CurrentAnthemPolicy N/A

Clinical Utilization Management Guidelines — Wisconsin Medicaid (CUMG) — Durable Medical Equipment (DME)

List of Anthem Clinical Utilization Management (CUMG) Guidelines adopted for Wisconsin BadgerCare Plus and Medicaid SSI programs; governs medical necessity and utilization review for covered services and durable medical equipment for affected Medicaid members and providers.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Guidelines — Wisconsin Medicaid (CUMG) — DME

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit medical necessity documentation per the listed CUMG entries and state Medicaid requirements; prior authorization may be required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG items listed across specialties

CG-DME-01..CG-DME-49+DME-related CUMG entries referenced

WisconsinState-specific applicability

~30CUMG entries in excerpt

Coverage Criteria Overview

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The Clinical Utilization Management Guidelines (CUMGs) listed in this document are adopted for Anthem Blue Cross and Blue Shield's Wisconsin BadgerCare Plus and Medicaid SSI programs to guide utilization review for covered services and durable medical equipment. MCG Care Guidelines may be referenced only for specified inpatient and outpatient review contexts — specifically for medical necessity review of medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and select outpatient services or procedures when no other Anthem Medical Policy or Clinical UM Guideline exists. Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

CUMG Identifiers

CUMG identifiers (no billing codes in this portion)mixed

CG-ADMIN-0O1	CUMG title = Clinical Utilization Management (UM) Guideline for Pre- Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists.
CG-ANC-04	CUMG title = Ambulance Services: Air and Water.
CG-ANC-05	CUMG title = Ambulance Services: Ground; Emergent.
CG-ANC-06	CUMG title = Ambulance Services: Ground; Nonemergent.
CG-ANC-07	CUMG title = Inpatient Interfacility Transfers.
CG-ANC-08	CUMG title = Mobile Device-Based Health Management Applications.
CG-BEH-02	CUMG title = Adaptive Behavioral Treatment.
CG-BEH-14	CUMG title = Intensive In-Home Behavioral Health Services.
CG-BEH-15	CUMG title = Activity Therapy for Autism Spectrum Disorders and Rett Syndrome.
CG-DME.03	CUMG title = Neuromuscular Stimulation in the Treatment of Muscle Atrophy.

1–10 of 49

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Provider Actions & Authorization Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for services and durable medical equipment when they are identified in the listed Clinical Utilization Management Guidelines (CUMGs) and when Anthem’s CUMG or Medical Policy indicates a pre-payment medical necessity review is applicable. Examples include but are not limited to inpatient utilization, certain DME items, and outpatient services where no separate Medical Policy exists. Providers should consult the specific CUMG title for details and submit authorization requests per Anthem Wisconsin procedures.

Affected items: CUMGs listed in the document (e.g., CG-ANC-04 through CG-DME.07, CG-SURG-83 through CG-TRANS-03).
Action: Submit prior authorization/pre-payment review requests when the specific CUMG or Medical Policy indicates review is required.

Note

Prior Authorization Not Specified in Excerpt — Verify Before Acting

The excerpted CUMG index does not explicitly specify prior authorization requirements for each listed guideline in this section. The document primarily lists guideline identifiers and titles with placeholders for new-item notation; providers must not assume authorization status from this list alone.

Action: Verify prior authorization requirements by reviewing the full CUMG text at providers.anthem.com/wisconsin-provider/resources/manuals-and-guides or the applicable Anthem Medical Policy.
Note: 'New item' flags in the index do not convey authorization or coverage determination details.

Note

Provider Communication — Email Signup

Anthem uses email as a primary channel for provider communications, including communications sent in lieu of fax or mail. Sign up to receive email notices and updates to ensure you get timely authorization and policy information.

Sign-up: http://anthem.ly/signup-abcbs-wi (or use the QR code referenced in the source).
Tip: Ensure your practice email on file is current to receive pre-payment review and policy change notices.

Documentation Required

Medical Necessity and Denial Referral Process

Medical necessity determinations are made on a case-by-case basis in accordance with Medicaid state contract definitions, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines. If a request does not meet established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if criteria are not met.

Decision basis: Medicaid contracts, regulatory guidance, CMS requirements, and Anthem Medical Necessity Criteria Policy ADMIN.OOO04.
Referral: Nonconforming requests will be reviewed by a licensed physician and may result in denial if clinical criteria are unmet.

Background and Scope

Anthem has adopted a broad set of Clinical Utilization Management Guidelines to support medical necessity determinations and utilization review for Wisconsin Medicaid members and providers. These guidelines are used to inform pre-payment review and site-of-service decisions, and determinations 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.OOO04. Requests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise for final determination. Providers should consult the publicly available CUMG listings on the Anthem provider website for specific guideline details and any CUMGs adopted by the Medical Operations Committee.

Key Definitions

Medical necessity — definition and basis for determinations

Definition of medical necessityDeterminations are made case-by-case in accordance with the definition contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy ADMIN.OOO04.

Basis for determinationsMedical necessity review may reference MCG Care Guidelines only for limited inpatient/outpatient contexts; Medicaid state contracts, regulatory guidance, CMS requirements, and Anthem Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Review and referral processIf a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make a decision.

Applicable contexts for MCG useMCG Care Guidelines are used only for: medical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient services where no established Medical Policy or Clinical UM Guideline exists.

Authority and hierarchyMedicaid state contracts, regulatory guidance, CMS requirements and Anthem Medical Policy/Clinical UM Guidelines take precedence over MCG Care Guidelines when conflicts exist.

Device-Specific Medical Necessity

Device-specific criteria — refer to individual CUMGs

See individual Clinical Utilization Management Guidelines (CUMGs) listed below for device-specific medical necessity criteria. Providers must consult the named CUMG for the full coverage criteria and documentation requirements; some items may require prior authorization.

CUMG-referenced criteria: Medical necessity and coverage criteria are specified in each named CUMG (for example: CG-DME-03 Neuromuscular Stimulation; CG-DME-04 Electrical Nerve Stimulation; CG-DME-05 Cervical Traction Devices; CG-DME-06 Compression Devices for Lymphedema; CG-DME-07 AAC Devices; CG-DME-08 Infant Home Apnea Monitors; CG-DME-09 Elastomeric Infusion Pumps; 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 Surfaces; 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 & KAFO Orthoses; CG-DME-23 Lifting Devices; CG-DME-24 Manual Wheeled Mobility Devices; CG-DME-25 Seat Lift Mechanisms; CG-DME-26 Back-Up Ventilators; 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 Stretch Devices; CG-DME-40 Noninvasive Electrical Bone Growth Stimulation; CG-DME-41 Ultraviolet Light Therapy Devices; CG-DME-42 Nonimplantable Insulin Infusion and BGM Devices; CG-DME-43 High Frequency Chest Compression Devices; CG-DME-44 Electric Tumor Treatment Field (TTF); CG-DME-45 Ultrasound Bone Growth Stimulation; CG-DME-46 Pneumatic Compression Devices for DVT Prevention; CG-DME-47 Noninvasive Home Ventilator Therapy; CG-DME-48 Vacuum Assisted Wound Therapy; CG-DME-49 Standing Frames).

This policy excerpt lists CUMG identifiers and titles only; consult the individual CUMG document for precise clinical criteria, thresholds, and prior authorization requirements.

Documentation and review: Requests that do not meet the criteria specified in the applicable CUMG will be referred to a licensed physician reviewer and may be denied. Determinations of medical necessity are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Anthem's Medical Necessity Criteria Policy.

Providers must submit medical necessity documentation per the named CUMG and state Medicaid requirements; prior authorization may be required where the CUMG indicates.

Rental, Purchase, and Replacement Rules

Item / CUMG	Rental vs Purchase Rule
CG-DME-07 — (New item)
CG-DME-08 — Infant Home Apnea Monitors
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 or Modifications for Individuals with Diabetes
CG-DME-21 — External Infusion Pumps for 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

Replacement — inventory note

Scope of replacement rules in this excerptReplacement intervals or detailed replacement rules are not specified in this document portion; replacement guidance is not provided here.

Related CUMG listingThe DME CUMG entries listed (e.g., CG-DME.07 through CG-DME-19 and others) reference specific device types but do not include replacement specifics in this excerpt.

Provider action implicationProviders must consult the individual CUMG for device-specific replacement intervals or replacement rules; this excerpt contains only the listing of CUMGs.

Where to find replacement rulesRefer to the full CUMG document for each DME item on the Anthem provider site to obtain replacement and frequency guidance.

Documentation & Submission Requirements

Documentation Required

Submit medical necessity documentation per CUMG and Medicaid rules; PA may be required

Submit complete medical necessity documentation in accordance with the named CUMG and Medicaid requirements; note that prior authorization may be required for some CUMG-listed items.

Provide clinical notes, rationale, and any required supporting tests or measurements as specified in the individual CUMG.
Failure to provide required documentation may result in referral to a physician reviewer and denial.