CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (DME-focused list)

List of Clinical Utilization Management (UM) Guidelines adopted by Highmark BCBS relevant to Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members, including numerous Durable Medical Equipment (DME) guidelines. Affects providers submitting requests for medical necessity review and prior authorization for listed services.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (DME-focused list)

Policy CodePolicy N/A

Change TypeInformational update

Effective DateN/A

Next Review DateN/A

Key ActionConsult the published Clinical UM Guidelines on the payer website for medical necessity review and prior authorization determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+Clinical UM Guidelines listed

MultipleDME-specific guidelines

MMC/HARP/CHPlus/EssentialPrograms referenced

severalItems marked NEW

Provider Actions and Prior Authorization Notes

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Prior Authorization

Use of Clinical UM Guidelines for Prior Authorization

Highmark BCBS uses adopted Clinical Utilization Management (UM) Guidelines (including MCG Care Guidelines where applicable) as the primary framework for medical necessity review and for assessing site-of-service appropriateness. These guidelines inform inpatient, inpatient rehabilitation, skilled nursing facility, and certain outpatient service reviews when no specific Medical Policy or Clinical UM Guideline exists. Providers should reference the publicly available Medical Policy and Clinical UM Guidelines on the Highmark provider site when preparing requests.

Clinical UM Guidelines are used for medical necessity review and site-of-service appropriateness.
MCG Care Guidelines are applied for inpatient review and where no specific Medical Policy/Clinical UM Guideline exists, except where superseded by Medicaid state contracts, regulatory guidance, CMS requirements, or Highmark Medical Policy/Clinical UM Guidelines.
Level of Care for Alcohol and Drug Treatment Referral 3.0 is used for substance abuse services per state requirements.

Note

Referral to Physician Reviewer When Criteria Unmet

If a request does not meet established guideline criteria, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for an individualized determination of medical necessity. Determinations are made case-by-case in accordance with the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004).

Requests not meeting guideline criteria are escalated to a licensed physician reviewer.
Medical necessity determinations follow Medicaid/CMS/state contract definitions and Highmark policy ADMIN.0004.

Note

Prior Authorization: Explicit Triggers Not Specified Here

The excerpt does not list explicit prior authorization triggers, required forms, or an itemized list of services that automatically require prior authorization. Providers should not assume automatic approval or denial from this section alone and must consult the full Clinical UM Guidelines and applicable Medical Policies for specific authorization requirements.

No explicit authorization or denial triggers are specified in the provided excerpt.
Providers must consult the full guideline or Medical Policy pages for service-specific prior authorization requirements.

Documentation Required

Medical Necessity Basis and Documentation Expectations

Providers should document clinical rationale and supporting records sufficient to demonstrate that care meets the applicable medical necessity criteria. Documentation should align with the definitions and requirements in the Medicaid state contract, regulatory guidance, CMS rules, and Highmark Medical Policy/Clinical UM Guideline expectations. Incomplete or insufficient documentation may delay review or result in denial.

Expectations: supply complete clinical records, rationale, and any test results or prior treatments relevant to the medical necessity determination.
Insufficient documentation can lead to delays or denial; submission should follow the referenced guidelines and state/CMS requirements.

Note

Provider Actions — Summary

Provider action summary: consult the Clinical UM Guidelines on the Highmark provider site for service-specific criteria, prepare complete documentation tied to medical necessity criteria, and be aware that requests not meeting criteria will be escalated to a physician reviewer. Do not rely on this excerpt for service-level prior authorization rules; verify requirements on the published guideline or Medical Policy pages.

Visit the Highmark provider Medical Policies and Clinical UM Guidelines page for guideline details and any New items or guideline titles.
Prepare and submit complete clinical documentation when requesting authorization or filing for review.
Expect escalation to a licensed physician reviewer if criteria are unmet.

Documentation and Recordkeeping Expectations

Documentation Required

Refer to specific DME Clinical UM Guidelines for documentation and coverage criteria

DME reviews are governed by the listed Clinical UM Guidelines (examples include Infant Home Apnea Monitors; Home Phototherapy for Neonatal Hyperbilirubinemia; Hospital Beds and Accessories; Pressure Reducing Support Systems; Home Oxygen Therapy; Therapeutic Shoes; External Infusion Pumps; Wheeled Mobility devices; Powered Wheelchairs; Electric Breast Pumps; Pediatric Gait Trainers; High Frequency Chest Compression Devices; Noninvasive Home Ventilator Therapy; and many others). Providers must refer to the specific DME guideline on the payer website for documentation expectations and coverage criteria when requesting DME.

Numerous CG‑DME guidelines are listed; view each CG‑DME guideline for item‑specific documentation and coverage criteria.
Use the payer website link to access full guideline text and any PA/coverage steps not shown in this inventory.

Background and Scope

Highmark Blue Cross Blue Shield (Highmark BCBS) has adopted a comprehensive set of Clinical Utilization Management (UM) Guidelines to standardize medical necessity reviews across inpatient, outpatient, and durable medical equipment (DME) services for members of Medicaid Managed Care, HARP, Child Health Plus, and the Essential Plan. These guidelines are the primary reference used during medical necessity review and to assess appropriate site-of-service. Requests that do not meet the applicable guideline criteria are referred for additional review by a licensed physician and may be denied if medical necessity is not demonstrated. Providers should consult the published Clinical UM Guidelines on the Highmark BCBS provider website when preparing documentation for prior authorization or medical necessity determinations.

List of Clinical UM Guidelines (DME-focused)

The following DME-specific Clinical UM Guidelines are listed in the Highmark BCBS guideline set (items shown as published): CG-DME-08: Infant Home Apnea Monitors (New item). CG-DME-09: Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Postoperative Period (New item). CG-DME-10: Durable Medical Equipment (New item). CG-DME-12: Home Phototherapy Devices for Neonatal Hyperbilirubinemia (New item). CG-DME-13: Lower Limb Prosthesis (New item). CG-DME-15: Hospital Beds and Accessories (New item). CG-DME-16: Pressure Reducing Support Systems Groups 1, 2 and 3 (New item). CG-DME-18: Home Oxygen Therapy (New item). CG-DME-19: Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes (New item). CG-DME-20: Orthopedic Footwear (New item). CG-DME-21: External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings (New item). CG-DME-23: Lifting Devices for Use in the Home (New item). CG-DME-24: Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight (New item). CG-DME-25: Seat Lift Mechanisms (New item). CG-DME-26: Back-Up Ventilators in the Home Setting (New item). CG-DME-30: Prothrombin Time Self-Monitoring Devices (New item). CG-DME-31: Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, With or Without Power Seating Systems, and Power Operated Vehicles (POVs) (New item). CG-DME-33: Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight (New item). CG-DME-34: Wheeled Mobility Devices: Wheelchair Accessories (New item). CG-DME-35: Electric Breast Pumps (New item). CG-DME-36: Pediatric Gait Trainers (New item). CG-DME-37: Air Conduction Hearing Aids (New item). CG-DME-39: Dynamic Low-Load Prolonged-Duration Stretch Devices (New item). CG-DME-40: Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton (New item). CG-DME-41: Ultraviolet Light Therapy Delivery Devices for Home Use (New item). CG-DME-42: Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices (New item). CG-DME-43: High Frequency Chest Compression Devices for Airway Clearance (New item). CG-DME-44: Electric Tumor Treatment Field (TTF) (New item). CG-DME-45: Ultrasound Bone Growth Stimulation.

OpenPayer

Clinical Utilization Management Guidelines (DME-focused list)

Provider Actions and Prior Authorization Notes

Documentation and Recordkeeping Expectations

Background and Scope

List of Clinical UM Guidelines (DME-focused)

Coding References and Identifiers