CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (CUMG) for DME and related services

Customize your policy alerts

Sign up for all Highmark Blue Cross Blue Shield Wny policy alerts

Know when Highmark Blue Cross Blue Shield Wny releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

A listing and adoption notice of Clinical Utilization Management Guidelines Highmark BCBSWNY uses for Medicaid Managed Care (MMC), HARP, and Child Health Plus (CHPlus) programs; includes many DME-related guideline titles. Affects providers submitting requests for medical necessity review and coverage under those programs.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) for DME and related services

Policy CodePolicy N/A

Change TypeInformational listing / adoption notice

Effective DateN/A

Next Review DateN/A

Key ActionConsult the listed CUMGs for specific medical necessity criteria and submit requests accordingly.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+CUMG items listed across categories

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Clinical Utilization Management Guidelines (CUMG) for DME and related services

Customize your policy alerts

Sign up for all Highmark Blue Cross Blue Shield Wny policy alerts

Know when Highmark Blue Cross Blue Shield Wny releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClinical Utilization Management Guidelines (CUMG) for DME and related services

Policy CodePolicy N/A

Change TypeInformational listing / adoption notice

Effective DateN/A

Next Review DateN/A

Key ActionConsult the listed CUMGs for specific medical necessity criteria and submit requests accordingly.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+CUMG items listed across categories

Coverage Criteria Overview

The MCG Care Guidelines serve as a clinical resource for utilization review but do not override higher‑level authorities. Medicaid state contracts, regulatory guidance, CMS requirements, and payer Medical Policy/Clinical UM Guidelines supersede MCG when there is any conflict or specific direction from those authorities.

Provider Actions, Authorization & Review

Prior Authorization

Use CUMGs for pre‑payment review & medical necessity

Clinical Utilization Management Guidelines (CUMG) are used to support pre-payment review and medical necessity determinations for Medicaid Managed Care (MMC), HARP, and Child Health Plus (CHPlus) members; providers should consult the listed CUMGs for coverage criteria and submit requests accordingly.

CUMGs adopted by Highmark BCBSWNY are listed on the provider policies page (see providerpublic.mybcbswny.com).

Note

Index lists CUMG titles — check each guideline for auth rules

The document provides an index of CUMG titles (many flagged as 'New item') for provider reference but does not state specific prior authorization requirements within the index itself.

Providers must open the individual CUMG cited in the index to determine any prior authorization or coverage criteria.

Denial Risk

Requests failing guideline criteria are referred for physician review

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 determination.

Be prepared to provide clinical documentation to support medical necessity when a case is escalated to physician review.

Step Therapy

No step therapy rules provided in the index

No step therapy rules are specified in the provided CUMG index or related chunks; providers should not assume step therapy requirements are contained here and must review individual CUMGs or Medical Policy for any such rules.

If step therapy applies it will be specified in the applicable individual guideline or Medical Policy, not in the index.

Documentation Required

Medical necessity determinations follow Medicaid/CMS/ADMIN.0004 standards

Determinations of medical necessity are made case-by-case in accordance with the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004).

Providers must document how requests meet the definition of medical necessity from the applicable Medicaid contract/regulatory guidance or ADMIN.0004.

Note

Providers may sign up to receive policy updates via email using the QR code or the online form (https://bit.ly/signup-hm-ny).

Use the QR code or the online form to enroll for timely notifications of guideline and policy changes.

Denial Risk

Non‑conforming requests may be denied after physician review

Requests that do not meet the established CUMG criteria will be referred to a licensed physician reviewer and may be denied if medical necessity is not met.

Ensure submitted documentation explicitly addresses the applicable CUMG criteria to reduce risk of denial.

Note

Index does not specify explicit authorization/denial triggers

The index entries enumerate many guideline titles and mark new items, but do not themselves define explicit authorization or denial triggers; providers must consult the full guideline text for any authorization or denial criteria.

Treat the index as a directory only — authorization/denial logic is in each individual CUMG or Medical Policy.

Background and Scope

MCG Care Guidelines are applied by Highmark for several utilization management functions: inpatient medical and behavioral health necessity review, evaluation of inpatient site‑of‑service appropriateness, review of inpatient rehabilitation and skilled nursing facility (SNF) stays, and for certain outpatient services or procedures when no other Medical Policy or Clinical UM Guideline exists. Level of Care tools (e.g., for substance use disorder) are used as required by state programs. Determinations of medical necessity are made case‑by‑case in accordance with the Medicaid state contract, applicable regulatory/CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004). If a request does not meet the established guideline criteria, it will be referred to a licensed physician reviewer with the appropriate clinical expertise and may be denied.

Key Definitions

Medical necessity (definition and authority)

DefinitionMedical necessity determinations are made case-by-case in accordance with the definition contained within the Medicaid state contract, regulatory guidance, CMS requirements, or Highmark's Medical Necessity Criteria Policy (ADMIN.0004).

Authority hierarchyMedicaid state contracts, regulatory guidance, CMS requirements, and payer Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Review processIf a request does not meet established criteria guidelines it will be referred to a licensed physician reviewer with appropriate clinical expertise for a decision.

Use of MCGMCG Care Guidelines are used for inpatient medical necessity review, inpatient site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services where no other policy exists.

DME Medical Necessity Criteria

DME medical necessity

Individual Clinical Utilization Management Guidelines (CUMGs) contain the medical necessity criteria for each DME equipment type listed. Providers must follow the specific CUMG criteria and applicable Medicaid/CMS requirements for coverage determinations.

General requirement: Coverage determinations require that requests meet the specific CUMG medical necessity criteria and applicable Medicaid/CMS requirements

Refer to the individual CUMG title listed in the index (e.g., CG-DME-18 Home Oxygen Therapy; CG-DME-31 Powered Wheeled Mobility Devices) for device-specific clinical criteria and documentation requirements.

Rental, Purchase, and Capped Rental Rules

DME Category	Rental vs Purchase	Notes / Reference
Durable Medical Equipment (general)	Rental \| Purchase \| Capped rental (as addressed within individual CUMGs)	See CG-DME-10 for the general Durable Medical Equipment guideline; rental/purchase rules are specified within each CUMG.
Home Oxygen Therapy	Rental \| Purchase \| See CUMG for specifics	CG-DME-18 lists Home Oxygen Therapy — consult the guideline for rental vs purchase and any capped rental provisions.
Wheeled Mobility Devices (manual & powered) and accessories	Rental \| Purchase \| Capped rental rules may apply per device type	CG-DME-24, CG-DME-31, CG-DME-33 and CG-DME-34 enumerate wheeled mobility device guidelines; rental/purchase treatment addressed in each guideline.
Hospital Beds and Accessories	Rental \| Purchase \| Refer to specific CUMG	CG-DME-15 covers hospital beds and accessories; rental vs purchase details available in that guideline.
Pressure Reducing Support Systems (Groups 1-3)	Rental \| Purchase \| Guideline specifies criteria	CG-DME-16 addresses pressure reducing support systems; consult for rental/purchase rules and any capped rental provisions.
External Infusion / Elastomeric Infusion Pumps	Rental \| Purchase \| See respective CUMG	CG-DME-21 and CG-DME-09 reference infusion pumps; rental/purchase guidance contained in the individual guidelines.
Orthotic / Footwear / Therapeutic Shoes	Rental \| Purchase \| CUMG specifies acquisition rules	CG-DME-19 and CG-DME-20 cover therapeutic shoes and orthopedic footwear; consult guideline for rental vs purchase treatment.
Prosthesis and Orthoses (e.g., lower limb prosthesis, AFO/KAFO)	Purchase (prostheses) \| Rental or purchase per device for orthoses — see CUMG	CG-DME-13 (Lower Limb Prosthesis) and CG-DME-22 (Ankle-Foot & Knee-Ankle-Foot Orthoses) provide device-specific acquisition rules.
Electric Breast Pumps	Purchase \| Refer to CUMG	CG-DME-35 lists electric breast pumps; consult the guideline for coverage and acquisition method.

Replacement Rules and Categories

DME categories and replacement/rental rules

Scope of DME categoriesIndex includes numerous DME guideline titles such as Home Oxygen Therapy; Therapeutic Shoes/Inserts; Orthopedic Footwear; External Infusion Pumps; Ankle‑Foot & Knee‑Ankle‑Foot Orthoses; Lifting Devices; Manual and Powered Wheeled Mobility Devices; Seat Lift Mechanisms; Back‑Up Ventilators; Prothrombin Time Self‑Monitoring Devices; Powered wheeled mobility; Wheelchair accessories; Electric breast pumps; Pediatric devices, and more.

Replacement rules locationReplacement intervals and eligibility are specified within each specific DME CUMG guideline rather than in this index.

Rental vs purchase rulesRental, purchase, and capped rental rules are addressed within the individual DME CUMGs; providers should consult the specific guideline for billing/rental vs purchase determinations.

Documentation directiveProviders must reference the individual CUMG listed for required documentation and clinical criteria when requesting coverage or prior authorization for DME items.

Documentation & Prior Authorization Support

Documentation Required

Consult the specific CUMG for required DME documentation

When requesting coverage or prior authorization for DME, consult the specific CUMG referenced for that equipment type to determine the required documentation and clinical criteria.

Examples of DME guideline titles include Home Oxygen Therapy, Hospital Beds and Accessories, Powered Wheeled Mobility Devices, and Electric Breast Pumps.
Follow the individual CUMG for documentation details applicable to the requested equipment.