policy or Clinical UM Guideline exists.

Relationship to Anthem policies and regulationsMedicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Medical necessity determinationsDeterminations are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem Medical Necessity Criteria Policy ADMIN.00004.

Escalation for non‑compliant requestsIf a request does not meet established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied.

Access to guidelinesThe Clinical Utilization Management Guidelines referenced can be viewed at Anthem's Provider Medical Policies website (Provider Medical Policies | Anthem.com).

Medical Necessity Approach for DME

General DME medical necessity approach

Covered when ALL of the following are met:

General requirement: Medical necessity determinations for durable medical equipment (DME) are made using the specific DME Clinical Utilization Management Guidelines (CUMG) listed (e.g., CG-DME-08, CG-DME-10, CG-DME-18, CG-DME-24, CG-DME-31, etc.).

Providers must follow the listed DME CUMG for documentation and medical necessity requirements; when no specific Anthem Medical Policy or Clinical UM Guideline exists, MCG Care Guidelines are used.

Regulatory alignment: Determinations are made in accordance with applicable Medicaid state contracts, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines, which supersede MCG Care Guidelines when applicable.

Requests not meeting criteria will be referred to a licensed physician reviewer and may be denied.

Durable Medical Equipment: Rental vs Purchase

Equipment	Rental vs Purchase Rule
Durable Medical Equipment (general)	Refer to the specific DME Clinical Utilization Management Guideline (CUMG) for rental versus purchase determinations (see applicable CG-DME documents such as CG-DME-10 and related device-specific CUMGs).

Documentation and Supporting Evidence

Documentation Required

Use specific DME CUMG (e.g., CG‑DME‑08, CG‑DME‑10, CG‑DME‑18, CG‑DME‑24) for documentation and medical necessity

For Durable Medical Equipment requests, refer to the specific DME Clinical UM Guidelines (for example: CG‑DME‑08 Infant Home Apnea Monitors; CG‑DME‑10 Durable Medical Equipment; CG‑DME‑18 Home Oxygen Therapy; CG‑DME‑24 Wheeled Mobility Devices) for documentation and medical necessity requirements when preparing submissions.

CG‑DME‑08 — Infant Home Apnea Monitors
CG‑DME‑10 — Durable Medical Equipment
CG‑DME‑18 — Home Oxygen Therapy
CG‑DME‑24 — Wheeled Mobility Devices