CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines — Durable Medical Equipment (DME) coverage criteria

Lists Clinical Utilization Management (UM) Guidelines adopted by Highmark BCBS relevant to Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan members; intended for providers and staff involved in medical necessity and utilization review processes.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines — Durable Medical Equipment (DME) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders should refer to the publicly available Medical Policies and Clinical UM Guidelines on the payer website for documentation and medical necessity criteria applicable to MMC, HARP, CHPlus, and Essential Plan members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~90+number of listed Clinical UM Guidelines and items shown in this excerpt

MMC, HARP, CHPlus, Essentialprograms explicitly referenced

MultipleNew item flags present (placeholders)

MCG referenceduse of MCG Care Guidelines for certain reviews

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What Providers Need to Know

Prior Authorization

Clinical UM Guidelines (review for prior authorization implications)

The health plan maintains an adopted list of Clinical Utilization Management (UM) Guidelines that guide medical necessity determinations and utilization review. Providers should review the Clinical UM Guidelines (for example, the CG-*** series such as CG-ANC, CG-SURG, CG-DME, CG-BEH, CG-ADMIN) to determine whether a prior authorization or pre‑payment review requirement may apply to the service requested.

Clinical UM Guidelines are publicly available on the Medical Policy and Clinical UM Guideline website (see payer site).
MCG Care Guidelines may be used where no specific Medical Policy or Clinical UM Guideline exists; regulatory and contract requirements supersede MCG guidance.

Note

Prior Authorization / Step Therapy — none specified in these chunks

No explicit prior authorization code lists or step-therapy rules are specified in the provided source content for this policy section. Where prior authorization is required, it will be documented in the applicable Medical Policy or Clinical UM Guideline on the payer website.

No PA code lists present in the extracted chunks.
No step therapy rules identified in the extracted chunks.

Documentation Required

Authorization, Denial, and Documentation — no rules specified in these chunks

The provided content does not include explicit authorization or denial rules or detailed documentation requirements. Providers must consult the Medical Policies and Clinical UM Guidelines on the payer website for specific authorization criteria, required supporting documentation, and operational instructions.

If a request does not meet guideline criteria it will be referred to a licensed physician reviewer with appropriate clinical expertise.
For documentation requirements and submission materials, refer to Medical Policies and Clinical UM Guidelines on the payer website (providerpublic.mybcbswny.com).

Note

Refer to payer website for full guidance and materials

Providers should consult the payer website (Medical Policies and Clinical UM Guidelines) for the full guideline list, specific coverage criteria, required forms, and submission instructions before submitting authorization requests.

Visit the Medical Policy and Clinical UM Guideline subsidiary website for the complete, current guideline list and documentation.
Contact the payer or submitters portal for case-specific questions or to escalate to medical review when criteria are not clearly met.

Policy Background and Context

Highmark Blue Cross Blue Shield (Highmark BCBS) uses a set of adopted Clinical Utilization Management (UM) Guidelines to support medical necessity reviews across inpatient and outpatient settings for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan members. These guidelines are intended to reduce inappropriate use of medical resources and to guide consistent utilization management determinations. The full list of Medical Policies and Clinical UM Guidelines is publicly available on the payer's Medical Policy and Clinical UM Guideline website.

In addition to the plan-specific Clinical UM Guidelines, MCG Care Guidelines are used where applicable — for example, for medical necessity review of medical and behavioral health inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services when no specific Medical Policy or Clinical UM Guideline exists. Medicaid state contracts, regulatory guidance, CMS requirements and the payer's Medical Policy/Clinical UM Guidelines take precedence over MCG guidance.

Medical necessity determinations are made on a case-by-case basis per the definition contained in the applicable Medicaid state contract, regulatory guidance, CMS requirements or the plan's Medical Necessity Criteria policy. If a request does not meet the established guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a determination.

For Durable Medical Equipment (DME) specifically, a series of CG-DME entries (for example, CG-DME-10 Durable Medical Equipment, CG-DME-18 Home Oxygen Therapy, CG-DME-24 Wheeled Mobility Devices, CG-DME-31 Powered Wheelchairs, and many others) are included in the Clinical UM Guidelines list; providers must consult the corresponding DME guideline for the medical necessity and documentation requirements applicable to each equipment category.

Key Definitions

Medical necessity

DefinitionMedical necessity: determinations made on a case‑by‑case basis in accordance with the definition contained within the Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy (ADMIN.00004).

Decision processIf a request does not meet established criteria/guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a determination.

Guiding referencesMedicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

MCG roleMCG Care Guidelines are used for inpatient medical and behavioral health necessity review, inpatient site‑of‑service appropriateness, inpatient rehabilitation and SNF review, and certain outpatient services lacking an established Medical Policy or Clinical UM Guideline.

ScopeApplies to reviews where medical necessity must be established for coverage decisions under Medicaid and related programs the payer administers.

Durable Medical Equipment — Medical Necessity Linkage

DME medical necessity linkage

Covered when the following linkage condition is met:

Medical necessity and coverage criteria for each Durable Medical Equipment (DME) category are defined in the individual Clinical UM Guideline (e.g., CG-DME-10 Durable Medical Equipment); providers must consult the corresponding guideline for specific criteria.

Refer to the applicable CG-DME-* guideline on the payer website for documentation, prior authorization implications, and category-specific clinical criteria.

Durable Medical Equipment Rental and Purchase

Category	Rental vs Purchase Rule	Notes / Provider Action
Durable Medical Equipment (general)	See individual Clinical UM Guideline (CG-DME-*) for rental vs purchase determination	Providers must consult the specific CG-DME guideline (for example CG-DME-18 through CG-DME-34 listed) for equipment-specific rental or purchase policies and medical necessity criteria; refer to payer website for full guideline text.
Home Oxygen Therapy (CG-DME-18)	Determination (rental vs purchase) defined in CG-DME-18	Refer to CG-DME-18 for documentation, medical necessity, and whether oxygen equipment is rented or purchased under member’s benefit.
Wheeled Mobility Devices (CG-DME-24, CG-DME-31, CG-DME-33)	Rules for manual, powered, and specialized wheelchairs are specified in their respective CG-DME guidelines	Consult the applicable CG-DME entry for coverage determination, repair, replacement intervals, and required documentation.
Therapeutic Shoes / Orthopedic Footwear (CG-DME-19, CG-DME-20)	Purchase vs rental guidance included in the specific CG-DME guideline	Follow CG-DME-19 and CG-DME-20 for criteria and supporting documentation requirements for diabetic footwear and orthopedic shoes.
Other DME categories (e.g., Back-Up Ventilators CG-DME-26; External Infusion Pumps CG-DME-21; Prothrombin Time Self-Monitoring Devices CG-DME-30)	Each category’s guideline (CG-DME-#) specifies whether items are rented, purchased, or reimbursed differently	See the corresponding CG-DME guideline for determination; providers should reference the payer’s public Clinical UM Guidelines list for the exact policy language.

Required Documentation and Guideline References

Documentation Required

See CG-DME-10 and CG-DME-* for DME documentation and medical necessity

See the specific Clinical UM Guideline CG-DME-10 (Durable Medical Equipment) and other CG-DME-* entries on the payer website for the applicable medical necessity criteria and documentation requirements for durable medical equipment.

Consult CG-DME-10 and relevant CG-DME-* guidelines for item-specific medical necessity and documentation rules
Access the full guidelines via the plan’s Medical Policy and Clinical UM Guideline subsidiary website