Highmark BCBS WNY DME CUMG Coverage Update

Coverage criteria and guideline applicability

General Medical Necessity and Guideline Use

Covered when ALL of the following are met:

CUMG and MCG use: Highmark BCBS uses Clinical Utilization Management Guidelines (CUMG) and MCG Care Guidelines to support medical necessity determinations and inpatient site-of-service appropriateness; these guidelines are applied for Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan members.

MCG is used for inpatient reviews and where no established medical policy exists; determinations are made case-by-case per applicable contracts and policies.

Superseding authorities: Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

When conflicts exist, follow the higher‑priority authority (Medicaid/CMS/Highmark policy).

Case-by-case determination: Medical necessity is determined on a case-by-case basis in accordance with the definition of medical necessity contained within 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 with appropriate clinical expertise.

The MCG Care Guidelines are available to support medical necessity determinations and inpatient site-of-service decisions; they are used for medical and behavioral health inpatient reviews, inpatient rehabilitation and skilled nursing facility review, and for outpatient services where there is no established Medical Policy or Clinical UM Guideline. However, Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede the MCG Care Guidelines. Medical necessity is determined 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.0004).

The sections of this document that list CUMG/CG policy identifiers (for example, CG-SURG-76 through CG-SURG-121 and related items) provide an index of guideline titles and codes only. These fragments enumerate policy identifiers and titles but do not contain item-specific coverage, exclusion, or clinical criteria within the listed text; providers must consult each individual CUMG for the full medical necessity and coverage rules.

Codes and guideline identifiers

DME CUMG Codes Listedmixed

CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04	Electrical Nerve Stimulation, Transcutaneous, Percutaneous
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-09	Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Postoperative Period
CG-DME-10	Durable Medical Equipment
CG-DME-12	Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13	Lower Limb Prosthesis

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CUMG / CG-SURG policy codes listedmixed

CG-SURG-76	Policy item listed (title present elsewhere in fragment)
CG-SURG-77	Refractive Surgery
CG-SURG-78	Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
CG-SURG-79	Implantable Infusion Pumps
CG-SURG-81	Cochlear Implants and Auditory Brainstem Implants
CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids
CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity
CG-SURG-84	Mandibular/Maxillary (Orthognathic) Surgery
CG-SURG-87	Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
CG-SURG-88	Mastectomy for Gynecomastia

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What providers must know and do

Prior Authorization

CUMG adoption for pre-payment review

Highmark BCBSWNY has adopted the Clinical Utilization Management Guidelines (CUMG) for use in pre‑payment review and medical necessity determinations when no other clinical UM guideline exists. These CUMG are used to guide medical necessity review and site-of-service appropriateness and will be applied during pre-payment review processes.

CUMG adoption announced June 27, 2024; view guidelines at providerpublic.mybcbswny.com or Search Medical Policies and Clinical Guidelines.
MCG Care Guidelines (CUMG) are used for medical necessity review for inpatient and certain outpatient services when no other Medical Policy or Clinical UM Guideline exists.

Note

Policy index listing — no PA stated in fragments

A consolidated index of the Clinical Utilization Management Guidelines is published; the fragments provided list many CUMG titles but do not state any separate prior authorization (PA) requirements. Providers should consult the full policy index on the Medical Policy and Clinical UM Guideline site for authoritative PA rules.

Policy index lists many CUMG titles (e.g., CG-ANC-03 Acupuncture; CG-DME-03 Neuromuscular Stimulation; CG-SURG-77 Refractive Surgery; CG-SURG-115 Mechanical Embolectomy; etc.).

Background and policy context

Highmark Blue Cross Blue Shield WNY uses Clinical Utilization Management Guidelines and MCG Care Guidelines to support medical necessity and site-of-service determinations, particularly for inpatient reviews and when no established Medical Policy exists. Where applicable, these MCG guidelines inform pre-payment review and clinical determinations, but are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark policies. If a request fails to meet established criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a final decision.

Key definitions

Medical necessity (ADMIN.0004)

DefinitionMedical necessity determinations are made on a case-by-case basis in accordance with the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004).

ApplicabilityApplies to review of medical and behavioral health inpatient services, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services/procedures when no established Medical Policy or Clinical UM Guideline exists.

HierarchyMedicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines when conflicts exist.

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 (may result in denial).

Medical necessity for DME items

DME medical necessity indexing — individual CUMG entries define medical necessity for each equipment type

Consult the specific CUMG listed below — each guideline entry defines the medical necessity criteria for that equipment type.

Index applies: This document is an index of DME‑related Clinical Utilization Management Guidelines (CG‑DME series); medical necessity criteria vary by equipment type and are specified within each individual CUMG entry.

Providers must consult the referenced CUMG (for example, CG‑DME‑24 for manual wheelchairs) for full, equipment‑specific criteria, documentation requirements, and any prior authorization rules.

Examples of listed CUMG entries: Included DME guideline examples (non‑exhaustive): CG‑DME‑03 Neuromuscular Stimulation; CG‑DME‑04 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‑09 Elastomeric Infusion Pumps; CG‑DME‑10 Durable Medical Equipment; CG‑DME‑12 Home Phototherapy; CG‑DME‑13 Lower Limb Prosthesis; CG‑DME‑15 Hospital Beds; CG‑DME‑16 Pressure Reducing Support Systems; CG‑DME‑18 Home Oxygen Therapy; CG‑DME‑19 Therapeutic Shoes for Diabetes; 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 Ventilators; CG‑DME‑30 PT/INR Self‑Monitoring; CG‑DME‑31 Powered Mobility; 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 Low‑Load Stretch Devices; CG‑DME‑40 Noninvasive Bone Growth Stimulation; CG‑DME‑41 UV Light Therapy; CG‑DME‑42 Continuous Glucose Monitoring; CG‑DME‑43 High Frequency Chest Compression; CG‑DME‑44 Tumor Treatment Field; 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; CG‑DME‑53 Biomechanical Footwear; CG‑DME‑54 Mechanical Insufflation‑Exsufflation; CG‑DME‑55 AEDs for Home Use.

Rental, purchase, and supply rules

Equipment / CUMG	Rental vs Purchase Rule
Neuromuscular Stimulation — CG-DME-03	Refer to the individual CUMG (CG-DME-03) for rental vs purchase determination.
Electrical Nerve Stimulation, Transcutaneous/Percutaneous — CG-DME-04	Refer to the individual CUMG (CG-DME-04) for rental vs purchase determination.
Cervical Traction Devices for Home Use — CG-DME-05	Refer to the individual CUMG (CG-DME-05) for rental vs purchase determination.
Compression Devices for Lymphedema — CG-DME-06	Refer to the individual CUMG (CG-DME-06) for rental vs purchase determination.
Augmentative & Alternative Communication (AAC) Devices — CG-DME-07	Refer to the individual CUMG (CG-DME-07) for rental vs purchase determination.
Infant Home Apnea Monitors — CG-DME-08	Refer to the individual CUMG (CG-DME-08) for rental vs purchase determination.
Elastomeric Infusion Pumps (postoperative analgesia) — CG-DME-09	Refer to the individual CUMG (CG-DME-09) for rental vs purchase determination.
Durable Medical Equipment (general) — CG-DME-10	Refer to the individual CUMG (CG-DME-10) for rental vs purchase determination.
Home Phototherapy Devices for Neonatal Hyperbilirubinemia — CG-DME-12	Refer to the individual CUMG (CG-DME-12) for rental vs purchase determination.
Lower Limb Prosthesis — CG-DME-13	Refer to the individual CUMG (CG-DME-13) for rental vs purchase determination.
Hospital Beds and Accessories — CG-DME-15	Refer to the individual CUMG (CG-DME-15) for rental vs purchase determination.
Pressure Reducing Support Systems Groups 1–3 — CG-DME-16	Refer to the individual CUMG (CG-DME-16) for rental vs purchase determination.
Home Oxygen Therapy — CG-DME-18	Refer to the individual CUMG (CG-DME-18) for rental vs purchase determination.
Therapeutic Shoes/Inserts/Modifications for Diabetes — CG-DME-19	Refer to the individual CUMG (CG-DME-19) for rental vs purchase determination.

Replacement rules for equipment

Durable Medical Equipment — replacement, rental & purchase notes

Replacement guidance summaryReplacement intervals and rules for DME items are not specified in this index; they are defined within the individual CUMG entry for each equipment type (e.g., CG-DME-24 for manual wheelchairs).

Rental vs purchaseRental versus purchase determinations are handled within each DME CUMG; consult the applicable guideline for the specific item.

DocumentationProviders must supply the documentation required by the individual CUMG to support replacement, rental, or purchase requests during pre-payment review.

Examples of DME covered by CUMG indexIncludes neuromuscular stimulation devices, electrical nerve stimulation, cervical traction, compression devices for lymphedema, wheelchairs, home ventilators, oxygen equipment, prostheses and others as listed in the CG-DME series.

Documentation required for review

Documentation Required

Refer to individual CUMG for documentation needed for pre‑payment review

Refer to the specific CUMG entry for the item being requested to determine what documentation is required for pre‑payment review and medical necessity determination; this index does not contain equipment‑specific documentation checklists.

Documentation requirements and rental/purchase rules are specified within each individual CUMG.
Medical necessity must follow Medicaid contract/regulatory guidance/CMS or Highmark ADMIN.0004 as noted in the CUMG.

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Clinical Utilization Management Guidelines (CUMG) list — DME and related policies