CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (Durable Medical Equipment highlights)

List and adoption notice of Clinical Utilization Management Guidelines used by Highmark BCBS for Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members; includes multiple DME-related guideline titles and references to where full guidelines are posted. Affects providers requesting DME and other services for those member programs.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (Durable Medical Equipment highlights)

Policy CodePolicy N/A

Change TypeInformational / adoption notice

Effective DateN/A

Next Review DateN/A

Key ActionProviders must consult the specific CG-DME-## guideline pages on the Highmark provider public website for documentation, prior authorization and medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~90+CUMG items listed across categories

Multiple DMEDME-related guidelines enumerated

9/9/2021Committee adoption date noted

~35Policy items in fragment

several

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Coverage Criteria Overview

This document lists Clinical Utilization Management (CUMG) guidelines adopted by Highmark Blue Cross Blue Shield for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan members. MCG Care Guidelines are used for medical necessity review of inpatient medical and behavioral health, for inpatient site-of-service appropriateness, for inpatient rehabilitation and skilled nursing facility review, and for outpatient services or procedures when no specific Medical Policy or Clinical UM Guideline exists. However, 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 per the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark’s Medical Necessity Criteria Policy ADMIN.0004.

CUMG Identifiers and Coding Notes

CUMG identifiers listed (not billing codes)mixed

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 48

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Provider Requirements and Actions

Prior Authorization

Consult CUMG webpage for prior authorization

Consult the Highmark Clinical Utilization Management (CUMG) guidelines for medical necessity and site-of-service review. The full list of Medical Policies and Clinical UM Guidelines is publicly available on the Highmark provider public website. Determinations of medical necessity are made case-by-case; requests that do not meet established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise.

MCG Care Guidelines are used for medical necessity and inpatient site-of-service appropriateness, inpatient rehabilitation and SNF review, and outpatient services where no Medical Policy/Clinical UM Guideline exists.
Medicaid state contracts, regulatory guidance, CMS requirements and Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.
Level of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance abuse services per state requirements.

Note

Policy index — no PA detail

This policy section indexes Clinical UM Guidelines but does not itself impose explicit prior authorization requirements. Providers should reference the listed CUMG policies on the Highmark provider public website for any procedure-specific prior authorization information.

Document Background

Highmark has adopted and indexed a set of Clinical Utilization Management Guidelines for use in medical necessity review and utilization management. The list of adopted CUMGs was approved by the Medical Operations Committee on September 9, 2021. Providers should consult the publicly posted guideline webpages for the full guideline text, equipment- or service-specific criteria, and documentation requirements; if a request does not meet the established guideline criteria it will be referred to a licensed physician reviewer with appropriate clinical expertise.

Key Definitions

CUMG / Clinical UM Guidelines

DefinitionClinical Utilization Management (CUMG) Guidelines are payer‑adopted guidelines used to determine medical necessity, site‑of‑service appropriateness, and to guide prepayment review when no other Medical Policy or Clinical UM Guideline exists.

Scope and purposeThe CUMG list is adopted by Highmark BCBS to help provide quality care by reducing inappropriate use of medical resources and to support medical necessity review for inpatient and outpatient services.

Use in reviewsMCG Care Guidelines are used for medical necessity review for inpatient medical and behavioral health, inpatient site‑of‑service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services where no other policy exists.

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

Adoption and applicabilityThe listed CUMGs were adopted by the medical operations committee (adoption date noted in the document: September 9, 2021) and apply to MMC, HARP, CHPlus, and Essential Plan members specified by Highmark BCBS.

DME Medical Necessity Criteria

DME guideline-level criteria

Specific medical necessity criteria exist per individual CG-DME-## guideline; providers must consult each listed guideline for precise criteria.

CUMG reference: Medical necessity and coverage criteria are defined within each CG-DME-## guideline (e.g., CG-DME-09 Continuous Local Delivery of Analgesia; CG-DME-10 Durable Medical Equipment; CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia; CG-DME-13 Lower Limb Prosthesis; CG-DME-15 Hospital Beds and Accessories; CG-DME-16 Pressure Reducing Support Systems; CG-DME-18 Home Oxygen Therapy).

Refer to the individual CG-DME-## guideline on the Highmark provider public website for full criteria and documentation requirements.

Additional DME guidelines (examples): CG-DME-19 Therapeutic Shoes/Inserts for Diabetes; CG-DME-20 Orthopedic Footwear; CG-DME-21 External Infusion Pumps; CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses; CG-DME-23 Lifting Devices for Home Use; CG-DME-24 Manual Wheelchairs; CG-DME-25 Seat Lift Mechanisms; CG-DME-26 Back-Up Ventilators; CG-DME-30 Prothrombin Time Self-Monitoring Devices; CG-DME-31 Powered Wheelchairs; 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 Electrical Bone Growth Stimulation; CG-DME-41 Home Ultraviolet Light Therapy; CG-DME-42 Insulin Infusion & Glucose Monitoring Devices; 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 for DVT Prevention; CG-DME-47 Home Ventilator Therapy; CG-DME-48 Vacuum Assisted Wound Therapy; CG-DME-49 Standing Frames.

Rental and Purchase Rules for DME

Durable Medical Equipment	Rental \| Purchase
Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump (CG-DME-09)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Durable Medical Equipment (general) (CG-DME-10)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Home Phototherapy Devices for Neonatal Hyperbilirubinemia (CG-DME-12)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Lower Limb Prosthesis (CG-DME-13)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Hospital Beds and Accessories (CG-DME-15)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Pressure Reducing Support Systems Groups 1, 2 and 3 (CG-DME-16)	rental \| purchase — see individual CUMG for specific rental vs purchase rules
Home Oxygen Therapy (CG-DME-18)	rental \| purchase — see individual CUMG for specific rental vs purchase rules

Replacement Rules

Replacement intervals for DME types

Replacement intervals — generalReplacement intervals for durable medical equipment are specified within each individual CG‑DME‑## guideline; providers must consult the specific CUMG for the interval applicable to that equipment type.

Where to find intervalsReplacement and service/repair rules are published on the Highmark provider public website within each CG‑DME guideline page (see providerpublic.mybcbswny.com references).

Examples of DME guideline titlesExamples of CG‑DME guidelines listed include CG‑DME‑10 Durable Medical Equipment; CG‑DME‑15 Hospital Beds and Accessories; CG‑DME‑16 Pressure Reducing Support Systems; CG‑DME‑18 Home Oxygen Therapy; CG‑DME‑19 Therapeutic Shoes/Inserts for Diabetes; CG‑DME‑31 Powered Wheelchairs, among others.

Provider actionProviders seeking replacement coverage must reference the specific CG‑DME‑## guideline for documentation and interval requirements before submitting claims or authorization requests.

No blanket intervals in indexThis document is an index and does not list equipment‑level replacement intervals; intervals are defined within each CUMG guideline.

Documentation Requirements

Documentation Required

Refer to CG‑DME‑## pages on providerpublic.mybcbswny.com for documentation

Providers must consult the full CG‑DME‑## guideline pages on the Highmark provider public website for equipment-specific documentation and coverage rules before submitting claims or prior authorization requests.

The guideline pages provide the precise documentation requirements and criteria necessary to support coverage for each DME type.

Not Covered / Exclusions

This excerpt does not list any item-level Durable Medical Equipment (DME) items that are explicitly designated as not covered. For exclusions or specific not-covered items, refer to each individual CG-DME-## guideline posted on the Highmark provider public website, and to applicable Medicaid/state contracts and Highmark Medical Policies which supersede CUMG guidance.