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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellpoint NJ Medicaid UM Policy Update | OpenPayer
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    ModifiedWellpointPolicy ADMIN.00004

    Clinical Utilization Management Guidelines

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    This document identifies the Clinical Utilization Management Guidelines adopted by Wellpoint for New Jersey Medicaid members and explains which clinical criteria sources are used for medical-necessity, site-of-service, and related utilization reviews. Determinations are made case by case under applicable Medicaid contracts, regulatory guidance, CMS requirements, and Wellpoint medical-necessity policies.

    Policy Summary
    PayerWellpoint
    PolicyClinical Utilization Management Guidelines
    Policy CodePolicy ADMIN.00004
    Change TypeModified — new guidelines adopted
    Effective DateN/A
    Next Review DateN/A
    Key ActionUse the applicable Wellpoint Clinical UM Guideline when one exists.
    SourceLink
    POLICY UPDATE CHANGES

    New Clinical Utilization Management Guidelines were adopted for Medicaid members.

    Multiple CG-SURG entries, including CG-SURG-100 through CG-SURG-118, are marked as new items.

    CG-SURG-130 and additional CG-THER-RAD and CG-TRANS guideline entries are listed as new items or references.

    10 pagesDocument length
    4Clinical criteria sources
    NJ Medicaid

    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.

    Population and jurisdiction
    Case-by-caseDetermination approach
    Physician reviewerEscalation

    Medical-Necessity and Utilization Review Framework

    Medical-necessity and utilization review framework

    Use the applicable criteria source, subject to superseding Medicaid and Wellpoint requirements.

    Applicable governing requirements: Medical-necessity determinations are made case by case using the definition of medical necessity in the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Wellpoint Medical Necessity Criteria Policy ADMIN.00004.

    These requirements supersede MCG Care Guidelines and InterQual Criteria.

    Criteria source: Use InterQual Criteria or MCG Care Guidelines for the specified inpatient, inpatient rehabilitation, skilled nursing, site-of-service, or qualifying outpatient review; use American Society of Addiction Medicine criteria for substance use disorder services according to state requirements; use a Wellpoint Medical Policy or Clinical UM Guideline when applicable.

    If no established Medical Policy or Clinical UM Guideline exists, InterQual or MCG may be used for an outpatient-based service or procedure.

    MCG Care Guidelines and InterQual Criteria support utilization review when applicable, but they do not supersede Medicaid state contracts, regulatory guidance, CMS requirements, or Wellpoint Medical Policies and Clinical UM Guidelines. Medical-necessity determinations must follow the applicable governing requirements.

    Clinical Utilization Management Guideline Index

    Ancillary and durable medical equipment CUMG identifiersmixed
    CG-ANC-03Acupuncture
    CG-ANC-04Ambulance Services: Air and Water
    CG-ANC-05Ambulance Services: Ground; Emergent
    CG-ANC-06Ambulance Services: Ground; Nonemergent
    CG-ANC-07Inpatient Interfacility Transfers
    CG-ANC-08Mobile Device-Based Health Management Applications
    CG-BEH-14Intensive In-Home Behavioral Health Services; Activity Therapy for Autism Spectrum Disorders
    CG-BEH-15Activity Therapy for Autism Spectrum Disorders and Rett Syndrome; Neuromuscular Stimulation in the Treatment of Muscle Atrophy
    CG-DME-04Transcutaneous Electrical Nerve Stimulation
    CG-DME-05Cervical Traction Devices for Home Use
    1–10 of 48
    1/5
    Laboratory CUMG identifiersmixed
    CG-LAB-09Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
    CG-LAB-10Zika Virus Testing
    CG-LAB-11Vitamin D Testing
    CG-LAB-12Testing for Oral and Esophageal Cancer
    CG-LAB-13Skin Nerve Fiber Density Testing
    CG-LAB-14Respiratory Viral Panel Testing in the Outpatient Setting
    CG-LAB-15Red Blood Cell Folic Acid Testing
    CG-LAB-16Serum Amylase Testing
    CG-LAB-17Molecular Gastrointestinal Pathogen Panel (GIPP)
    CG-LAB-19Testing for Infectious Diarrhea in the Outpatient Setting
    1–10 of 24
    1/3
    Medical CUMG identifiersmixed
    CG-MED-02Esophageal pH Monitoring
    CG-MED-05Ketogenic Diet for Treatment of Intractable Seizures
    CG-MED-08Home Enteral Nutrition
    CG-MED-19Custodial Care
    CG-MED-21Anesthesia Services and Moderate (Conscious) Sedation
    CG-MED-23Home Health
    CG-MED-24Electromyography and Nerve Conduction Studies
    CG-MED-26Neonatal Levels of Care
    CG-MED-28Iontophoresis
    CG-MED-34Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
    1–10 of 55
    1/6
    Orthotics, radiology, and rehabilitation CUMG identifiersmixed
    CG-OR-PR-02Prefabricated and Prophylactic Knee Braces
    CG-OR-PR-03Custom-made Knee Braces
    CG-OR-PR-04Cranial Remodeling Bands and Helmets (Cranial Orthoses)
    CG-OR-PR-05Myoelectric Upper Extremity Prosthesis Devices
    CG-OR-PR-06Spinal Orthoses: Thoracic-Lumbosacral, Lumbosacral, and Lumbar
    CG-OR-PR-08Microprocessor Controlled Lower Limb Prosthesis
    CG-OR-PR-09Microprocessor Controlled Knee-Ankle-Foot Orthosis
    CG-OR-PR-10Osseointegrated Limb Prostheses
    CG-RAD-26Maternity Ultrasound in the Outpatient Setting
    CG-RAD-27Scrotal Ultrasound
    1–10 of 19
    1/2
    Surgical CUMG identifiersmixed
    CG-SURG-01Colonoscopy
    CG-SURG-03Blepharoplasty, Blepharoptosis Repair and Brow Lift
    CG-SURG-05Maze Procedure
    CG-SURG-07Vertical Expandable Prosthetic Titanium Rib
    CG-SURG-09Temporomandibular Disorders
    CG-SURG-10Ambulatory or Outpatient Surgery Center Procedures
    CG-SURG-11Surgical Treatment for Dupuytren's Contracture
    CG-SURG-12Penile Prosthesis Implantation
    CG-SURG-15Endometrial Ablation
    CG-SURG-17Trigger Point Injections
    1–10 of 62
    1/7

    Utilization Review and Escalation Requirements

    Prior Authorization

    Apply the applicable UM criteria

    Use the applicable Wellpoint Clinical UM Guideline when one exists. For services without an established Medical Policy or Clinical UM Guideline, InterQual or MCG criteria may be used for outpatient-based review; additional criteria apply to specified inpatient, rehabilitation, skilled nursing, site-of-service, and substance use disorder reviews.

    • Use Wellpoint Medical Policy or Clinical UM Guidelines when applicable.
    • Use InterQual or MCG Care Guidelines when no established Wellpoint policy or guideline exists for an outpatient-based service or procedure.
    • Use American Society of Addiction Medicine criteria for substance use disorder services according to state requirements.
    Denial Risk

    Failure to meet applicable criteria

    If a request does not meet established criteria guidelines, it will be referred to a licensed physician reviewer with the appropriate clinical expertise to make a decision.

    Policy Context

    This document provides an index of Clinical Utilization Management Guidelines (CUMG) adopted by Wellpoint for New Jersey Medicaid members. It is not a condition-specific medical-necessity policy. The listed criteria support medical-necessity and utilization review, including inpatient, site-of-service, rehabilitation, skilled nursing, and certain outpatient services when no established Wellpoint Medical Policy or Clinical UM Guideline applies. Determinations are made case by case under the applicable Medicaid contract, regulatory guidance, CMS requirements, or Wellpoint Medical Necessity Criteria Policy ADMIN.00004.

    Criteria Sources and Terminology

    Clinical Utilization Management Guidelines (CUMG)
    DefinitionClinical Utilization Management Guidelines adopted by Wellpoint for Medicaid members.
    UseUsed to support medical-necessity and utilization determinations.
    PurposeHelp provide quality care by reducing inappropriate use of medical resources.
    InterQual Criteria or MCG Care Guidelines
    DefinitionCriteria used for medical-necessity review and utilization review.
    Applicable settingsMedical and behavioral health inpatient review; inpatient site-of-service appropriateness; inpatient rehabilitation; and skilled nursing facility review.
    Policy Summary
    PayerWellpoint
    PolicyClinical Utilization Management Guidelines
    Policy CodePolicy ADMIN.00004
    Change TypeModified — new guidelines adopted
    Effective DateN/A
    Next Review DateN/A
    Key ActionUse the applicable Wellpoint Clinical UM Guideline when one exists.
    SourceLink
    On This Page
    Medical-Necessity and Utilization Review FrameworkClinical Utilization Management Guideline IndexUtilization Review and Escalation RequirementsPolicy ContextCriteria Sources and Terminology
    • Ensure the request is supported by the applicable established criteria guideline.
    • Be aware that failure to meet the criteria triggers physician review for a medical-necessity decision.
    Note

    Use superseding requirements

    Evaluate medical necessity case by case under the applicable Medicaid state contract, regulatory guidance, CMS requirements, or Wellpoint Medical Necessity Criteria Policy ADMIN.00004. These requirements, along with Wellpoint Medical Policies and Clinical UM Guidelines, supersede MCG Care Guidelines and InterQual Criteria.

    • Apply the definition of medical necessity in the applicable governing requirements.
    • Do not rely on MCG or InterQual criteria when superseded by Medicaid contracts, regulatory guidance, CMS requirements, or Wellpoint policies.
    Outpatient use
    May be used for an outpatient-based service or procedure when there is no established Medical Policy or Clinical UM Guideline.
    Governing requirementsMedicaid state contracts, regulatory guidance, CMS requirements, and Wellpoint Medical Policy or Clinical UM Guidelines supersede MCG Care Guidelines and InterQual Criteria.
    American Society of Addiction Medicine criteria
    DefinitionCriteria used for substance use disorder services.
    ApplicationUsed according to state requirements.
    Service areaSubstance use disorder services.