CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (CUMG) List

A catalog of Clinical Utilization Management Guidelines adopted for MMC, HARP, Child Health Plus, and Essential Plan members; identifies guideline codes and titles across DME, medical, surgical, lab, rehab, and other areas and guides medical necessity determinations for providers.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) List

Policy CodePolicy N/A

Change TypeInformational listing (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionFollow the specific Clinical UM Guideline for each DME item when submitting documentation and medical necessity requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120+listed Clinical UM Guidelines and Medical Policy items

~30CUMG items listed in this excerpt

MMC/HARP/CHPlus/EPPrograms governed

Adopted Clinical Utilization Management Guidelines

Adoption and application

Listed CUMG items are adopted for use; each guideline contains its own criteria for coverage determination.

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The listed Clinical Utilization Management Guidelines (CUMG) are provided for Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan (EP) members and are adopted to support medical necessity determinations. Medicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines and InterQual Criteria. Determinations of medical necessity are made on a case‑by‑case basis in accordance with the definitions contained in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy (ADMIN.00004).

Requests that do not meet the established guideline criteria will be referred to a licensed physician reviewer with appropriate clinical expertise for final determination. The listed CUMG items are intended as the primary clinical references for reviewers and may be used for pre‑payment review and prior authorization decisions where applicable; when no internal guideline exists, external criteria such as InterQual® or MCG Care Guidelines may be used as adjunct resources for level‑of‑care and medical necessity review.

Prior Authorization, Review, and Provider Responsibilities

Prior Authorization

Use of CUMG for prior authorization

InterQual® Criteria or MCG Care Guidelines are used for medical necessity review for inpatient and certain outpatient services and may be applied for pre-payment review and prior authorization determinations. Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede these guidelines. Determinations of medical necessity are made on a case-by-case basis in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.00004).

InterQual® and MCG Care Guidelines may be used for: inpatient medical and behavioral health review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; outpatient-based services or procedures where no established Medical Policy/Clinical UM Guideline exists.
Level of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance use disorder services per state requirements.
Medical policies and Clinical UM Guidelines are publicly available on the Highmark Medical Policy and Clinical UM Guideline website.

Note

Medical necessity review and referral process

If a request does not meet the established criteria or guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make a determination.

Note

Provider actions not specified in source excerpts

No specific prior authorization, step therapy, or other provider action requirements are stated in the provided excerpts for this section.

No prior authorization requirements specified in these chunks.
No step therapy requirements specified in these chunks.
No additional provider actions provided in these chunks.

Documentation Required

Basis for medical necessity determinations

References that form the basis for medical necessity determinations include Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines. These references supersede CUMG/InterQual where applicable.

Medical necessity definition and determinations follow Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy ADMIN.00004.

Referenced External Criteria and Terms

InterQual/MCG — external clinical criteria used as adjunct resources

DefinitionInterQual® Criteria or MCG Care Guidelines are external clinical criteria used as adjunct resources for medical necessity and level-of-care determinations when no internal guideline exists.

Typical applicationsMedical necessity review for inpatient services, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and selected outpatient services/procedures.

HierarchyState Medicaid contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines supersede these external criteria.

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(reserved)No short definition or additional term was provided in this document fragment; entry reserved for any brief definitions if later found.

Source noteDefinition list in source contains only InterQual/MCG entry; no other short-definition entries present in these chunks.

ActionRefer to full Clinical UM Guideline list or Medical Policy website for further definitions if needed.

Rental vs Purchase and Capped Rental Policies

Equipment category (CUMG code)	Typical designation / notes
CG-DME-03 — Neuromuscular Stimulation
CG-DME-04 — Transcutaneous Electrical Nerve Stimulation (TENS)
CG-DME-05 — Cervical Traction Devices for Home Use
CG-DME-06 — Compression Devices for Lymphedema
CG-DME-07 — Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
CG-DME-08 — Infant Home Apnea Monitors
CG-DME-10 — Durable Medical Equipment (general)
CG-DME-12 — Home Phototherapy Devices for Neonatal Hyperbilirubinemia
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
CG-DME-40 — Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
CG-DME-41 — Ultraviolet Light Therapy Delivery Devices for Home Use
CG-DME-42 — Continuous Glucose Monitoring Devices
CG-DME-43 — High Frequency Chest Compression Devices for Airway Clearance
CG-DME-44 — Electric Tumor Treatment Field (TTF) Therapy
CG-DME-45 — Ultrasound Bone Growth Stimulation
CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis in the Home Setting
CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure

Replacement and Durability Rules

Listed DME items — enumerated items related to replacement rules

Enumerated DME itemsCG-DME-03 Neuromuscular Stimulation; CG-DME-04 Transcutaneous 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-10 Durable Medical Equipment; CG-DME-12 Home Phototherapy Devices; 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; CG-DME-20 Orthopedic Footwear; CG-DME-21 External Infusion Pumps; CG-DME-22 AFO/KAFO; CG-DME-23 Lifting Devices; CG-DME-24 Manual Wheelchairs; CG-DME-25 Seat Lift Mechanisms; CG-DME-26 Back-Up Home Ventilators; CG-DME-30 PT/INR Self-Monitoring; CG-DME-31 Powered Wheelchairs; 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 Bone Growth Stimulation; CG-DME-41 Home UV Therapy; CG-DME-42 Continuous Glucose Monitors; CG-DME-43 High Frequency Chest Compression; CG-DME-44 Tumor Treatment Field Therapy; CG-DME-45 Ultrasound Bone Growth Stimulation; CG-DME-46 Pneumatic Compression Devices; CG-DME-47 Noninvasive Home Ventilator Therapy; CG-DME-48 Vacuum Assisted Wound Therapy; CG-DME-49 Standing Frames; CG-DME-50 Automated Insulin Delivery; CG-DME-51 External Insulin Pumps; CG-DME-52 Continuous Passive Motion Devices; CG-DME-53 Biomechanical Footwear Therapy; CG-DME-54 Mechanical Insufflation-Exsufflation Devices; CG-DME-55 Home AEDs; CG-DME-57 Compression Stockings; CG-DME-59 Spinal Unloading Devices.

Replacement guidanceReplacement intervals and repair/replacement policy are not specified in this fragment — refer to each individual CG-DME guideline for replacement rules and intervals.

Documentation instructionProviders must follow the specific Clinical UM Guideline for each DME item for documentation and medical necessity evidence; requests not meeting guideline criteria will be referred to physician review.

Documentation Requirements for DME Requests

Documentation Required

Follow the listed CUMG for DME-specific documentation and evidence

Providers must follow the specific Clinical UM Guideline (CUMG) for each DME item to meet documentation and medical necessity requirements; requests that do not meet guideline criteria will be referred for physician review.

Refer to the individual CG-DME guideline for item-specific documentation and medical necessity criteria.
The full list of Medical Policies and Clinical UM Guidelines is available on the Medical Policy and Clinical UM Guideline subsidiary website.

Note

No DME-specific documentation in these excerpts

No DME-specific documentation requirements are stated in the provided excerpts.

Policy Context and External Resources

External clinical criteria including InterQual® Criteria and MCG Care Guidelines are referenced as adjunctive resources for the medical necessity review of inpatient services, inpatient site‑of‑service determinations, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when there is no established Medical Policy or Clinical UM Guideline. These resources are intended to supplement the payer’s internal policies and CUMG; however, Medicaid contracts, regulatory guidance, CMS requirements, and the payer’s Medical Policy/Clinical UM Guidelines supersede InterQual and MCG when conflicts arise.

OpenPayer

Clinical Utilization Management Guidelines (CUMG) List

Adopted Clinical Utilization Management Guidelines

Listed Clinical UM Guidelines and Coding Groups

Prior Authorization, Review, and Provider Responsibilities

Referenced External Criteria and Terms

DME-specific Medical Necessity References

Rental vs Purchase and Capped Rental Policies

Replacement and Durability Rules

Documentation Requirements for DME Requests

Policy Context and External Resources