CurrentBlue Cross Blue Shield - MainePolicy N/A

Clinical Utilization Management Criteria (Anthem UM Guidelines list)

A registry/listing of Clinical Utilization Management (UM) Guidelines and Clinical Utilization Management Criteria adopted by Anthem Blue Cross and Blue Shield Medicaid / Ohio Medicaid Managed Care, describing criteria titles and their adoption status; intended for providers and internal reviewers who reference applicable UM guidelines for medical necessity determinations.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClinical Utilization Management Criteria (Anthem UM Guidelines list)

Policy CodePolicy N/A

Change TypeInformational listing — no material change

Effective DateN/A

Next Review DateN/A

Key ActionReference the publicly available Medical Policies and Clinical UM Guidelines on the subsidiary website when submitting requests and sign up for email updates.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+listed Clinical UM Criteria/Policies

2024-03-28adoption date (items marked new)

Pg 3/4pagination

Coverage criteria & applicability

inv-01: Application of MCG and Clinical UM Guidelines

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General Application: 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 services/procedures when there is not an established Medical Policy or Clinical UM Guideline.

Medicaid state contracts, regulatory guidance, CMS requirements and our Medical Policy/Clinical UM Guidelines, when approved by the Department for Medicaid Services (DMS), supersede MCG Care Guidelines.

Medical Necessity Determinations: Determinations of medical necessity are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy; requests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

inv-02: Behavioral health medical necessity tools

Behavioral health tools

Behavioral Health and Substance Use: When MCG Care Guidelines do not cover a behavioral health service, the following standardized tools are used for medical necessity determinations: Adults — LOCUS; Children and Adolescents — CASII; Young Children — ECSII. For substance use services, ASAM criteria are used according to state requirements.

This document lists the Clinical Utilization Management (UM) Guidelines and MCG Care Guidelines adopted for use with our Medicaid lines of business. MCG Care Guidelines are applied for medical necessity review of inpatient and behavioral health inpatient services, for inpatient site-of-service appropriateness, for inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when there is not an established Medical Policy or Clinical UM Guideline. Medicaid state contracts, regulatory guidance, CMS requirements and our Medical Policy/Clinical UM Guidelines, when approved by the Department for Medicaid Services (DMS), supersede MCG Care Guidelines.

Medical necessity determinations are made case-by-case in accordance with the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy. If a requested service does not meet the established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise and may be considered not medically necessary.

Listed Clinical UM Criteria and code groups

Listed Clinical UM Criteria and Policiesmixed

CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre- Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-DME-06	Pneumatic Compression Devices for Lymphedema
CG-DME-37	Air Conduction Hearing Aids
CG-DME-46	Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
CG-DME-49	Standing Frames
CG-LAB-03	Tropism Testing for HIV Management
CG-LAB-10	Zika Virus Testing
CG-LAB-11	Screening for Vitamin D Deficiency in Average Risk Individuals
CG-LAB-14	Respiratory Viral Panel Testing in the Outpatient Setting

1–10 of 73

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What providers must do

Prior Authorization

Use of UM Guidelines for medical necessity

Medical necessity reviews use the listed Medical Policies and Clinical UM Guidelines and, where applicable, MCG Care Guidelines to determine coverage and appropriate site of service for inpatient and outpatient services.

MCG Care Guidelines apply for inpatient medical and behavioral health reviews, inpatient site-of-service decisions, inpatient rehabilitation and SNF review, and for outpatient services when no specific Medical Policy/Clinical UM Guideline exists.
When MCG does not cover a behavioral health service, LOCUS, CASII, ECSII, or ASAM criteria (for substance use) are used as appropriate.

Note

Reference and communications

Providers should reference the publicly available Medical Policies and Clinical UM Guidelines on the plan’s Medical Policy and Clinical UM Guideline website when submitting prior authorization requests or clinical documentation to support medical necessity determinations.

Include citations to the specific Medical Policy or Clinical UM Guideline relied upon in the request.
If a service is not covered by a Medical Policy/Clinical UM Guideline, note which MCG guideline or standardized tool was used.

Denial Risk

Failure to meet criteria

If a request does not meet the established Medical Policy, Clinical UM Guideline, MCG Care Guideline or applicable standardized tool criteria, the request will be referred to a licensed physician reviewer with appropriate clinical expertise for final determination.

Appeals or additional clinical information may be requested by the physician reviewer to complete the determination.
Providers should ensure complete clinical documentation is submitted to avoid unnecessary referrals or delays.

Documentation Required

Provider responsibilities (actionable)

When submitting requests, be prepared to document which guideline(s) were used and provide supporting clinical information to expedite review and decision-making.

Provide relevant history, prior treatment, objective findings, and rationale linking the requested service to guideline criteria.
Incomplete or missing documentation may delay review or result in referral to a physician reviewer.

Background and rationale

When there is not an applicable Medical Policy or Clinical UM Guideline, MCG Care Guidelines are the standardized reference used to assess medical necessity for inpatient and outpatient services. For behavioral health and substance use services not covered by MCG, standardized tools are used: Adults: LOCUS; Children/Adolescents: CASII; Young Children: ECSII; and ASAM criteria for substance use. The listed Clinical UM Criteria (for example, multiple laboratory-related CG-LAB and LAB items) supplement the MCG framework when an explicit Clinical UM Guideline exists.

Key definitions

MCG Care Guidelines — definition and use

DefinitionMCG Care Guidelines are standardized clinical guidelines used for medical necessity reviews when no established Medical Policy or Clinical UM Guideline exists.

Primary usesMedical and behavioral health inpatient medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no established Medical Policy or Clinical UM Guideline exists.

Behavioral health fallback toolsIf MCG does not cover a behavioral health service, use LOCUS for adults, CASII for children/adolescents, and ECSII for young children; use ASAM criteria for substance use services per state requirements.

HierarchyMedicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines (when approved by the Department for Medicaid Services) supersede MCG Care Guidelines.

Decision processMedical necessity determinations are made case-by-case per the Medicaid definition; requests not meeting established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

Clinical UM Criteria for specific tests and panels

inv-12: Various laboratory tests and panels with Clinical UM Criteria

Listed laboratory Clinical UM criteria (titles shown) — applicable Clinical UM Guidelines exist for each listed test/panel.

Laboratory tests with Clinical UM Criteria: Tropism testing for HIV management (CG-LAB-03); Zika virus testing (CG-LAB-10); Screening for vitamin D deficiency in average-risk individuals (CG-LAB-11); Respiratory viral panel testing in the outpatient setting (CG-LAB-14); Serum amylase testing (CG-LAB-16); Molecular Gastrointestinal Pathogen Panel (GIPP) testing for infectious diarrhea in the outpatient setting (CG-LAB-17); Thyroid testing (CG-LAB-20); Serum iron testing (CG-LAB-21); Outpatient urine culture (CG-LAB-24); Outpatient glycated hemoglobin and protein testing (CG-LAB-25); Outpatient alpha-fetoprotein testing (CG-LAB-26); Human chorionic gonadotropin testing (CG-LAB-27); Prostate specific antigen testing (CG-LAB-28); Gamma glutamyl transferase testing (CG-LAB-29); Outpatient laboratory-based blood glucose testing (CG-LAB-30).

Each listed item corresponds to a Clinical UM Guideline (see criteria code) that will be used for medical necessity determinations.

Ordering & submission requirements

Billing Rule

ORDERING REQUIREMENTS: consult published policies and subscribe for updates

Providers should reference the Medical Policies and Clinical UM Guidelines on the subsidiary website for ordering guidance and may sign up for email updates to receive policy changes and communications.

Use the subsidiary website to locate the applicable Clinical UM Guideline title before ordering.
Subscribe to email updates at http://anthem.ly/signup-abcbs-oh for notifications.

Exclusions and not-covered items

This document is a registry of Clinical UM Criteria titles and does not enumerate explicit coverage exclusions. No specific laboratory tests are listed as categorically excluded here; instead the file lists criteria titles (for example CG-LAB-03 Tropism Testing, CG-LAB-10 Zika Virus Testing, LAB.00037 Serologic Testing for IBS biomarkers, among many others) that are subject to their individual Clinical UM Guidelines.