CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (CUMG) - Index (Durable Medical Equipment)

A listing/index of Anthem Clinical Utilization Management (CUMG) guidelines adopted by the medical operations committee on September 9, 2021; intended for Anthem members and providers to identify applicable guideline documents.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (CUMG) - Index (Durable Medical Equipment)

Policy CodePolicy N/A

Change TypeInformational indexno material changes

Effective DateSep 9, 2021

Next Review DateN/A

Key ActionConsult the specific CG-DME guideline listed in this index for medical necessity, prior authorization, and documentation requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2021-09-09adoption date

100+listed CUMG entries

NEWentries marked NEW

3pages in excerpt

Actions for Providers and Billing

Prior Authorization

Specific guideline prior authorization — consult individual CUMG

Some Clinical Utilization Management (CUMG) policies include specific prior authorization (PA) requirements. When a CUMG lists an individual guideline (for example, any CG-DME-, CG-SURG-, or similarly coded guideline), consult that specific guideline document to determine whether prior authorization is required for the service or device.

Action: Check the listed individual CUMG (e.g., CG-DME-10) for any Prior Authorization requirements before scheduling or billing the service.
If prior authorization is required, follow the authorization process described in that individual guideline.

Denial Risk

No explicit authorization/denial triggers in the index

The index listing of CUMG titles does not itself state explicit authorization or denial triggers (clinical criteria that alone cause an authorization or denial). Providers must not assume coverage or denial from the index alone.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (CUMG) - Index (Durable Medical Equipment)

Policy CodePolicy N/A

Change TypeInformational indexno material changes

Effective DateSep 9, 2021

Next Review DateN/A

Key ActionConsult the specific CG-DME guideline listed in this index for medical necessity, prior authorization, and documentation requirements.

SourceLink

On This Page

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Alert: The index is a directory of guideline titles only — it does not contain the clinical criteria that determine authorization or denial.
Action: Review the full text of the relevant CUMG for the clinical criteria that drive authorization decisions.

Note

Where to find guideline documents

Full Clinical Utilization Management Guideline documents are available from Anthem’s CUMG search page. Use that resource to access the complete guideline text, PA instructions, step therapy, documentation requirements, and other operational details.

Where to find guidelines: https://www11.anthem.com/ny_search.html
Action: Open the specific CUMG from the Anthem guideline search page to find PA forms, submission contact information, and clinical criteria.

Note

Provider action / general flag

When an index entry or CUMG summary is silent on authorization, step therapy, or denial triggers, treat this as a flag to obtain the full guideline and any pre-service authorization if clinically appropriate.

Flag: Absence of detail in the index = obtain the full guideline before rendering service when possible.
Action: If no clinical UM guideline exists for a requested service, follow the administrative pre-payment review process (see CG-ADMIN-01) for medical necessity determinations.

Documentation Required

Pre-payment review when no clinical UM guideline exists

Administrative pre-payment review applies when there is no other clinical UM guideline for a requested service. CG-ADMIN-01 governs pre-payment medical necessity determinations in those cases.

When no applicable clinical CUMG exists, submit documentation per the Pre-Payment Review guideline (CG-ADMIN-01) to support medical necessity reviews.
Operational note: Follow submission instructions in CG-ADMIN-01 to avoid claim delays or denials.

Document Background and Scope

This document is an index of Anthem Clinical Utilization Management Guidelines (CUMG) adopted by the medical operations committee on September 9, 2021. It lists numerous guideline identifiers and titles across clinical areas — including a broad series of DME items (e.g., CG-DME-03 through CG-DME-49) as well as administrative, surgical, genetic, laboratory, rehabilitation, and transplant guidelines. Many entries are annotated as New item, indicating recent additions to the guideline library. Providers should use this index to identify the specific CUMG document they need and then review that individual guideline for clinical criteria, documentation requirements, and any prior authorization or utilization management instructions.

Key Terms

CUMG — Key definitions

AcronymCUMG

DefinitionClinical Utilization Management Guidelines — an indexed collection of guideline documents referenced by Anthem (titles and identifiers listed in this index).

PurposeTo identify specific clinical UM guideline documents providers should consult for medical necessity, documentation, and authorization requirements.

How to useRefer to the specific CUMG identifier (e.g., CG-SURG-96) listed in the index to locate the full guideline for detailed criteria and requirements.

Document statusEntries in the index may be annotated as 'New item' indicating recently added guidelines; the index excerpt was adopted by the medical operations committee on 2021-09-09.

Medical Necessity Guidance

MEDICAL NECESSITY — Durable Medical Equipment (DME) guidance

Medical necessity determinations for durable medical equipment (DME) are defined in the individual CG‑DME guideline documents listed below; providers must refer to the specific CG‑DME policy for the complete medical necessity criteria, required documentation, and any prior authorization rules.

Refer to the specific CG‑DME guideline for the item being requested (for example: CG‑DME‑09, 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, CG‑DME‑37, CG‑DME‑39, CG‑DME‑40 and others listed in the CUMG index) for the applicable medical necessity criteria and coverage rules.

If no specific CG‑DME guideline exists for the requested item, follow administrative medical necessity review processes (see CG‑ADMIN‑01) and consult the Anthem guideline search page to locate applicable CUMG documents (https://www11.anthem.com/ny_search.html).

Prior authorization, step therapy, documentation requirements, and pre‑payment review procedures (when applicable) are specified within each CG‑DME guideline; the index document does not itself contain specific prior authorization or step therapy rules.

Documentation and Record Requirements

Documentation Required

Refer to each CG-DME guideline for documentation requirements

The index includes numerous CG-DME entries (for example, CG-DME-03 through CG-DME-49); providers must refer to each specific CG-DME guideline to identify required documentation for medical necessity and claims support.

Examples of listed CG-DME documents include CG-DME-03, CG-DME-04, CG-DME-05, CG-DME-06, CG-DME-07, CG-DME-08, CG-DME-09, 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, CG-DME-37, CG-DME-39, CG-DME-40