Consult CUMGs for medical necessity and prior authorization guidance

Use the CUMG list to guide medical necessity reviews and outpatient services/procedures when no established Medical Policy or Clinical UM Guideline exists; consult the specific CUMG page on the Medical Policies and Clinical UM Guidelines website for prior authorization requirements.

• MCG Care Guidelines are used for medical necessity review for inpatient care, inpatient site-of-service appropriateness, inpatient rehabilitation and SNF review, and outpatient services/procedures when no established Medical Policy exists.
• Medicaid state contracts, regulatory guidance, CMS requirements, and Simply’s Medical Policy/Clinical UM Guidelines supersede MCG Care Guidelines.

Inventory shows new/updated CUMGs — check individual guidelines for requirements

The inventory lists many CUMG/CG titles and marks several entries as “New item,” but this section does not specify explicit prior authorization requirements, affected billing codes, or implementation details — providers must view each guideline page for specific authorization rules.

• Several CUMG entries in the catalog are annotated “New item.”
• This inventory excerpt is an index only; individual CUMG documents contain the prior authorization and billing specifics.

Follow each specific CUMG page for actionable provider steps

When a CUMG applies to the requested service, providers must follow the guidance on that specific CUMG page; if the inventory entry is blank on explicit actions, consult the linked guideline for required documentation and authorization steps.

• The CUMG list is published on the Medical Policies and Clinical UM Guidelines website — use the specific guideline for actionable requirements.
• If a request falls outside established criteria, it will be referred to a licensed physician reviewer.

Inventory titles without details require provider follow-up to the guideline page

For inventory entries that simply list a title without details, providers should navigate to the corresponding CUMG on the website to determine whether prior authorization is required and what documentation/billing codes apply.

• The document is an adopted guideline catalog; action and authorization requirements are provided on each CUMG’s page.
• CUMG numbering (1 = title, 2 = New item) is used in the index; it does not convey authorization rules in the inventory excerpt.

Apply Medicaid/CMS/ADMIN.00004 medical necessity standard to requests

Determinations of medical necessity are made case-by-case according to the Medicaid state contract, regulatory guidance, CMS requirements, or the Medical Necessity Criteria Policy ADMIN.00004; follow those standards when preparing documentation or prior authorization requests.

• Medical necessity decisions adhere to the Medicaid state contract, regulatory guidance, CMS requirements, or Admin.00004.
• If a request does not meet established guideline criteria it will be referred to a licensed physician reviewer.

No action listed in inventory entries — consult full guideline

When the inventory provides no explicit provider actions for an item, providers must consult the full CUMG document and the Medical Policies and Clinical UM Guidelines website for the required steps, documentation, and any authorization processes.

• Several inventory entries in this excerpt contain no actionable notes in the index.
• Individual CUMG pages contain the actionable requirements.

Noncompliance with CUMG criteria may trigger physician review and denial

If a request fails to meet the applicable CUMG criteria, the case will be referred to a licensed physician reviewer with appropriate clinical expertise and may result in denial if criteria are not met.

• Requests that do not meet established criteria guidelines will be referred to a licensed physician reviewer.
• Failure to meet criteria may result in denial.

No other provider actions specified in this excerpt — consult guideline pages

No additional provider actions are stated in this inventory excerpt; providers should rely on the specific CUMG pages and the Medical Policies and Clinical UM Guidelines website for any remaining actionable guidance.

• The excerpted inventory contains index entries but does not state further provider steps within this section.
• Consult the guideline pages for remaining provider-action notes.

Provide device-specific documentation for DME medical necessity reviews

For DME items, include the specific DME CUMG number or title with clinical justification and supporting documentation (e.g., device type, clinical indications) to enable medical necessity review; the document lists many DME CUMG titles that correspond to separate documentation expectations.

• Examples of DME CUMGs listed include neuromuscular stimulation (CG-DME-03), TENS (CG-DME-04), home ventilator therapy (CG-DME-47), lower limb prosthesis (CG-DME-13), and powered wheeled mobility devices (CG-DME-31).
• Each listed CUMG contains the specific documentation requirements on its guideline page.

Attach CUMG-referenced supporting records when documentation details are not in the inventory

When the inventory or excerpt does not state documentation specifics, providers must rely on the individual CUMG documents for the required supporting records and should attach those records to authorization requests to prevent delays.

• The inventory excerpt lists CUMG titles but offers no supplemental documentation checklists in this section.
• Attach the clinical and device-specific records referenced by the applicable CUMG when submitting requests.