CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (DME and related services)

List and adoption notice of Clinical Utilization Management Guidelines (CUMG) used by Highmark BCBS WNY for Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan (EP) members, including numerous Durable Medical Equipment (DME)–related guidelines. Affects providers submitting medical necessity or utilization management requests for those member groups.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (DME and related services)

Policy CodePolicy N/A

Change TypeInformational — adopted CUMG list

Effective DateN/A

Next Review DateN/A

Key ActionProviders must reference the adopted Clinical UM Guidelines and Medical Policies on the Highmark BCBSWNY provider website when submitting requests for medical necessity review for MMC, HARP, CHPlus, and EP members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+CUMG items listed

MultipleDME-specific CUMGs

MMC, HARP, CHPlus, EPPrograms in-scope

MCG referencedMCG referenced

Coverage Criteria Overview

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The Clinical Utilization Management Guidelines (CUMG) and referenced MCG Care Guidelines are adopted as tools to support medical necessity determinations for Medicaid Managed Care (MMC), HARP, Child Health Plus (CHPlus), and Essential Plan (EP) members. Where a specific Medicaid state contract, regulatory requirement, CMS requirement, or a Highmark Medical Policy/Clinical UM Guideline conflicts with MCG guidance, those state/CMS/payer authorities supersede MCG Care Guidelines. All determinations of medical necessity are made on a case‑by‑case basis in accordance with the applicable Medicaid/state/CMS definitions and Highmark's Medical Necessity Criteria Policy.

Highmark BCBSWNY uses Clinical Utilization Management Guidelines, including the MCG Care Guidelines where applicable, to inform medical necessity reviews across inpatient, outpatient, rehabilitation, skilled nursing facility, and durable medical equipment settings. These guidelines are applied for pre‑payment and utilization review when no specific Medical Policy or Clinical UM Guideline exists. If a request does not meet the established guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a medical necessity determination.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required / Pre-Payment Medical Necessity Review

Prior authorization and pre-payment review: Medical necessity determinations for services are performed using the adopted Clinical Utilization Management Guidelines (CUMG) and MCG Care Guidelines where applicable. Requests for inpatient, outpatient, or other services that require review will be evaluated against these guidelines; when no other Clinical UM Guideline exists, CG-ADMIN-01 (Pre-Payment Review Medical Necessity Determinations) will be applied.

Applies to inpatient medical and behavioral health review, inpatient site-of-service appropriateness, inpatient rehabilitation and SNF review, and certain outpatient services when no specific Medical Policy/CUMG exists (see MCG Care Guidelines usage).
MCG Care Guidelines are supplemental and are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines.
When requests do not meet established criteria, they will be referred to a licensed physician reviewer with appropriate clinical expertise.

Note

Prior Authorization Not Stated on Title List

Prior authorization not explicitly stated for many listed CUMG titles: the source list provides guideline titles (e.g., Acupuncture; Ambulance Services; various DME and surgical topics) but does not include explicit prior authorization instructions on each listed guideline page. Providers should not assume absence of authorization requirements based solely on the guideline title listing.

The document lists many CUMG titles without per-item authorization language — check the full Clinical UM Guideline or Medical Policy on the Highmark website for specific prior authorization instructions.
CG-ADMIN-01 governs pre-payment review when no other guideline exists; other listed CUMGs may carry their own authorization rules within the full guideline text.

Documentation Required

Provider Documentation Required

Provider action — documentation and submission: Providers must reference and attach relevant Clinical UM Guidelines and Medical Policies when submitting authorization or pre-payment review requests. Include clinical records, rationale, and any supporting imaging or test results to allow medical necessity review per the applicable CUMG or MCG guideline.

Reference the adopted Clinical UM Guidelines and Medical Policies available on the Highmark website when preparing requests.
Include clinical notes, diagnostic test results, imaging, and prior treatment history as applicable to the guideline criteria.

Denial Risk

Denial Risk if Criteria Not Met

Failure to meet criteria may trigger denial: If the submitted request does not meet the established guideline criteria, the case will be referred to a licensed physician reviewer and may be denied if medical necessity is not demonstrated.

Denials may occur when documentation is insufficient or when clinical criteria in the applicable CUMG/MCG are not met.
Providers may be asked for additional information during review; unresolved gaps can lead to an adverse determination.

Note

No Explicit Prior Authorization Indicated in Title List

No explicit authorization/prior authorization note: Some chunks list CUMG titles but do not specify whether prior authorization is required. Providers should assume authorization may be required and verify requirements for the specific service or procedure via Highmark’s Medical Policy and Clinical UM Guideline webpages or prior authorization tools.

Do not rely solely on the presence of a guideline title to determine authorization needs.
Verify authorization requirements per-service on Highmark’s Medical Policy/Clinical UM Guideline site or through provider portals.

DME Medical Necessity Approach

DME medical necessity approach

Covered when ALL of the following are met:

Reference individual CUMG: Providers must follow the specific Clinical UM Guideline (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, CG-DME-35, CG-DME-36, CG-DME-37, CG-DME-39, CG-DME-52, etc.) for item-specific medical necessity criteria; MCG Care Guidelines may be used where applicable but are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and payer Medical Policy/Clinical UM Guidelines.

See corresponding CUMG documents on the Highmark BCBSWNY provider website for full, item-specific criteria and documentation requirements.

Item / Guideline	Rental vs Purchase Rule
Durable Medical Equipment (CG-DME-10)
rental \| purchase \| capped_rental (see individual CUMG for specific rule)

Key Definitions

MCG Care Guidelines — definition and role

Definition of MCG Care GuidelinesA referenced set of clinical guidance used for medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation/skilled nursing review, and certain outpatient services when no specific Medical Policy or Clinical UM Guideline exists.

Role when payer guideline absentMCG Care Guidelines are used to review outpatient services or procedures only when there is not an established Medical Policy or Clinical UM Guideline; they inform medical necessity determinations in those cases.

Hierarchy relative to other authoritiesMedicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Related use for substance abuseLevel of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance abuse services according to state requirements (MCG does not override state-mandated tools).

Medical Necessity — definition and governing references

Medical Necessity — authoritative sourcesDeterminations are made case-by-case in accordance with the definition of medical necessity contained within the Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy ADMIN.0004.

Decision processIf a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with appropriate clinical expertise to make a determination.

Superseding hierarchyMedicaid state contracts, regulatory guidance, CMS requirements and Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines for medical necessity determinations.

Scope of determinationsApplies across medical and behavioral health inpatient review, inpatient site-of-service and rehabilitation reviews, and applicable outpatient services where policies are not established.

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-DME-03	Neuromuscular Stimulation in the Treatment of Muscle Atrophy.
CG-DME-04	Electrical Nerve Stimulation, Transcutaneous, Percutaneous.
CG-DME-05	Cervical Traction Devices for Home Use.

OpenPayer

Clinical Utilization Management Guidelines (DME and related services)

Coverage Criteria Overview

CUMG Identifiers and Coding Notes

Provider Actions, Authorization & Documentation

DME Medical Necessity Approach

Rental, Purchase and Capped Rental Rules

General DME Replacement Policies

Documentation and Supporting Materials

Key Definitions