CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines — DME (California | Medi‑Cal)

List of Clinical Utilization Management Guidelines adopted by Anthem for California / Medi‑Cal Managed Care providers, serving as an index of CUMG items used for medical necessity and utilization management for DME and other services.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — DME (California | Medi‑Cal)

Policy CodePolicy N/A

Change TypeNo material changes identified

Effective DateN/A

Next Review DateN/A

Key ActionProviders should consult the specific CUMG for documentation required for each DME item and for medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+Listed CUMG items

~50DME-related identifiers

California (Medi‑Cal)Jurisdiction

~11MCG items in excerpt

Application of Clinical Utilization Management Guidelines

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

CUMG use: CUMG/MCG 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-based services or procedures where there is not an established Medical Policy or Clinical UM Guideline.

See individual guideline documents for item-specific medical necessity criteria and thresholds.

The listed MCG/CUMG care guidelines are used by Anthem for utilization management activities including: medical necessity review for inpatient medical and behavioral health services, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures where no Anthem Medical Policy or Clinical UM Guideline exists. Providers should consult the published guidelines on Anthem’s provider policy site for the specific criteria that apply to a service.

This document excerpt is an index of adopted CUMG/MCG guideline identifiers and titles and does not itself contain item-specific coverage criteria, exclusions, or medical necessity logic. For each listed guideline (for example, CG‑SURG‑96, CG‑SURG‑99, CG‑SURG‑100, etc.), providers must refer to the individual guideline document for the applicable criteria, exclusions, and decision logic.

Listed Clinical Utilization Management Guideline Identifiers

Listed CUMG identifiers (excerpt)mixed

CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04	Transcutaneous Electrical Nerve Stimulation
CG-DME-05	Cervical Traction Devices for Home Use
CG-DME-06	Compression Devices for Lymphedema
CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
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

1–10 of 46

1/5

Other listed CUMG identifiers (excerpt)mixed

CG-ADMIN-01	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-LAB-03	Tropism Testing for HIV Management

1–10 of 14

1/2

Referenced MCG guideline codes (not billing codes)mixed

No codes listed

inv-07: miscellaneous coding key/value (empty label in inventory)

Document typeClinical Utilization Management Guidelines (CUMG) list adopted by Anthem for Medi-Cal Managed Care in California

JurisdictionCalifornia (Medi-Cal)

PurposeIndex of adopted CUMG/MCG care guideline identifiers and titles used for utilization management and medical necessity review

AccessFull guidelines available on Anthem provider medical policies website

ScopeIncludes DME-related guideline identifiers and many other specialty guidelines; refer to individual guideline documents for item-specific criteria

inv-08: miscellaneous coding key/value (empty label in inventory)

MCG care guidelines example rangeIncludes numerous CG-SURG items such as CG-SURG-96 through CG-SURG-128 in the excerpt

MCG adoption noteSome MCG items in the list are indicated as New and were adopted by the Medical Operations Committee for Medicaid members

Reference formatGuideline identifiers are listed as CG-XXX-## with corresponding titles (e.g., CG-SURG-96: Intraocular Telescope)

Where to viewProvider Medical Policies | Anthem.com (site hosts full guideline text)

What Providers Must Do / Be Aware Of

Prior Authorization

Use of CUMG for pre-payment and medical necessity review

Anthem uses the Clinical Utilization Management Guidelines (CUMG/MCG) as part of pre-payment and medical necessity review processes. CUMG are applied for inpatient medical and behavioral health reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no Anthem Medical Policy or Clinical UM Guideline exists.

Used for medical necessity review of medical and behavioral health inpatient care
Applied for inpatient site-of-service and post-acute settings (rehab, SNF)
Used for outpatient services when no established Anthem policy exists

Documentation Required

Medical necessity decision standard

Determinations of medical necessity are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, and Anthem’s Medical Necessity Criteria Policy (ADMIN.00004). When a case does not meet established guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for final determination.

Medical necessity decisions follow Medicaid/CMS/Anthem rules and ADMIN.00004
Case-by-case review and licensed physician referral when criteria are not met

Denial Risk

Referral and potential denial when criteria not met

If a submitted request does not meet the applicable CUMG or Anthem criteria, the case will be referred to a licensed physician reviewer and may be denied if the reviewer determines the service is not medically necessary. Providers should expect referral for physician review and potential denial when documentation or clinical indications do not support the guidelines.

Nonconforming requests are referred to a physician reviewer
Potential for denial if medical necessity is not supported by documentation or guideline criteria

DME Medical Necessity References

inv-20: DME medical necessity reference — individual CUMG docs define criteria; this doc is an index

This document is an index of adopted CUMG items. Individual CUMG documents define the medical necessity criteria for each listed DME item.

Index nature: This document lists adopted CUMG/MCG guideline identifiers and titles for durable medical equipment and related services; it does not contain item-specific medical necessity criteria.

Providers must refer to the referenced CUMG (e.g., CG-DME-03 through CG-DME-57) for the specific clinical criteria, documentation requirements, rental vs. purchase rules, and replacement intervals.

Rental vs Purchase and Replacement Rules

Equipment / Guideline	Rental vs Purchase
Infant Home Apnea Monitors (CG-DME-08)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Continuous Local Delivery of Analgesia using an Elastomeric Infusion Pump (CG-DME-09)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Durable Medical Equipment (CG-DME-10)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Home Phototherapy Devices for Neonatal Hyperbilirubinemia (CG-DME-12)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Lower Limb Prosthesis (CG-DME-13)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Hospital Beds and Accessories (CG-DME-15)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Pressure Reducing Support Systems Groups 1, 2 and 3 (CG-DME-16)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Home Oxygen Therapy (CG-DME-18)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.
Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes (CG-DME-19)
See individual CUMG document for item-specific rental vs purchase rules; this index does not specify rental vs purchase.

inv-22: Replacement rules key/value (unspecified in inventory)

Replacement / replacement intervalsNot specified in this index; replacement rules and intervals are defined within each individual DME CUMG document

Action for providersConsult the specific CUMG for the DME item to determine allowable replacements and timing

Rental vs purchaseRental vs purchase rules also specified in individual DME CUMG documents (not in this index)

Documentation Requirements for Providers

Documentation Required

Consult the specific CUMG for required documentation

Providers must consult the specific CUMG for the DME item to determine the exact documentation required; documentation consistent with the guideline will influence medical necessity determinations.

Documentation must align with the CUMG criteria for the cited DME item.
Follow Medicaid/CMS/Anthem requirements when preparing supporting clinical records.

Documentation Required

Document clinical necessity per guideline and policy

Prepare and submit clinical records and justification per the individual guideline and applicable regulations; if the excerpt does not specify additional requirements, rely on the CUMG and Anthem Medical Policy guidance for documentation content and sufficiency.

Policy Definitions and Guideline References

inv-18: Medical necessity definition per Medicaid/CMS/Anthem

Definition of medical necessityDeterminations 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 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

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

inv-19: MCG care guideline references and example identifiers

MCG / MCG identifiers includedMCG care guideline identifiers and titles are listed (examples: CG-SURG-96: Intraocular Telescope; CG-DME-08: Infant Home Apnea Monitors)

MCG as referenceThis document is an index of MCG/ CUMG identifiers; consult the named guideline for full criteria and identifiers

Where to find full guideline textView guidelines at Provider Medical Policies | Anthem.com

Examples of MCG items in excerptSurgical (CG-SURG-96 to CG-SURG-128 series) and DME items (CG-DME-03 through CG-DME-57 shown in the DME list) are present

Policy Background and Scope

This document functions as a catalog of Clinical Utilization Management Guidelines (CUMG) and MCG care guideline titles and identifiers that Anthem has adopted for use in California Medi‑Cal managed care. It is intended to inform providers which guideline items are in use; specific clinical criteria, documentation requirements, rental/purchase rules, and replacement intervals are defined within the individual guideline documents referenced in this index.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — DME (California | Medi‑Cal)

Policy CodePolicy N/A

Change TypeNo material changes identified

Effective DateN/A

Next Review DateN/A

Key ActionProviders should consult the specific CUMG for documentation required for each DME item and for medical necessity requirements.

SourceLink

On This Page