CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines for Durable Medical Equipment (CUMG)

List and adoption notice of Clinical Utilization Management Guidelines (CUMG) Highmark BCBS uses for medical necessity and utilization review, including numerous DME-related guidelines; affects providers serving Highmark BCBS Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members (EP-specific information emphasized).

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines for Durable Medical Equipment (CUMG)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen submitting requests, providers must reference the listed CUMG titles and publicly available Medical Policies and Clinical UM Guidelines on Highmark's provider site for documentation and medical necessity support.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed CUMG titles across categories

MultipleDME-related guideline entries

EP-specificprogram specificity noted

~50MCG guideline items listed

Provider Actions and Operational Notes

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Note

MCG Care Guidelines Usage

MCG Care Guidelines are used by Highmark BCBS WNY for medical necessity reviews across inpatient and outpatient settings when no other Medical Policy or Clinical UM Guideline applies. Specifically, they support medical and behavioral health inpatient review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services or procedures lacking an established Medical Policy or Clinical UM Guideline. Level of Care for Alcohol and Drug Treatment Referral 3.0 is used for substance use disorder services per state requirements. Note that Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Used for medical necessity review for medical and behavioral health inpatient review
Used to determine inpatient site-of-service appropriateness
Applied to inpatient rehabilitation and skilled nursing facility review
Applied to outpatient services/procedures when no Medical Policy or Clinical UM Guideline exists
Level of Care for Alcohol and Drug Treatment Referral 3.0 used for SUD services per state requirements
Medicaid state contracts, regulatory guidance, CMS requirements and Highmark Medical Policy/Clinical UM Guidelines supersede MCG

Documentation Required

Documentation Sources and Standards

The Clinical Utilization Management Guidelines and Medical Policies referenced by Highmark are publicly available on the Highmark provider site. Providers should consult these resources and cite applicable Medical Policies and Clinical UM Guidelines when submitting prior authorization or medical necessity requests. Determinations of medical necessity are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.00004).

Access Medical Policies and Clinical UM Guidelines at Highmark's provider site: https://providerpublic.mybcbswny.com/western-new-york-provider/medical-policies-and-clinical-guidelines
Reference applicable Medical Policy or Clinical UM Guideline when submitting requests
Medical necessity defined per Medicaid state contract, regulatory guidance, CMS requirements, or ADMIN.00004

Denial Risk

Referral and Denial Risk

If a request does not meet established criteria or guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise for determination. Providers should be prepared to supply complete clinical documentation to support medical necessity determinations.

Requests not meeting criteria are referred to a licensed physician reviewer
Provide complete clinical documentation to avoid referral delays or denials

Note

MCG Guideline References (Informational)

Informational: The policy lists specific MCG Clinical Guideline identifiers and titles used by Highmark for surgical and procedure-related reviews (examples include CG-SURG-55 through CG-SURG-79 and others). Providers may reference these MCG items when applicable, but should prioritize Highmark Medical Policies and Clinical UM Guidelines and state/CMS requirements.

Examples of MCG items referenced: CG-SURG-55; CG-SURG-56 (Diagnostic Fiberoptic Flexible Laryngoscopy); CG-SURG-57 (Diagnostic Nasal Endoscopy); CG-SURG-58 (Radioactive Seed Localization of Nonpalpable Breast Lesions); CG-SURG-61 (Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver); CG-SURG-70 (Gastric Electrical Stimulation); CG-SURG-71 (Reduction Mammaplasty); CG-SURG-72 (Endothelial Keratoplasty); CG-SURG-73 (Balloon Sinus Ostial Dilation); CG-SURG-75 (Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions); CG-SURG-76 (Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty); CG-SURG-77 (Refractive Surgery); CG-SURG-78 (Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver); CG-SURG-79 (Implantable Infusion)
This list is informational; consult Highmark policies for coverage and prior authorization requirements

Medical Necessity Determination

General medical necessity process for DME

MCG Care Guidelines and Highmark policies are used to determine medical necessity for DME; Medicaid contracts and CMS requirements supersede MCG where applicable. Requests that do not meet established criteria are referred for physician review.

General requirement: Requests for durable medical equipment (DME) must meet the applicable Clinical Utilization Management Guideline (CUMG) or Highmark Medical Policy/Clinical UM Guideline criteria listed for the service or device.

Use the specific CUMG titles (e.g., CG-DME series) and applicable Medical Necessity Criteria when submitting requests; determinations follow Medicaid state contract/regulatory guidance/CMS and Highmark Medical Necessity Criteria ADMIN.00004.

Fallback guidance: When no specific Medical Policy or Clinical UM Guideline exists for an outpatient service or procedure, MCG Care Guidelines will be used to perform the medical necessity review.

MCG Care Guidelines supplement Highmark policies but are superseded by Medicaid contracts, regulatory guidance, CMS requirements, or Highmark Medical Policy.

Physician referral for nonconforming requests: If a request does not meet the established criteria guidelines, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for case-by-case determination of medical necessity.

Determinations follow the definition of medical necessity in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Highmark Medical Necessity Criteria Policy ADMIN.00004.

Scope of application: CUMG guidance applies across inpatient and outpatient settings including inpatient site of service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services where no other guideline exists.

Providers should reference the publicly available Medical Policies and Clinical UM Guidelines on Highmark's provider site when submitting requests.

OpenPayer

Clinical Utilization Management Guidelines for Durable Medical Equipment (CUMG)

Provider Actions and Operational Notes

Medical Necessity Determination

Documentation and Reference Requirements

Background and Scope