CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (CUMG) list — Durable Medical Equipment (DME) index and associated CUMG titles

A catalog of Clinical Utilization Management Guidelines adopted by Highmark BCBS for MMC, HARP, Child Health Plus, and Essential Plan members; informs providers which CUMG documents exist and where to find them.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) list — DME index

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the listed CUMGs on the payer website and follow pre-payment review prior authorization instructions when no other Clinical UM Guideline exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150listed Clinical UM Guidelines and Medical Policy titles

~40clinical policy titles listed in this excerpt

MMC/HARP/CHPlus/Essentialprograms affected

6document chunks in this window

Coverage Criteria Overview

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MCG Care Guidelines may be used by Highmark BCBS for medical necessity reviews and site-of-service determinations; however, Medicaid state contracts, regulatory guidance, CMS requirements and Highmark’s Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Medical necessity is determined on a case‑by‑case basis according to the definition in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Highmark’s Medical Necessity Criteria Policy ADMIN.0004. Requests that do not meet established criteria will be referred to a licensed physician reviewer for a determination.

Provider Actions, Authorization & Documentation

Note

Policy index — no prior authorization details

The policy index below lists Clinical UM Guideline (CUMG) titles adopted by Highmark BCBS; it is an index only and does not itself state prior authorization requirements. Consult individual CUMG or Medical Policy documents for any prior authorization or prior approval rules.

CG-SURG-51 through CG-SURG-117 and multiple CG-THER/CG-TRANS items are listed as CUMG titles (see index).

Denial Risk

Denial triggers for not meeting criteria

If a requested service does not meet the applicable established criteria or guideline, the request will be referred to a licensed physician reviewer with appropriate clinical expertise for case-by-case medical necessity determination. Requests that the reviewer determines do not meet medical necessity criteria may be denied.

Medical necessity determinations follow Medicaid/CMS/Highmark definitions and may be made case-by-case.
Requests not meeting criteria are referred to a licensed physician reviewer and may be denied.

Note

No explicit authorization or denial trigger in the index

The index excerpts do not include explicit operational language that automatically approves or denies services. They do not define specific authorization triggers; providers must refer to the individual Clinical UM Guideline or Medical Policy for explicit prior authorization, pre-service, or pre-payment review requirements.

No explicit authorization/denial trigger language is present in the index excerpts.
Pre-payment review applies where no other Clinical UM Guideline exists; consult listed sources and Medical Policy/Clinical UM Guidelines for applicability.

Note

Provider communications signup

Sign up to receive provider communications, alerts and policy updates by email. Use the QR code provided in communications or submit your information via the Highmark online form to ensure you receive timely notices about policy changes, guideline adoptions, and authorization requirements.

Sign up online: https://bit.ly/signup-hm-ny
Use the QR code in Highmark communications to enroll for email updates.

Documentation Required

Documentation and medical necessity basis

Documentation and medical necessity basis: determinations are made in accordance with Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines. Maintain complete clinical documentation to support requests; absence of supporting documentation can increase denial risk.

Decisions rely on Medicaid/CMS/Highmark policies and Medical Necessity Criteria Policy ADMIN.0004.
Provide full clinical records and rationale when submitting requests to support medical necessity review.

Medical Necessity and DME Guidelines

DME guideline index (refer to individual GUIDELINES)

Refer to the specific CG‑DME guideline for detailed medical necessity criteria for each equipment type.

DME guideline references: Each CG‑DME titled item (for example: CG‑DME‑09 Continuous Local Delivery of Analgesia; CG‑DME‑10 Durable Medical Equipment; CG‑DME‑12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia; CG‑DME‑13 Lower Limb Prosthesis; CG‑DME‑15 Hospital Beds and Accessories; CG‑DME‑16 Pressure Reducing Support Systems Groups 1, 2 and 3; CG‑DME‑18 Home Oxygen Therapy; CG‑DME‑19 Therapeutic Shoes/Inserts for Individuals with Diabetes; CG‑DME‑21 External Infusion Pumps; CG‑DME‑22 Ankle‑Foot & Knee‑Ankle‑Foot Orthoses; CG‑DME‑24 Manual Wheelchairs; CG‑DME‑31 Powered Wheeled Mobility Devices; 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‑43 High Frequency Chest Compression Devices; CG‑DME‑47 Noninvasive Home Ventilator Therapy; CG‑DME‑49 Standing Frames, etc.) contains its own medical necessity criteria which providers must consult.

This document lists available CG‑DME guideline titles only; consult the individual CG‑DME for full medical necessity criteria and any prior authorization, rental vs. purchase, or documentation requirements.

DME Guideline (CG-DME ID)	Title / Description	Rental vs Purchase Rules
CG-DME-35
Electric Breast Pumps
Not specified in index — consult the CG-DME-35 guideline for rental vs purchase rules

Documentation Requirements

Documentation Required

Documentation — check each CG-DME for required medical records

Refer to the specific CG-DME guideline for documentation requirements—this index lists many DME-related CUMG titles (for example, Durable Medical Equipment; Pressure Reducing Support Systems; Home Oxygen Therapy; Powered Wheeled Mobility Devices; Hospital Beds and Accessories; Wheelchair Accessories) and indicates providers should consult the individual guideline for supporting documentation expectations.

Providers should obtain the documentation requirements from the corresponding CG-DME prior to submitting an authorization request or claim.

Background and Purpose

This document is a registry of the Clinical Utilization Management Guidelines (CUMG) that Highmark BCBS has adopted for use with Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan members. The full list of Medical Policies and Clinical UM Guidelines is available on the payer’s subsidiary website and is intended to support appropriate use of medical resources.

Highmark notes that certain CUMG items were adopted by the Medical Operations Committee on June 22, 2023. Providers should monitor Highmark communications for updates and are encouraged to sign up to receive email notices for important guideline and policy changes.

Key Definitions

MCG Care Guidelines — definition and scope

DefinitionMCG Care Guidelines are external care guidelines used for medical necessity review (medical and behavioral health inpatient review), inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services/procedures when no payer Medical Policy or Clinical UM Guideline exists.

Superseded byMedicaid state contracts, regulatory guidance, CMS requirements, and Highmark's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Use in determinationsMedical necessity determinations are made case-by-case using the Medicaid definition of medical necessity; requests not meeting established criteria are referred to a licensed physician reviewer with appropriate clinical expertise.

Additional tool referencedLevel of Care for Alcohol and Drug Treatment Referral 3.0 is used for substance abuse services per state requirements.

AvailabilityThe full list of Medical Policies and Clinical UM Guidelines is publicly available on the payer's Medical Policy and Clinical UM Guideline subsidiary website.

CUMG / CG-SURG — definition and examples

Acronym meaningCUMG stands for Clinical Utilization Management Guideline; CG-SURG indicates a Clinical Guideline - Surgical.

PurposeCUMG/CG-SURG entries list guideline titles (for example: CG-SURG-51 Outpatient Cystourethroscopy; CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services; CG-SURG-55 Cardiac Electrophysiological Studies and Catheter Ablation).

Index natureThe document provides an index of CUMG/CG-SURG titles and 'New item' annotations but does not itself state specific clinical criteria or prior authorization requirements—consult each listed guideline for details.

Example entriesExamples in the list include CG-SURG-51 (Outpatient Cystourethroscopy), CG-SURG-55 (Cardiac Electrophysiological Studies and Catheter Ablation), CG-SURG-59 (Vena Cava Filters).

OpenPayer

Clinical Utilization Management Guidelines (CUMG) list — Durable Medical Equipment (DME) index and associated CUMG titles

Coverage Criteria Overview

Provider Actions, Authorization & Documentation

Medical Necessity and DME Guidelines

Rental and Purchase Rules for DME

Documentation Requirements

Background and Purpose

Key Definitions