CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines — Wisconsin BadgerCare Plus and Medicaid SSI (DME index)

A listing of Clinical Utilization Management (CUMG) guidelines adopted by Anthem Blue Cross and Blue Shield for Wisconsin BadgerCare Plus and Medicaid SSI programs; defines use of CUMGs for medical necessity and utilization review for covered services and informs providers which guidelines apply. Affects providers treating Anthem members under Wisconsin Medicaid programs.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — Wisconsin BadgerCare Plus and Medicaid SSI (DME index)

Policy CodePolicy N/A

Change TypeInformational update (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionFollow the listed CUMG titles for DME medical necessity and submit pre-payment reviews when no specific Medical Policy or Clinical UM Guideline exists (see CG-ADMIN-01).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120+CUMG items listed in this partial document window

~24CUMG titles in these chunks

WisconsinState program governed

NCAlso applicable state

Coverage Criteria Overview

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Actions Providers Must Take

Prior Authorization

Provider Action Summary

Anthem uses these Clinical UM Guidelines and referenced MCG Care Guidelines for pre-payment and utilization review. When no specific Medical Policy or Clinical UM Guideline exists, MCG Care Guidelines may be used for inpatient medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services or procedures. Medical necessity determinations are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines. American Society of Addiction Medicine (ASAM) criteria are used for substance abuse services where required by the state.

Pre-Payment Review and Prior Authorization: Requests for services subject to Anthem Clinical UM Guidelines or MCG will require pre-payment review or prior authorization per Anthem processes; providers should follow Anthem’s prior authorization procedures and submit required clinical documentation.
Documentation and medical necessity basis: Determinations are made case-by-case per Medicaid contract, CMS guidance, and Anthem Medical Necessity Criteria Policy (ADMIN.OOO04).
Denial triggers: Requests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise; failure to meet criteria may result in denial.
No explicit authorization or denial triggers provided in the listed CUMG title list: The CUMG list (titles) is informational and does not by itself provide specific prior authorization rules or explicit authorization/denial triggers — providers must consult the specific guideline or Anthem Medical Policy for concrete requirements.
No step therapy requirements specified: The provided chunks do not specify any step therapy requirements or quantity limits; check the applicable policy/guideline for any such constraints.
Provider communications signup: Providers are encouraged to sign up to receive email communications from Anthem (QR code or http://anthem.ly/signup-abcbs-wi) to receive updates, including notices sent in lieu of fax or mail.

Denial Risk

Denial Risk and Documentation

If a request does not meet the established Clinical UM or MCG criteria, the case will be escalated to a licensed physician reviewer. Providers should ensure submitted documentation clearly supports medical necessity according to Anthem’s and state-specific criteria to reduce the risk of denial.

When criteria are not met, expect referral to a licensed physician reviewer with appropriate expertise.
Include comprehensive clinical documentation and references to the specific guideline or policy used for the service request.

Note

Guideline Titles vs. Authorization Rules

The CUMG list in this document provides guideline titles adopted by Anthem but does not enumerate per-item prior authorization requirements, explicit authorization triggers, or denial criteria. Providers must consult the specific Clinical UM Guideline, Anthem Medical Policy, or contact Anthem Provider Services for authorization rules for a given service.

The title list (e.g., CG-SURG-101 through CG-SURG-117 examples) is informational only — it does not specify prior authorization rules.
For actionable authorization/denial triggers, refer to the published guideline or Anthem’s provider portal.

Definitions and Referenced Guidance

MCG Care Guidelines — External clinical guidance referenced by Anthem for inpatient and select outpatient medical necessity reviews.

DefinitionMCG Care Guidelines: external clinical guidance used by Anthem for medical necessity review for medical and behavioral health inpatient review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and selected outpatient services when no Anthem Medical Policy or Clinical UM Guideline exists.

ScopeUsed only for specified purposes; superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines.

Use in reviewsApplied for inpatient medical necessity and select outpatient procedures when no Anthem policy exists.

Decision processIf a request does not meet established criteria, it is referred to a licensed physician reviewer with appropriate clinical expertise.

AccessFull list of Medical Policies and Clinical UM Guidelines is publicly available on Anthem's Medical Policy and Clinical UM Guideline subsidiary website.

ASAM criteria — Standards used for substance abuse services in accordance with state requirements.

DefinitionASAM criteria: standards from the American Society of Addiction Medicine used for substance abuse services in accordance with state requirements.

ApplicabilityUsed where state requirements for substance abuse services specify ASAM criteria.

Relationship to other guidanceASAM criteria are referenced alongside Clinical UM Guidelines; state contracts and regulatory guidance supersede external criteria where applicable.

Clinical Utilization Management Guidelines (CUMG) titles listed — index of CUMG titles mentioned in the document.

CUMG index example (DME)CG-DME-09: Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump; CG-DME-10: Durable Medical Equipment; CG-DME-12: Home Phototherapy Devices for Neonatal Hyperbilirubinemia; CG-DME-13: Lower Limb Prosthesis; CG-DME-15: Hospital Beds and Accessories; CG-DME-16: Pressure Reducing Support Systems Groups 1, 2 and 3; CG-DME-18: Home Oxygen Therapy; CG-DME-19: Therapeutic Shoes/Inserts/Modifications for Individuals with Diabetes.

CUMG index example (Surgical & Procedural)CG-SURG-101: Ablative Techniques as a Treatment for Barrett's Esophagus; CG-SURG-102: Alcohol Septal Ablation for Hypertrophic Cardiomyopathy; CG-SURG-103: Penile Circumcision; CG-SURG-104: Intraoperative Neurophysiological Monitoring; CG-SURG-105: Corneal Collagen Cross-Linking; CG-SURG-106: Venous Angioplasty with or without Stent Placement.

Availability noteCUMG titles indicated as new were adopted by the Medical Operations Committee for Anthem members on March 28, 2024; full guidelines are available via Anthem's Provider Medical Policy Search.

DME Medical Necessity Guidelines

DME guideline index

Multiple DME CUMG titles are listed indicating Anthem has developed or adopted guidelines for these equipment types; specific medical necessity criteria are contained within each individual CUMG (not included in this window).

DME guideline listing: Individual CUMG titles (e.g., CG-DME-09 Continuous Local Delivery of Analgesia using an Elastomeric Infusion Pump; CG-DME-10 Durable Medical Equipment; CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia; CG-DME-13 Lower Limb Prosthesis; CG-DME-15 Hospital Beds and Accessories; CG-DME-16 Pressure Reducing Support Systems Groups 1, 2 and 3; CG-DME-18 Home Oxygen Therapy; CG-DME-19 Therapeutic Shoes/Inserts for Diabetes; CG-DME-21 External Infusion Pumps; CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses; CG-DME-23 Lifting Devices for Home Use; CG-DME-24 Manual Wheeled Mobility Devices; CG-DME-25 Seat Lift Mechanisms; CG-DME-26 Back-Up Ventilators in the Home; CG-DME-30 Prothrombin Time Self-Monitoring Devices; CG-DME-31 Powered Wheeled Mobility Devices; CG-DME-33 Ultra Lightweight Manual Wheelchairs; CG-DME-34 Wheelchair Accessories; CG-DME-35 Electric Breast Pumps; CG-DME-36 Pediatric Gait Trainers; CG-DME-37 Air Conduction Hearing Aids; CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices, etc.) indicate separate CUMG pages exist for each equipment type

Full criteria not present in this partial document

Rental and Purchase Information

CUMG ID	Title
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
CG-DME-15
Hospital Beds and Accessories
CG-DME-16
Pressure Reducing Support Systems Groups 1, 2 and 3
CG-DME-18
Home Oxygen Therapy
CG-DME-19
Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes
CG-DME-21
External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
CG-DME-22
Ankle-Foot & Knee-Ankle-Foot Orthoses
CG-DME-23
Lifting Devices for Use in the Home
CG-DME-24
Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
CG-DME-25
Seat Lift Mechanisms
CG-DME-26
Back-Up Ventilators in the Home Setting
CG-DME-30
Prothrombin Time Self-Monitoring Devices
CG-DME-31
Powered Wheeled Mobility Devices
CG-DME-33
Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
CG-DME-34
Wheeled Mobility Devices: Wheelchair Accessories
CG-DME-35
Electric Breast Pumps
CG-DME-36
Pediatric Gait Trainers
CG-DME-37
Air Conduction Hearing Aids
CG-DME-39
Dynamic Low-Load Prolonged-Duration Stretch Devices

OpenPayer

Clinical Utilization Management Guidelines — Wisconsin BadgerCare Plus and Medicaid SSI (DME index)

Coverage Criteria Overview

Actions Providers Must Take

Definitions and Referenced Guidance

DME Medical Necessity Guidelines

Rental and Purchase Information

Replacement Rules

Documentation Requirements

Policy Background

Exclusions and Not Medically Necessary Determinations