Clinical Utilization Management Guidelines (DME and other services)
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List and index of Clinical Utilization Management (CUMG) Guidelines adopted by Highmark BCBS for MMC, HARP, CHPlus, and Essential Plan members; includes numerous DME-related guideline identifiers and titles. Affects providers submitting medical necessity/preauthorization requests for those plans.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
Highmark Blue Cross Blue Shield of Western New York uses external clinical guidance for utilization review, but Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines. Determinations of medical necessity are made 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.00004).
Provider Actions & Prior Authorization
CUMG Item Additions Noted
Clinical Utilization Management Guidelines (CUMG) items have been added or noted for use in prior authorization and pre-payment medical necessity review. Refer to the listed CUMG entries (including numerous DME- and surgical-specific guidelines) when preparing requests; these items are being incorporated as reference guidance for medical necessity determinations.
- New CUMG items have been added across categories (e.g., CG-ADMIN-01; multiple CG-DME entries; multiple CG-SURG entries).
- Providers should reference the applicable CUMG entry for the service or device when submitting requests for prior authorization or pre-payment review.
Failure to Meet Guideline Criteria
Medical necessity determinations are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, and our Medical Policy/Clinical UM Guidelines. If a request does not meet the applicable guideline criteria, it will be referred to a licensed physician reviewer with the appropriate clinical expertise and may be denied.
- Requests not meeting established criteria will undergo physician review and are at risk for denial.
No Explicit Authorization/Denial Trigger
The listed CUMG entries and 'New item =' annotations enumerate guideline additions and references but do not by themselves constitute an explicit automatic authorization or denial trigger. Each authorization decision will be based on application of the guidelines to the individual clinical facts of the request.
- Presence of a CUMG entry is informational — it indicates available guidance for review, not an automatic approval or denial rule.
Documentation Requirements Not Specified
There are no additional, specific documentation requirements enumerated within these CUMG listing chunks. Providers should continue to submit the standard clinical documentation used for medical necessity review (including history, relevant diagnostics, prior conservative therapy where applicable, and rationale for the requested service). If documentation beyond standard submission is required, the reviewer will request it.
- No separate documentation checklist is specified here — follow standard prior authorization documentation practices.
- Be prepared to provide supporting clinical records, test results, prior treatment history, and device-specific information when applicable.
Medical Necessity Guidance for DME
DME medical necessity guidance pointer
Providers should consult the specific CUMG entry for each equipment type for medical necessity criteria.
See CUMG identifiers in the document (e.g., CG-DME-03, CG-DME-04, CG-DME-05, CG-DME-06, CG-DME-07, CG-DME-08, 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).
Documentation Notes
Documentary references for DME authorizations — consult listed CUMG titles
Numerous DME-specific CUMG titles are listed (e.g., Neuromuscular Stimulation, Cervical Traction Devices, Pneumatic Compression Devices, AAC Devices, Infant Home Apnea Monitors, Hospital Beds, Pressure Reducing Support Systems, Home Oxygen Therapy, Therapeutic Shoes for Diabetes, Wheeled Mobility devices, External Infusion Pumps, AFO/KAFO, Back-Up Ventilators, Electric Breast Pumps, Pediatric Gait Trainers, Home Ventilator Therapy, Vacuum Assisted Wound Therapy, Standing Frames, etc.); providers should reference the corresponding guideline for documentation expectations.
- The DME CUMG identifiers (e.g., CG-DME-03 through CG-DME-34) correspond to specific equipment categories listed in the index.
- Refer to the individual CUMG for required clinical notes, measurements, and supporting documentation when submitting authorizations.
Background
Highmark BCBS uses the Clinical Utilization Management Guidelines (CUMG) and MCG Care Guidelines to perform medical necessity reviews and to determine site‑of‑service appropriateness for inpatient, outpatient, rehabilitation and skilled nursing services, and for many durable medical equipment (DME) items. Providers should reference the specific CUMG entry for each equipment type when requesting prior authorization, recognizing that numerous DME‑specific guideline titles (for example, elastomeric infusion pumps, pressure‑reducing support systems, hospital beds and accessories, and many others) are listed in the guideline index. If a request does not meet established guideline criteria, it will be referred to a licensed physician reviewer and may be denied if medical necessity is not met.
Definitions and External Guidance
Referenced CUMG & Guideline Index
Index pointer — consult full CUMG documents for authorization and billing rules
The CUMG list includes many guideline items across DME and surgical categories with multiple 'New item =' annotations; consult the indexed guideline list when preparing clinical or billing submissions.
- This index serves as a pointer to the full CUMG documents which contain the specific prior authorization, documentation, and clinical criteria.
- Providers should not rely on the index alone to determine coverage or billing rules.
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