CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (CUMG) — DME and related CUMG listing

A listing of Clinical Utilization Management Guidelines (CUMG) adopted by Highmark Blue Cross Blue Shield Western New York for use in medical necessity and utilization review for specified programs (MMC, HARP, CHPlus, and Essential Plan). Applies to providers caring for members in those programs.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) — DME and related CUMG listing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the specific CUMG document on the provider site for detailed medical necessity criteria when requesting DME or related services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+CUMG items listed

MMC,HARP,CHPlus,EssentialPrograms referenced

Mar 23, 2023Adoption date referenced

~30Policy titles listed

1New items marked

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Coverage Criteria & Policy Scope

General utilization management application

MCG Care Guidelines are used as described below for utilization management and medical necessity determinations.

General application: MCG Care Guidelines are used for medical necessity review for medical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient services where no other Medical Policy or Clinical UM Guideline exists.

Medicaid state contracts, regulatory guidance, CMS requirements and payer Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Determinations of medical necessity are made on a case‑by‑case basis; requests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

Medicaid state contracts, regulatory guidance, CMS requirements and Highmark Blue Cross Blue Shield Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. When there is any conflict between an applicable state contract, regulation, CMS requirement, or an internal Medical Policy/Clinical UM Guideline and an MCG guideline, the state contract/regulation/CMS requirement or internal policy controls. This policy follows that hierarchy when applying CUMGs to medical necessity and utilization review.

CUMG Codes and Titles

CUMG codes and titles listedmixed

CG-ADMIN-01	Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ANC-03	Acupuncture
CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-05	Ambulance Services: Ground; Emergent
CG-ANC-06	Ambulance Services: Ground; Nonemergent
CG-ANC-07	Inpatient Interfacility Transfers
CG-ANC-08	Mobile Device-Based Health Management Applications
CG-BEH-02	Adaptive Behavioral Treatment
CG-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04	Electrical Nerve Stimulation, Transcutaneous, Percutaneous

1–10 of 201

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Provider Actions, Prior Authorization & Communication

Prior Authorization

Use of CUMGs for medical necessity and pre-payment review

MCG Care Guidelines (CUMGs) are used by Highmark BCBS for medical necessity determinations and pre-payment review, including inpatient medical and behavioral health review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when no specific Medical Policy or Clinical UM Guideline exists. Level of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance abuse services per state requirements. Medical necessity determinations follow Medicaid state contracts, regulatory guidance, CMS requirements, and internal Medical Necessity Criteria; requests that do not meet established criteria are referred to a licensed physician reviewer with appropriate clinical expertise.

MCG Care Guidelines used for medical necessity and pre-payment/inpatient review
Level of Care for Alcohol and Drug Treatment Referral 3.0® used for substance abuse services per state requirements
Medicaid state contracts, regulatory guidance, CMS requirements and internal policies supersede CUMGs
Requests not meeting criteria will be referred to a licensed physician reviewer

Background & Use of External Guidelines

Highmark BCBS uses MCG Care Guidelines as external clinical guidance to support utilization management activities when no internal Medical Policy or Clinical UM Guideline exists. Specifically, MCG Care Guidelines are applied to: medical necessity review for medical and behavioral health inpatient care; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient services or procedures where an internal guideline is not established. Determinations of medical necessity are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or the Medical Necessity Criteria Policy (ADMIN.0004). Requests that do not meet established guideline criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

Definitions

MCG Care Guidelines — definition and application

DefinitionMCG Care Guidelines: external clinical guidance used by the payer for various utilization management determinations when no internal policy exists.

Primary usesUsed for medical necessity review (medical and behavioral health inpatient), inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services where no other Medical Policy or CUMG exists.

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

Decision processMedical necessity determinations are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy ADMIN.0004.

EscalationRequests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

DME-related CUMGs (titles only)

Rental and Purchase Guidance

DME Category	Representative CUMG Code / Title	Rental vs Purchase Guidance
Durable Medical Equipment (general)	CG-DME-10 — Durable Medical Equipment	See the individual CUMG for specific rental vs purchase rules
Hospital beds and accessories	CG-DME-15 — Hospital Beds and Accessories	See the individual CUMG for specific rental vs purchase rules
Pressure reducing support systems	CG-DME-16 — Pressure Reducing Support Systems Groups 1, 2 and 3	See the individual CUMG for specific rental vs purchase rules
Home oxygen therapy	CG-DME-18 — Home Oxygen Therapy	See the individual CUMG for specific rental vs purchase rules
Home phototherapy devices (neonatal)	CG-DME-12 — Home Phototherapy Devices for Neonatal Hyperbilirubinemia	See the individual CUMG for specific rental vs purchase rules

Documentation & Determination Guidance

Documentation Required

Documentation and authority for medical necessity determinations

Medical necessity determinations follow applicable Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark’s Medical Necessity Criteria Policy ADMIN.0004; when no internal policy exists, MCG Care Guidelines are used.

MCG Care Guidelines apply for medical necessity review, inpatient site‑of‑service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services.