Clinical Utilization Management Guidelines — CUMG index (DME-focused)
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria and Guideline Hierarchy
General medical necessity and guideline hierarchy
Use of guidelines for medical necessity determinations
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
| 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 |
| 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
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 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.
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
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.
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 Rental vs Purchase
| 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
Submission and Documentation Guidance
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.
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