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    v1.0.28
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)SimplyHealthcare CUMG DME Index Coverage | OpenPay…
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    CurrentsimplyhealthcarePolicy ADMIN.00004

    Clinical Utilization Management Guidelines (CUMG) list

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    A catalog of Clinical Utilization Management Guidelines adopted by Simply Healthcare Plans, Inc. describing guideline identifiers and titles used for medical necessity and utilization review; applies to Simply Healthcare Plans members and providers (Florida/FHK referenced).

    Policy Summary
    Payersimplyhealthcare
    PolicyClinical Utilization Management Guidelines (CUMG) list
    Policy CodePolicy ADMIN.00004
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionConsult the listed CG-DME guideline for item-specific documentation and prior authorization requirements.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    100+CUMG items listed
    MultipleDME-related CUMGs
    FloridaPlan context
    ~40Items in excerpt

    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.

    How Clinical Utilization Management Guidelines Are Used

    General application of CUMGs

    The listed CUMGs are used for medical necessity review; when no specific Medical Policy or CUMG exists, MCG Care Guidelines may be used unless superseded by contracts or regulatory/CMS requirements.

    Use of Guidelines: Requests are evaluated using the applicable Clinical Utilization Management Guideline (CUMG). If no other Medical Policy or CUMG exists, MCG Care Guidelines may be used for medical necessity review; determinations follow Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy.

    Specific clinical criteria are not included in this index; refer to individual CUMG documents for detailed criteria.

    The document lists the Clinical Utilization Management Guidelines (CUMGs) adopted by Simply Healthcare Plans for use in medical necessity and utilization review. MCG Care Guidelines are specified as a source for medical necessity review when no specific Medical Policy or Clinical UM Guideline exists, but are explicitly superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines.

    Requests and reviews should follow the hierarchy described: first consult the applicable Medical Policy/Clinical UM Guideline or the listed CUMG; if no applicable guideline exists, MCG Care Guidelines may be applied only when not preempted by state/CMS/payer requirements.

    Determinations of medical necessity are made on a case-by-case basis in accordance with the definition of medical necessity contained within the applicable Medicaid state contract, regulatory guidance, CMS requirements, or the payer's Medical Necessity Criteria Policy (ADMIN.00004).

    If a request does not meet the established guideline criteria, the case will be referred to a licensed physician reviewer with the appropriate clinical expertise to render a decision.

    Referenced Guideline Identifiers and Code Lists

    Listed CUMG identifiers (sample)mixed
    CG-ADMIN-01Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
    CG-ANC-04Ambulance Services: Air and Water
    CG-ANC-05Ambulance Services: Ground; Emergent
    CG-ANC-06Ambulance Services: Ground; Nonemergent
    CG-ANC-08Mobile Device-Based Health Management Applications
    CG-BEH-14Intensive In-Home Behavioral Health Services
    CG-BEH-15Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
    CG-DME-03Neuromuscular Stimulation in the Treatment of Muscle Atrophy
    CG-DME-04Atrophy Transcutaneous Electrical Nerve Stimulation
    CG-DME-05Cervical Traction Devices for Home Use
    1–10 of 45
    1/5
    Referenced CUMG identifiers (not billing codes)mixed
    No codes listed

    What Providers Should Know / Do

    Prior Authorization

    Consult listed CUMGs for pre-payment review topics

    The enumerated CUMG identifiers (for example, CG-ADMIN-01 and multiple CG-DME items) indicate topics subject to medical necessity review and may trigger pre-payment guideline-driven review; providers should consult the listed CUMG for any applicable pre-payment or prior authorization requirements.

    • Sample CUMG examples listed: CG-ADMIN-01, CG-DME-03, CG-DME-04, CG-DME-05, CG-DME-06, CG-DME-07, CG-DME-08, CG-DME-10
    Note

    Index does not define prior authorization rules

    This index lists CUMG identifiers and titles but does not specify prior authorization rules within the excerpt; providers must review the individual CUMG pages on the payer website to determine whether prior authorization is required.

    • The index itself does not include authorization rules — see each CUMG for requirements
    • Guideline access: Search Medical Policies and Clinical Guidelines on the provider site
    Documentation Required

    Follow each CUMG for specific provider requirements

    Refer to each referenced CUMG document for item-specific clinical criteria, prior authorization instructions, and documentation checklists; the index only enumerates guideline identifiers and titles.

    • Index does not include the specific medical necessity criteria
    • Providers must view individual CG-DME guideline pages for details
    Denial Risk

    Index lacks explicit authorization/denial triggers

    The CUMG list functions as an index only and does not present authorization or denial trigger language in this excerpt; providers should not assume authorization criteria are contained here and must check the detailed guideline content.

    • This excerpt is an index of CUMG items without explicit approval/denial triggers
    • Do not rely on the index for decision-making — consult full guideline text
    Documentation Required

    Medical necessity determinations reference ADMIN.00004 and may use MCG

    Determinations of medical necessity are made case-by-case per the Medical Necessity Criteria Policy (ADMIN.00004); MCG Care Guidelines may be used when no other Medical Policy or CUMG exists, and Medicaid/CMS/regulatory requirements supersede MCG guidance.

    • Medical necessity follows the definition in Medicaid state contract, regulatory guidance, CMS requirements, or ADMIN.00004
    • MCG Care Guidelines used where no other policy exists but are superseded by contract/regulatory/CMS rules
    Documentation Required

    No item-level documentation in index — consult CG‑DME guidelines

    The index does not include equipment-specific documentation language; where an item is DME-related, providers must consult the corresponding CG-DME guideline for the documentation required to support medical necessity and authorization.

    • Numerous CG-DME identifiers are listed (e.g., CG-DME-03 through many CG-DME items)
    • Individual CG-DME pages contain the item-specific documentation requirements
    Denial Risk

    Non‑conforming requests will be referred to physician reviewer

    If a request does not meet the established criteria in the applicable guideline, the case will be referred to a licensed physician reviewer with appropriate clinical expertise for a determination.

    • Nonconforming requests are referred to a licensed physician reviewer
    • Decisions are made on a case-by-case basis
    Note

    Index contains no explicit authorization/denial triggers

    This excerpt is an index of guideline identifiers and does not include explicit authorization or denial triggers; treat the list as a navigational index and review the full guideline text for any triggers or decision rules.

    • No explicit authorization/denial triggers present in these chunks
    • The text functions as an index of CUMG items

    Purpose and Scope of the CUMG Index

    This document functions as an index of Clinical Utilization Management Guidelines (CUMGs) that Simply Healthcare Plans has adopted to support medical necessity review across settings including inpatient, outpatient, rehabilitation, skilled nursing, and home care. The list directs providers to the public Medical Policy and Clinical UM Guideline website for full guideline content and titles.

    The index indicates that where a specific Medical Policy or CUMG is not available, MCG Care Guidelines may be used for review activities such as inpatient medical necessity and site-of-service appropriateness, inpatient rehabilitation and skilled nursing facility review, and certain outpatient services — subject to the superseding authorities noted above.

    Key Terms

    Definition of Clinical Utilization Management (CUMG)
    DefinitionClinical Utilization Management (CUMG): Guideline documents used to assess medical necessity and appropriateness of services for utilization management and pre-payment review.
    PurposeSupport medical necessity review across inpatient, outpatient, rehabilitation, skilled nursing, and home settings; used where no other Medical Policy or Clinical UM Guideline exists.
    Relationship to MCGMCG Care Guidelines may be used for reviews when no specific Medical Policy or CUMG exists, but are superseded by Medicaid state contracts, regulatory guidance, CMS requirements, and the payer's Medical Policy/Clinical UM Guidelines.
    Decision processRequests that do not meet established criteria will be referred to a licensed physician reviewer for a case‑by‑case determination of medical necessity.
    CUMG identifier definition — used to reference detailed coverage elsewhere
    Identifier meaningA CUMG identifier (e.g., CG-DME-03, CG-ADMIN-01, CG-SURG-124) is a shorthand reference used to locate the full guideline document containing detailed coverage and utilization policies.
    How to useProviders should consult the listed CUMG by its identifier on the payer's Medical Policy and Clinical UM Guideline website to view specific criteria, documentation, and prior authorization requirements.
    ScopeIdentifiers cover clinical areas across the document (surgery, DME, ancillary services, etc.) and map to individual guideline titles shown in the CUMG index.
    Status flagThe index marks items 'New' where applicable; the identifier plus the 'New' flag indicates recently adopted guidelines.

    Where to Find DME Medical Necessity Criteria

    DME: where to find criteria — CUMG identifiers for many DME categories are listed; index does not include full criteria

    CUMG identifiers for many DME categories are listed in the index; this document does not contain the item-specific medical necessity criteria.

    Index guidance: Refer to the specific CG-DME guideline (for example, CG-DME-03, CG-DME-04, CG-DME-05, CG-DME-06, CG-DME-07, CG-DME-08, CG-DME-10, CG-DME-13, CG-DME-15, CG-DME-16, CG-DME-18, CG-DME-43, CG-DME-44, CG-DME-45, CG-DME-46, CG-DME-47, CG-DME-48, CG-DME-49, CG-DME-50, CG-DME-51, CG-DME-52, CG-DME-53, CG-DME-54, CG-DME-55, CG-DME-57) for complete medical necessity criteria, documentation requirements, and any prior authorization rules for each durable medical equipment category.

    This CUMG index only enumerates guideline titles and identifiers; consult the payer website or the individual guideline pages for full criteria and operational instructions.

    DME Categories and Rental/Purchase Notes

    DME CategoryNotes on rental vs purchase rules
    Durable Medical Equipment (general)Index lists the category (CG-DME-10) but does not specify rental versus purchase rules; consult the referenced CG-DME guideline for item-specific billing/rental/purchase policy.
    Neuromuscular stimulation devices (CG-DME-03)Listed in the index; rental vs purchase guidance is not included here — refer to the CG-DME-03 guideline for applicable rules.
    Transcutaneous electrical nerve stimulation (CG-DME-04)Included in the CUMG list but rental/purchase determinations are not provided in this document; see CG-DME-04 for details.
    Cervical traction devices for home use (CG-DME-05)Category appears in the index without rental vs purchase instructions; review CG-DME-05 for coverage and acquisition rules.
    Compression devices for lymphedema (CG-DME-06)Referenced in the index; rental versus purchase policies are established in the specific CG-DME guideline, not in this index.
    Augmentative & alternative communication devices (CG-DME-07)Listed as a DME category; this index does not include rental/purchase rules — consult CG-DME-07 for guidance.
    Infant home apnea monitors (CG-DME-08)Present in the CUMG index; rental vs purchase instructions must be obtained from the CG-DME-08 guideline.
    Lower limb prosthesis (CG-DME-13)Listed among DME items; the index does not state rental or purchase rules — see CG-DME-13 for policy details.
    Hospital beds and accessories (CG-DME-15)Included in the CUMG list; rental vs purchase criteria are not provided here and are defined in CG-DME-15.
    Pressure-reducing support surfaces (CG-DME-16)Referenced in the index without rental/purchase guidance; consult CG-DME-16 for coverage and acquisition rules.
    Home oxygen therapy / therapeutic shoes/inserts/modifications (CG-DME-18)Listed in the index; rental versus purchase policies are not specified in this document — refer to CG-DME-18 for specifics.
    Powered wheeled mobility devicesThe index references general DME categories including mobility devices but does not provide rental vs purchase rules; review the applicable CG-DME guideline for device-specific policies.

    Replacement, Repairs, and Related DME Items

    Various DME items (replacement/repair references from index)
    Neuromuscular stimulationCG-DME-03 — Neuromuscular Stimulation in the Treatment of Muscle Atrophy.
    Transcutaneous electrical nerve stimulationCG-DME-04 — Atrophy Transcutaneous Electrical Nerve Stimulation.
    Cervical traction devicesCG-DME-05 — Cervical Traction Devices for Home Use.
    Compression devicesCG-DME-06 — Compression Devices for Lymphedema.
    AAC devicesCG-DME-07 — Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output.
    Infant home monitorsCG-DME-08 — Infant Home Apnea Monitors.
    General DMECG-DME-10 — Durable Medical Equipment (general category).

    Documentation and Prior Authorization References

    Documentation Required

    Consult each CG‑DME guideline for item‑specific documentation and prior authorization

    The document lists numerous CG‑DME guideline identifiers (for example CG-DME-03, CG-DME-04, CG-DME-05, CG-DME-06, CG-DME-07, CG-DME-08, CG-DME-10); providers must open each CG‑DME guideline to find item‑specific documentation expectations and prior authorization rules.

    • Refer to the individual CG‑DME page on the Medical Policy and Clinical UM Guideline website for required documentation and whether prior authorization is needed.
    Note

    No DME documentation details in this excerpt — consult guideline pages

    The index itself does not include DME‑specific documentation requirements; it only lists guideline identifiers and titles that may contain equipment‑specific documentation and prior authorization rules on their respective guideline pages.

    • If documentation requirements are needed for claims or authorizations, view the full text of the referenced CG‑DME guideline on the provider website.

    Exclusions and Non-Covered Items

    This index document does not list any explicit exclusions for Durable Medical Equipment (DME). Providers should note that no DME-specific exclusions are identified in this index; coverage determinations for DME items must be made by consulting the individual CG-DME guidelines or applicable Medical Policies referenced by the index.

    Policy Summary
    Payersimplyhealthcare
    PolicyClinical Utilization Management Guidelines (CUMG) list
    Policy CodePolicy ADMIN.00004
    Change TypeNo material change
    Effective Date
    Next Review Date
    Key ActionConsult the listed CG-DME guideline for item-specific documentation and prior authorization requirements.
    SourceLink
    On This Page
    How Clinical Utilization Management Guidelines Are UsedReferenced Guideline Identifiers and Code ListsWhat Providers Should Know / DoPurpose and Scope of the CUMG IndexKey TermsWhere to Find DME Medical Necessity CriteriaDME Categories and Rental/Purchase NotesReplacement, Repairs, and Related DME ItemsDocumentation and Prior Authorization ReferencesExclusions and Non-Covered Items