Highmark BCBS Wny DME CUMG Policy Update

Provider Actions & Authorization Notes

Note

Provider Advisory — Actions & What’s Missing

Highmark BCBS uses Clinical Utilization Management Guidelines (CUMG) and MCG Care Guidelines to inform medical necessity determinations and utilization review for Medicaid programs. The excerpt lists adopted CUMG titles but does not state explicit prior authorization (PA) requirements or specific documentation checklists. Providers should consult the full Medical Policy and Clinical UM Guideline site for procedure-specific PA or submission requirements.

CUMG listing: excerpt provides titles of adopted guidelines but does not specify prior authorization requirements or code-level PA triggers.
No provider actions stated in this excerpt: the document does not include explicit steps for authorization submission, required forms, timelines, or supporting documentation.
Determinations of medical necessity are case-by-case and follow the Medicaid state contract, regulatory guidance, CMS requirements, and the payer's Medical Necessity Criteria Policy ADMIN.00004.
If a request does not meet the listed guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise — this presents a potential denial risk if criteria are not met.

Policy Background & Scope

This document is an index of the Clinical Utilization Management Guidelines (CUMG) adopted by Highmark Blue Cross Blue Shield WNY for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan (EP) members. The listed CUMG items cover a broad range of services including many durable medical equipment (DME) topics and are intended to guide medical necessity determinations, utilization management, and pre‑payment review of covered services.

The CUMG are publicly available on the payer website and are used to support medical necessity and site‑of‑service reviews; when no other Medical Policy or CUMG exists, the CUMG referenced here (for example, the Clinical Utilization Management Guideline for Pre‑Payment Review Medical Necessity Determinations) may be applied for inpatient and outpatient reviews. Providers should consult the full guideline text for equipment‑specific criteria, documentation expectations, and any prior authorization or rental/purchase rules that apply.

Key Definitions

Medical necessity definition and decision authority

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 Medical Necessity Criteria Policy ADMIN.00004.

Decision authority for unresolved requestsRequests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise to make a decision.

Guideline hierarchyMedicaid state contracts, regulatory guidance, CMS requirements, and Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

MCG Care Guidelines usesUsed for medical necessity review (including inpatient and outpatient where no established Medical Policy/CUMG exists), inpatient site of service appropriateness, and inpatient rehabilitation/skilled nursing facility review.

Where to view CUMGTo view a guideline, visit 'Search Medical Policies and Clinical Guidelines' on the mybcbswny.com provider site.

Medical Necessity & DME Guideline Index

DME guideline index

CUMG index entries exist for many durable medical equipment (DME) categories. Consult the full guideline for each listed item for detailed medical necessity criteria, documentation requirements, and any prior authorization or rental/purchase rules.

CUMG index enumerates multiple DME-specific guidelines covering a broad range of equipment types (e.g., neuromuscular stimulation, TENS, cervical traction, compression devices, AAC devices, infant home apnea monitors).

Additional DME topics listed include but are not limited to: durable medical equipment general guideline, home phototherapy devices, lower limb prosthesis, hospital beds and accessories, pressure reducing support systems, home oxygen therapy, therapeutic shoes/inserts, orthopedic footwear, external infusion pumps, AFO/KAFO orthoses, lifting devices, wheeled mobility devices (manual and powered), seat lift mechanisms, backup home ventilators, prothrombin time self-monitoring devices, electric breast pumps, pediatric gait trainers, bone growth stimulation devices, continuous glucose monitoring, high frequency chest compression devices, pneumatic compression devices, vacuum assisted wound therapy, standing frames, automated insulin delivery and external insulin pumps, continuous passive motion devices, biomechanical footwear therapy, mechanical insufflation-exsufflation devices, automated external defibrillators, and compression stockings.

Each CUMG listed in the index represents a separate guideline containing the specific medical necessity criteria; the index entry itself does not provide the full criteria or operational details (e.g., exact thresholds, required documentation, prior authorization processes).

Rental and Purchase Rules for DME

CUMG index entry	Implication for rental vs purchase	Notes / consult
CG-DME-09	May be general DME — rule determined in specific guideline	See CG-DME-09 full guideline for equipment-specific rental vs purchase determination
CG-DME-10 — Durable Medical Equipment	Category includes items that may be rental or purchase depending on equipment type	Consult CG-DME-10 for criteria and rental/purchase rules for listed equipment
CG-DME-12 — Home Phototherapy Devices for Neonatal Hyperbilirubinemia	Device-specific — purchase or rental determined by guideline criteria	Refer to CG-DME-12 for documentation and billing instructions
CG-DME-13 — Lower Limb Prosthesis	Prosthetic devices typically have purchase rules; confirm in guideline	See CG-DME-13 for prosthesis-specific coverage and acquisition rules
CG-DME-15 — Hospital Beds and Accessories	May include rental rules (beds often rented) — check CUMG	Refer to CG-DME-15 for rental duration, purchase exceptions, and accessories
CG-DME-16 — Pressure Reducing Support Systems Groups 1, 2 and 3	Support surfaces may be rental or purchased per clinical criteria and group	Consult CG-DME-16 for group-specific rental vs purchase guidance
CG-DME-18 — Home Oxygen Therapy	Home oxygen equipment often follows defined rental/purchase rules in guideline	See CG-DME-18 for specific coverage and equipment acquisition rules
CG-DME-19 — Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes	Typically purchase (shoes/inserts) — verify in CUMG	Refer to CG-DME-19 for documentation and replacement interval details
CG-DME-20 — Orthopedic Footwear	Footwear rules (purchase) detailed in guideline	See CG-DME-20 for allowed items and billing guidance
CG-DME-21 — External Infusion Pumps	Equipment acquisition (rental vs purchase) addressed in CUMG	Consult CG-DME-21 for criteria, rental duration, and accessories
CG-DME-22 — Ankle-Foot & Knee-Ankle-Foot Orthoses	Orthoses often purchased — confirm in guideline for exceptions	Refer to CG-DME-22 for fitting, replacement, and billing rules
CG-DME-23 — Lifting Devices for Use in the Home	May be purchase or rental depending on device — see CUMG	See CG-DME-23 for criteria and equipment acquisition guidance
CG-DME-24 — Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight	Wheeled mobility devices have detailed rental/purchase and exception rules in guideline	Consult CG-DME-24 for categorical rules and payment method
CG-DME-25 — Seat Lift Mechanisms	Acquisition method determined by device type and CUMG criteria	Refer to CG-DME-25 for coverage and rental/purchase policies
CG-DME-26 — Back-Up Ventilators in the Home Setting	Ventilator equipment rules (rental/purchase) specified in guideline	See CG-DME-26 for clinical indications and acquisition rules
CG-DME-30 — Prothrombin Time Self-Monitoring Devices	Device-specific purchase rules to be confirmed in CUMG	Consult CG-DME-30 for coverage criteria and supply replacement
CG-DME-31 — Powered Wheeled Mobility Devices	Powered mobility has distinct purchase criteria and exceptions in guideline	Refer to CG-DME-31 for documentation, evaluation, and payment policy
CG-DME-33 — Wheeled Mobility Devices: Manual Wheelchairs-Ultra-Lightweight	Specific class rules determine rental vs purchase — see CUMG	See CG-DME-33 for eligibility and acquisition guidance
CG-DME-34 — Wheeled Mobility Devices: Wheelchair Accessories	Accessories may follow accessory-specific purchase rules in guideline	Consult CG-DME-34 for covered accessories and billing instructions
CG-DME-35 — Electric Breast Pumps	Typically purchased (or supplied) — confirm in CUMG	Refer to CG-DME-35 for coverage conditions and supply limits
CG-DME-36 — Pediatric Gait Trainers	Equipment acquisition rules provided in guideline (purchase vs rental)	See CG-DME-36 for medical necessity and procurement details
CG-DME-37 — Air Conduction Hearing Aids	Hearing aids typically follow purchase rules — verify in CUMG	Consult CG-DME-37 for fitting, replacement, and coverage specifics
CG-DME-39 — Dynamic Low-Load Prolonged-Duration Stretch Devices	Device-specific acquisition (rental vs purchase) determined in guideline	Refer to CG-DME-39 for clinical indications and billing guidance

Documentation & Where to Find Full Guidelines

Documentation Required

Consult full CUMG text on payer website for equipment‑specific documentation

The index enumerates numerous DME‑related CUMG topics but does not include equipment‑specific documentation or evidence requirements in this excerpt; providers should consult the full guideline text on the payer website for equipment‑specific documentation, clinical evidence requirements, and any required forms.

Consult the full CUMG/Medical Policy pages on the provider website for item‑level documentation expectations.
The index is intended to guide where to find the detailed criteria and documentation rules.

OpenPayer

Clinical Utilization Management Guidelines — DME and related guidelines