CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (DME and other services)

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A catalogue of Clinical Utilization Management (CUMG) guidelines adopted by Highmark BCBS for Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members; includes multiple DME-related guideline titles and indicates use of MCG Care Guidelines where applicable.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (DME and other services)

Policy CodePolicy N/A

Change TypeInformational / Catalog update

Effective DateN/A

Next Review DateN/A

Key ActionProviders must reference the specific Clinical UM Guideline (CUMG) for each DME item to determine prior authorization and medical necessity requirements.

SourceLink

80+listed Clinical UM Guidelines and Medical Policies (approx.)

MMC, HARP, CHPlus, Essentialprograms this applies to

~95policy items listed (estimate)

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CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (DME and other services)

Customize your policy alerts

Sign up for all Highmark Blue Cross Blue Shield Wny policy alerts

Know when Highmark Blue Cross Blue Shield Wny releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (DME and other services)

Policy CodePolicy N/A

Change TypeInformational / Catalog update

Effective DateN/A

Next Review DateN/A

Key ActionProviders must reference the specific Clinical UM Guideline (CUMG) for each DME item to determine prior authorization and medical necessity requirements.

SourceLink

80+listed Clinical UM Guidelines and Medical Policies (approx.)

MMC, HARP, CHPlus, Essentialprograms this applies to

~95policy items listed (estimate)

Coverage Criteria Overview

Medicaid state contracts, regulatory guidance, CMS requirements and the Medical Policy/Clinical UM Guidelines take precedence over the MCG Care Guidelines. When there is a conflict, the contractual and regulatory requirements and Highmark's own Medical Policy/Clinical UM Guidelines supersede MCG guidance.

Provider Actions and Authorization

Prior Authorization

Refer to CUMG for Prior Authorization

Refer to the Clinical Utilization Management Guidelines (CUMG) listed in this section for prior authorization and medical necessity determinations. These CUMG documents (including numerous DME- and procedure-specific guidelines) are used as the reference for prior authorization decisions when applicable.

Note

Prior Authorization Summary

Prior authorization summary: the CUMG index above lists the Clinical UM Guideline numbers and titles that may be used as the basis for prior authorization and medical necessity review. These indexed items include multiple DME, surgical, and therapy-specific guidelines (see cited list). Specific prior-authorization decisions are made per the applicable CUMG and our Medical Policy/Clinical UM Guidelines; this block is an index and does not itself convey individualized authorization decisions.

Note

Provider Action — No Explicit Triggers in Excerpt

None of the listed items in this excerpt contain explicit authorization, prior-authorization trigger, or definitive denial rule language within this section. Providers must consult the individual CUMG documents and applicable Medical Policy/Clinical UM Guidelines for the precise prior authorization criteria and denial conditions.

Durable Medical Equipment Medical Necessity Guidance

DME Medical Necessity Guidance (refer to specific guideline)

DME-specific Clinical Utilization Management Guidelines (CUMG) are adopted for medical necessity determinations. Providers must consult the individual guideline listed below for the exact criteria, documentation requirements, and any prior-authorization rules that apply.

Consult individual CUMG: Providers must refer to the specific Clinical UM Guideline (e.g., CG-DME-09, CG-DME-10, CG-DME-12, CG-DME-13, CG-DME-15, CG-DME-16, CG-DME-18, CG-DME-19, CG-DME-20, CG-DME-21, CG-DME-22, CG-DME-23, CG-DME-24, CG-DME-25, CG-DME-26, CG-DME-30, CG-DME-31, CG-DME-33, CG-DME-34, CG-DME-35, CG-DME-36) for the exact medical necessity criteria for each durable medical equipment type.

Failure to meet the specific CUMG criteria may result in referral to a physician reviewer and possible denial.

Rental and Purchase Guidance for DME

Durable Medical Equipment (general)	Rental vs Purchase Rule
Durable Medical Equipment (DME) — general (refer to individual CUMG for item-specific rules)	Rental or purchase is governed by the specific Clinical Utilization Management Guideline (e.g., CG-DME-10) and applicable program contract; providers must consult the individual CUMG for the applicable rental versus purchase determination.

Documentation Requirements

Documentation Required

Provide documented clinical justification referenced to the specific CUMG

Documented clinical justification and adherence to the specific Clinical UM Guideline is implied for the DME items listed; include documentation that maps the patient’s presentation to the guideline criteria when submitting requests.

Supporting documentation should reference the applicable CUMG title/number and demonstrate how each criterion is met.

Background and Guideline Use

The MCG Care Guidelines are used to support medical necessity review for inpatient medical and behavioral health services, inpatient site-of-service determinations, inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when no specific Medical Policy or Clinical UM Guideline exists. Determinations of medical necessity are made on a case-by-case basis in accordance with applicable Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004). Requests that do not meet established guideline criteria are referred to a licensed physician reviewer and may be denied if medical necessity is not met.

Definitions

MCG Care Guidelines

DefinitionMCG Care Guidelines: External clinical guidelines used by Highmark BCBS for medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services when no specific internal Medical Policy or Clinical UM Guideline exists.

Scope of UseApplied for medical and behavioral health inpatient reviews and for outpatient services/procedures lacking an established Medical Policy or Clinical UM Guideline.

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

Decision BasisDeterminations of medical necessity are made case-by-case in accordance with the Medicaid state contract definition of medical necessity, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy ADMIN.0004.

Referral on NoncomplianceRequests that do not meet established guideline criteria are referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if medical necessity is not met.