CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines — CUMG index (DME-focused)

Lists Clinical Utilization Management Guidelines adopted by Highmark BCBSWNY for MMC, HARP, and Child Health Plus members; intended for providers and administrators for utilization review and prior authorization, with numerous CG‑DME entries referenced.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) — index of adopted guidelines

Policy CodePolicy N/A

Change TypeInformational / Index

Effective DateN/A

Next Review DateN/A

Key ActionReference the specific CG‑DME guideline identifier when submitting prior authorization or medical necessity documentation for DME requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+CUMGs listed

MMC, HARP, CHPlusPrograms affected

MultipleDME entries

severalItems marked New

Coverage Criteria and Guideline Hierarchy

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General application: Medical necessity determinations are made case-by-case according to the Medicaid state contract, regulatory guidance, CMS requirements, or Medical Necessity Criteria Policy ADMIN.0004; MCG Care Guidelines may be used for inpatient and some outpatient reviews but are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and payer Medical Policy/Clinical UM Guidelines when conflicts exist.

Requests that do not meet established criteria guidelines will be referred to a licensed physician reviewer with appropriate clinical expertise and may be denied if medical necessity is not met.

MCG Care Guidelines may be used by Highmark BCBSWNY for medical necessity review and site-of-service appropriateness, including inpatient medical and behavioral health reviews, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services where 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 when there is a conflict. Providers should continue to reference the controlling state or federal requirements and applicable Highmark medical policy when preparing requests.

When a request does not meet the established guideline criteria, it will be referred to a licensed physician reviewer with appropriate clinical expertise for a final determination. Such nonconforming requests may be determined not medically necessary and denied if, after clinical review, they do not satisfy the applicable medical necessity standards described in the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark’s Medical Necessity Criteria Policy (ADMIN.0004).

Listed CUMG Codes and Code Groups

Listed CUMG codes (sample of DME-focused items)mixed

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
CG-DME-06	Compression Devices for Lymphedema
CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
CG-DME-08	Infant Home Apnea Monitors
CG-DME-09	Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Postoperative Period
CG-DME-10	Durable Medical Equipment
CG-DME-12	Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13	Lower Limb Prosthesis

1–10 of 43

1/5

Selected medical and ancillary CUMG codesmixed

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-MED-40	External Ambulatory Cardiac Monitors
CG-MED-08	Home Enteral Nutrition
CG-MED-19	Custodial Care
CG-OR-PR-02	Prefabricated and Prophylactic Knee Braces
CG-REHAB-12	Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Provider Responsibilities, Prior Authorization, and Communication

Documentation Required

Medical Necessity Definition and Use

MCG Care Guidelines are used for medical necessity review for medical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation and skilled nursing facility review; and outpatient-based services or procedures where there is not an established Medical Policy or Clinical UM Guideline. Level of Care for Alcohol and Drug Treatment Referral 3.0® is used for substance abuse services per state requirements. Medicaid state contracts, regulatory guidance, CMS requirements and Highmark Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

MCG Care Guidelines may be applied when no specific Medical Policy or Clinical UM Guideline exists.
Determinations of medical necessity are made case-by-case per the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark Medical Necessity Criteria Policy ADMIN.0004.

Denial Risk

Denial Risk and Authorization Clarification

If a request does not meet established guideline criteria, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for determination. There are no explicit authorization or denial criteria listed in this index excerpt; the content shown is an index of Clinical Utilization Management Guidelines (CUMGs) and 'New' flags.

Absent specific CUMG criteria in this excerpt, prior authorization requirements are not specified here.
Requests non-conforming to applicable criteria may be denied following review by a licensed physician reviewer.

Note

Provider Communication and Resources

Providers should consult the full list of Medical Policies and Clinical UM Guidelines on the Highmark BCBSWNY Medical Policies and Clinical UM Guideline website and enroll to receive email communications for updates. Email is the quickest and most direct way to receive important information; providers can sign up via the provided QR code or the online form.

Visit: Search Medical Policies and Clinical Guidelines (providerpublic.mybcbswny.com) to view guidelines referenced in the index.
Sign up for email updates via https://bit.ly/signup-hm-ny or the QR code on provider communications.

Policy Background and Purpose

Highmark BCBSWNY adopts Clinical Utilization Management Guidelines (CUMGs) and may use MCG Care Guidelines to standardize medical necessity reviews across inpatient and certain outpatient settings. These guidelines support consistent review processes, but determinations are made on a case-by-case basis in accordance with the definition of medical necessity contained in the Medicaid state contract, regulatory guidance, CMS requirements, or the Medical Necessity Criteria Policy (ADMIN.0004).

Key Definitions

Medical necessity — definition and summary

DefinitionMedical necessity determinations 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 Medical Necessity Criteria Policy ADMIN.0004.

Guideline hierarchyMCG Care Guidelines may be used for medical necessity and site-of-service review but are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and Highmark Medical Policy/Clinical UM Guidelines when conflicts exist.

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

Scope of useMCG Care Guidelines are used for inpatient medical and behavioral health reviews, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and outpatient services where no established Medical Policy or Clinical UM Guideline exists.

DME Guideline References and Criteria

DME guideline reference

Each listed CG-DME guideline provides the medical necessity criteria for that equipment type; providers must consult the specific guideline (by CG-DME number) for detailed criteria.

Reference-specific CUMG for criteria: Medical necessity and coverage criteria for DME items are defined within each CG-DME guideline listed (for example, CG-DME-03 through CG-DME-53).

This document is an index of CG-DME guidelines; providers must reference the applicable CG-DME identifier when submitting prior authorization or medical necessity documentation.

Durable Medical Equipment (CG-DME) guideline	Rental vs Purchase rules (documented here)
CG-DME-10: Durable Medical Equipment	Not specified in this index excerpt; consult the specific CG-DME-10 guideline for rental versus purchase determinations.

Replacement and Repair Rules

DME replacement notes and index guidance

Reference ruleProviders must reference the specific CG-DME guideline identifier when submitting requests; the document lists CG-DME entries for many equipment types.

Replacement intervalsReplacement intervals are not specified in this index; replacement timing, if any, is defined within each specific CG-DME guideline.

Examples of DME entriesListed CG-DME items include Neuromuscular Stimulation (CG-DME-03), Electrical Nerve Stimulation (CG-DME-04), Cervical Traction Devices (CG-DME-05), Compression Devices for Lymphedema (CG-DME-06), Infant Home Apnea Monitors (CG-DME-08), Elastomeric Infusion Pumps (CG-DME-09), and Durable Medical Equipment (CG-DME-10).

Action for providersConsult the applicable CG-DME guideline (by its CG-DME number) for replacement and coverage criteria rather than relying on this index alone.

Submission and Documentation Guidance

Documentation Required

Reference CG-DME guideline identifier in requests

Include the specific CG-DME guideline identifier (e.g., CG-DME-10, CG-DME-19, etc.) in prior authorization or medical necessity documentation for DME items so the request can be reviewed against the correct guideline.

Reference the CG-DME number for the equipment type when submitting requests.

Non-Covered Items and Denial Indicators

Requests that do not meet the established CUMG or applicable Highmark criteria may be denied. This index does not list every specific exclusion for individual DME items; providers must consult the applicable CG‑DME guideline for item‑level exclusions and detailed coverage limitations. Denial decisions follow referral to a licensed physician reviewer when medical necessity criteria are not met.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) — index of adopted guidelines

Policy CodePolicy N/A

Change TypeInformational / Index

Effective DateN/A

Next Review DateN/A

Key ActionReference the specific CG‑DME guideline identifier when submitting prior authorization or medical necessity documentation for DME requests.

SourceLink

On This Page

OpenPayer

Clinical Utilization Management Guidelines — CUMG index (DME-focused)

Coverage Criteria and Guideline Hierarchy

Listed CUMG Codes and Code Groups

Provider Responsibilities, Prior Authorization, and Communication

Policy Background and Purpose

Key Definitions

DME Guideline References and Criteria

Durable Medical Equipment Rental vs Purchase

Replacement and Repair Rules

Submission and Documentation Guidance

Non-Covered Items and Denial Indicators