CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines (Durable Medical Equipment list)

Lists Clinical Utilization Management (CUMG) guidelines adopted by Anthem HealthKeepers/HealthKeepers Plus Medicaid products, including many DME-related guidelines; informs providers about which MCG/coverage guidelines are used for medical necessity review and pre-payment determinations.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines (Durable Medical Equipment list)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionConsult the listed CUMG/MCG guidelines on the payer website for medical necessity and pre-payment prior authorization requirements and document clinical justification per the referenced guideline.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG / MCG guideline items listed

~40MCG guideline items in excerpt

MedicaidApplies to

MultipleDME-specific entries

Coverage Criteria Overview

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Referenced Guideline and Code Listings

Listed CUMG / MCG Items (selected sample)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 55

1/6

MCG Care Guideline items listedmixed

CG-SURG-84	Mandibular/Maxillary (Orthognathic) Surgery
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

1–10 of 40

1/4

Misc coding key/value

Primary identifierCG-ADMIN-01

ScopeClinical Utilization Management (UM) Guideline for Pre-Payment Review when no other Clinical UM Guideline exists

Category examplesIncludes DME-related CUMGs such as CG-DME-03 through CG-DME-59 listed elsewhere in the document

Adoption noteGuidelines marked 'New item' were adopted by the Medical Operations Committee for Medicaid members

Provider Requirements and Prior Authorization

Prior Authorization

Use of MCG/CUMG for Pre-Payment and Prior Authorization

MCG Care Guidelines and the Clinical Utilization Management Guidelines (CUMG) are used for medical necessity determinations in pre-payment review and prior authorization processes. These guidelines apply to inpatient medical and behavioral health reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures where no other Coverage Guideline or Clinical UM Guideline exists. ASAM criteria are used for substance use disorder services as required by state rules. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Coverage/Clinical UM Guidelines supersede MCG/CUMG.

If a request does not meet established guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise.
Providers may view adopted guidelines at Anthem's Clinical Guidelines search page.

Prior Authorization

MCG Guideline References for Prior Authorization

Specific MCG/CUMG guideline references are used for prior authorization and review. Examples include (non-exhaustive): CG-ADMIN-01 (Clinical UM Guideline for Pre-Payment Review), multiple CG-ANC and CG-DME titles (e.g., Ambulance Services, Neuromuscular Stimulation, TENS), numerous CG-SURG items (e.g., Mandibular/Maxillary Surgery CG-SURG-84; Mohs Micrographic Surgery CG-SURG-90; Panniculectomy and Abdominoplasty CG-SURG-99), CG-THER-RAD-07 (Intravascular Brachytherapy), and CG-TRANS items (e.g., Kidney Transplantation CG-TRANS-02). These and other listed CUMG items are used to determine medical necessity where applicable.

Providers should reference the specific CUMG ID when submitting authorization requests to facilitate review.
MCG/CUMG lists are illustrative and may be updated; state and CMS requirements take precedence.

Documentation Required

Documentation Guidance

Documentation requirements are governed by the applicable MCG/CUMG criteria and by Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Coverage/Clinical UM Guidelines. While explicit documentation checklists are not provided in this excerpt, providers must supply clinical information sufficient to demonstrate that requested services meet the stated guideline criteria. Requests lacking required clinical information may be referred to a licensed physician reviewer or denied.

Include relevant diagnosis, prior treatments, imaging/lab results, and rationale tying clinical findings to guideline criteria.
If documentation is incomplete, expect a request for additional information or referral to physician review.

Step Therapy

Step therapy is not specified in the provided MCG/CUMG excerpt. There are no step therapy rules referenced in the listed guideline items for this section.

When applicable, Anthem's Coverage Guidelines or state-specific rules will indicate any step therapy requirements separate from these MCG/CUMG references.
Providers should check the specific Coverage Guideline or Clinical UM Guideline for step therapy rules when applicable.

Note

Medical Necessity and Referral for Physician Review

Medical necessity determinations are made on a case-by-case basis in accordance with the definition contained within applicable Medicaid state contracts, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria (e.g., ADMIN.00004). If requests do not meet established guideline criteria, they will be referred to a licensed physician reviewer with appropriate clinical expertise.

MCG/CUMG are tools for consistency but do not override state or federal requirements or Anthem Coverage Guidelines.
Providers should reference the medical necessity definition in applicable contracts or Anthem policy when preparing prior authorization requests.

Definitions and Guideline Terms

Evidence-based clinical guidance (MCG Care Guidelines)

Evidence-based guidance usedMCG Care Guidelines

ApplicationsMedical necessity review for inpatient medical and behavioral health; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; outpatient services when no Coverage or Clinical UM Guideline exists

Supplementary criteriaASAM criteria used for substance use disorder services per state requirements

HierarchyMedicaid state contracts, regulatory guidance, CMS requirements and payer Coverage/Clinical UM Guidelines supersede MCG Care Guidelines

CUMG items adopted by Medical Operations Committee

DefinitionCUMG (Clinical Utilization Management Guideline) — specific guideline items adopted by the Medical Operations Committee for Medicaid members, each referenced by a CG-XXX-## code

ExamplesIncludes items such as CG-ADMIN-01 (pre-payment review), CG-DME-08 (Infant Home Apnea Monitors), CG-DME-21 (External Infusion Pumps)

AccessTo view a guideline, visit the payer's Clinical Guidelines search (Anthem provider policies/clinical guidelines)

MCG Care Guidelines / CUMG (term mapping)

Term mapping: MCG vs CUMGMCG Care Guidelines = the evidence-based source; CUMG = Clinical Utilization Management Guidelines (CG-XXX-##) derived from MCG and adopted for payer use

UsageMCG Care Guidelines inform CUMG creation and are used for medical necessity and site-of-service decisions; when no Coverage Guideline exists use CG-ADMIN-01

Adoption indicatorMany listed CUMG items in the document are annotated as 'New item' indicating recent adoption by the Medical Operations Committee

Durable Medical Equipment Medical Necessity Direction

General DME medical necessity direction

Refer to the specific CUMG listed for equipment-specific medical necessity criteria; when no specific CUMG exists, use CG-ADMIN-01 for pre-payment review and medical necessity determinations.

General rule: Medical necessity determinations for durable medical equipment must follow the referenced Clinical Utilization Management Guidelines (CUMG)/MCG Care Guidelines. If no specific CUMG exists for the requested equipment, CG-ADMIN-01 (Clinical Utilization Management Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists) applies.

Requests that do not meet established criteria guidelines will be referred to a licensed physician reviewer; determinations are made case-by-case per the Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria ADMIN.00004.

DME criteria not present

none: No DME medical necessity criteria are provided in this excerpt; refer to the specific CUMG items listed elsewhere in this document for equipment-specific criteria.

Rental and Purchase / Acquisition Rules

Equipment / Item	Rental vs Purchase Rule	Notes / Citation
Balloon Dilation of the Eustachian Tubes (CG-SURG-117)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-117).
Intraocular Anterior Segment Aqueous Drainage Devices (CG-SURG-118)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-118).
Treatment of Varicose Veins (Lower Extremities) (CG-SURG-119)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-119).
Vagus Nerve Stimulation (CG-SURG-120)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-120).
Fetal Surgery for Prenatally Diagnosed Malformations (CG-SURG-121)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-121).
Lingual Frenotomy for Ankyloglossia-Related Feeding Difficulties (CG-SURG-122)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-122).
Autologous Fat Grafting and Injectable Soft Tissue Fillers (CG-SURG-123)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-123).
Viscocanalostomy (CG-SURG-124)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-124).
Canaloplasty (CG-SURG-125)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-125).
Tibial Nerve Stimulation (CG-SURG-126)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-126).
Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses (CG-SURG-127)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-127).
Presbyopia and Astigmatism-Correcting Intraocular Lenses (CG-SURG-128)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-128).
Internal Rib Fixation Systems (CG-SURG-129)	Not specified (no rental or purchase rule provided in excerpt)	MCG Care Guideline listed; excerpt contains guideline title but does not state rental/purchase rules (see CG-SURG-129).

Documentation and Justification

Documentation Required

Document clinical justification per MCG/CUMG and Medicaid medical necessity

Document clinical justification according to the referenced MCG/CUMG guideline for the service and the Medicaid medical necessity definition; when no specific Coverage Guideline exists use CG-ADMIN-01 for pre‑payment review.

Follow the CUMG/MCG criteria listed for the specific CG-XXX-## item.
If no specific guideline exists, use CG-ADMIN-01 (Pre‑Payment Review).

Documentation Required

No DME‑specific documentation requirements in excerpt

The excerpt contains no DME‑specific documentation requirements or detailed documentation checklists for DME items.

OpenPayer

Clinical Utilization Management Guidelines (Durable Medical Equipment list)

Coverage Criteria Overview

Referenced Guideline and Code Listings

Provider Requirements and Prior Authorization

Background and Scope

Definitions and Guideline Terms

Durable Medical Equipment Medical Necessity Direction

Rental and Purchase / Acquisition Rules

Replacement Rules

Documentation and Justification

Not Covered / Exclusions