By Category

PW_A092201
Clinical UM Guidelines  
 

Dates associated with medical policies and clinical UM guidelines

Each medical policy and clinical UM guideline includes a Last Review Date and the Publish Date. A medical policy or clinical UM guideline is made available on Pulse and our public websites on its Publish Date. While the Publish Date is enterprise-wide, the actual implementation date may differ, depending on notification requirements. Local health plans will determine if new or revised medical policies and clinical UM guidelines require advance provider notification due to a material adverse change, based upon state laws, provider contracts and other considerations.

Publish Date (formerly known as “Current Effective Date”): The date a document (medical policy or clinical UM guideline) is published to the internet.  The publish date is updated when code changes are made and/or after policy committee review of a document.  The history section may be updated with minor revisions to a document without issuing a new publish date.

Implementation Date: This date is not included in the medical policy or clinical UM guideline. It is the date that a health plan may begin using the new or updated medical policy or clinical UM guideline. The Implementation Date may be the same as the Publish Date when an updated document is an expansion of current criteria. When a document is published that is more restrictive than an existing document or represents a new review of existing services, the implementation date is determined by the local health plan since requirements regarding provider notification vary based upon state laws, provider contracts and other considerations.

Last Review Date: The last review date is the most recent date that the Medical Policy & Technology Assessment Committee (MPTAC) reviewed or revised the medical policy or clinical UM guideline. This is not the same date as the Publish Date/current effective date. After the MPTAC meeting and prior to publication, the Office of Medical Policy requires time to finalize our documents and provide information to the health plans for systems updates and notifications.

It is important to emphasize that changes that are expansions can be applied without provider notification, however, some situations require advance provider notification. In cases where a new or revised medical policy or clinical UM guideline results in the denial of benefits for services which have historically been covered, local health plans may provide advance notice of the changes prior to the medical policy or clinical UM guideline taking effect. Requirements regarding provider notification vary across the enterprise and local health plans will determine applicable local requirements are met prior to applying any retractions.

 
 
Administrative  
CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
CG-ADMIN-02 Clinically Equivalent Cost Effective Services – Targeted Immune Modulators
 
Ancillary, Miscellaneous  
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; Non-Emergent
 
 
Behavioral Health  
CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
CG-BEH-03 Psychiatric Disorder Treatment
CG-BEH-04 Substance-Related and Addictive Disorder Treatment
CG-BEH-05 Eating and Feeding Disorder Treatment
CG-BEH-07 Psychological Testing
CG-BEH-09 Assertive Community Treatment
CG-BEH-10 Basic Skills Training/Social Skills Training
CG-BEH-11 Mental Health Support Services
CG-BEH-12 Psychosocial Rehabilitation Services
CG-BEH-13 Targeted Case Management
CG-BEH-14 Intensive In-home Behavioral Health Services
 
Durable Medical Equipment  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep.  
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.  
 
CG-DME-01 External (Portable) Continuous Insulin Infusion Pumps
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 Pneumatic Compression Devices for Lymphadema
CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
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 Post-Operative Period
CG-DME-10 Durable Medical Equipment
CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13 Lower Limb Prosthesis
CG-DME-15 Hospital Beds and Accessories
CG-DME-16 Pressure Reducing Support Surfaces - Groups 1 , 2 & 3
CG-DME-18 Home Oxygen Therapy
CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes
CG-DME-20 Orthopedic Footwear
CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses
CG-DME-23 Lifting Devices for Use in the Home
CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs-Standard, Heavy Duty and Lightweight
CG-DME-25 Seat Lift Mechanisms
CG-DME-26 Back-Up Ventilators in the Home Setting
CG-DME-30 Prothrombin Time Self-Monitoring Devices
CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
CG-DME-35 Electric Breast Pumps
CG-DME-36 Pediatric Gait Trainers
CG-DME-37 Air Conduction Hearing Aids
CG-DME-38 Continuous Interstitial Glucose Monitoring
CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
CG-DME-40 Electrical Bone Growth Stimulation
CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
 
 
Prescription Drugs  
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®) and Direct Thrombin Inhibitors in the Outpatient Setting
CG-DRUG-05 Recombinant Erythropoietin Products
CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease
CG-DRUG-09 Immune Globulin (Ig) Therapy
CG-DRUG-11 Infertility Drugs
CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy
CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults
CG-DRUG-16 White Blood Cell Growth Factors
CG-DRUG-18 Nesiritide (Natrecor®)
CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women
CG-DRUG-20 Enfuvirtide (Fuzeon®)
CG-DRUG-21 Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence
CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
CG-DRUG-27 Clostridial Collagenase Histolyticum Injection
CG-DRUG-28 Alglucosidase alfa (Lumizyme®)
CG-DRUG-29 Hyaluronan Injections in the Knee
CG-DRUG-31 Oncology Drug Treatment Regimens for Adults **NOTE: At this time, this guideline is not implemented for medical benefit determinations
CG-DRUG-33 Palonosetron
CG-DRUG-34 Docetaxel (Docefrez™, Taxotere®)
CG-DRUG-38 Pemetrexed Disodium (Alimta®)
CG-DRUG-40 Bortezomib (Velcade®)
CG-DRUG-41 Zoledronic Acid
CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase)
CG-DRUG-43 Natalizumab (Tysabri®)
CG-DRUG-44 Pegloticase (Krystexxa®)
CG-DRUG-45 Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
CG-DRUG-46 Fosaprepitant (Emend®)
CG-DRUG-47 Level of Care: Specialty Pharmaceuticals
CG-DRUG-48 Azacitidine (Vidaza®)
CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection
CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®)
CG-DRUG-51 Romidepsin (Istodax®)
CG-DRUG-52 Temsirolimus (Torisel®)
CG-DRUG-53 Drug Dosage, Frequency, and Route of Administration
CG-DRUG-54 Agalsidase beta (Fabrazyme®)
CG-DRUG-55 Elosulfase alfa (Vimizim®)
CG-DRUG-56 Galsulfase (Naglazyme®)
CG-DRUG-57 Idurasufase (Elaprase®)
CG-DRUG-58 Laronidase (Aldurazyme®)
CG-DRUG-59 Testosterone Injectable
CG-DRUG-60 Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications
CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
CG-DRUG-62 Fulvestrant (FASLODEX®)
CG-DRUG-63 Levoleucovorin Calcium (Fusilev®)
CG-DRUG-64 FDA-Approved Biosimilar Products
CG-DRUG-65 Tumor Necrosis Factor Antagonists
CG-DRUG-66 Panitumumab (Vectibix®)
CG-DRUG-68 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
CG-DRUG-69 Ustekinumab (Stelara®)
CG-DRUG-70 Eribulin mesylate (Halaven®)
CG-DRUG-71 Ziv-aflibercept (Zaltrap®)
CG-DRUG-72 Pertuzumab (Perjeta®)
CG-DRUG-73 Denosumab (Prolia®, Xgeva®)
CG-DRUG-74 Canakinumab (Ilaris®)
CG-DRUG-75 Romiplostim (Nplate®)
CG-DRUG-76 Plerixafor Injection (Mozobil™)
CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo®)
CG-DRUG-78 Antihemophilic Factors and Clotting Factors
CG-DRUG-79 Siltuximab (Sylvant®)
CG-DRUG-80 Cabazitaxel (Jevtana®)
CG-DRUG-81 Tocilizumab (Actemra®)
 
 
Genetics  
CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
CG-GENE-02 Analysis of KRAS Status
CG-GENE-03 BRAF Mutation Analysis
CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
 
 
Laboratory/Pathology  
CG-LAB-03 Tropism Testing for HIV Management
CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
CG-LAB-10 Zika Virus Testing
CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals
 
 
Medicine  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep.  
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us.  
 
CG-MED-02 Esophageal pH Monitoring
CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
CG-MED-08 Home Enteral Nutrition
CG-MED-19 Custodial Care
CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
CG-MED-22 Neuropsychological Testing
CG-MED-23 Home Health
CG-MED-24 Electromyography and Nerve Conduction Studies
CG-MED-26 Neonatal Levels of Care
CG-MED-28 Iontophoresis for Medical Indications
CG-MED-29 Inpatient Subacute Care
CG-MED-31 Skilled Nursing Facility Services
CG-MED-32 Ancillary Services for Pregnancy Complications
CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
CG-MED-35 Retinal Telescreening Systems
CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry
CG-MED-40 External Ambulatory Event Monitors to Detect Cardiac Arrhythmias
CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
CG-MED-42 Maternity Ultrasound in the Outpatient Setting
CG-MED-44 Holter Monitors
CG-MED-45 Transrectal Ultrasonography
CG-MED-46 Ambulatory Electroencephalography and Video Electroencephalography
CG-MED-47 Fundus Photography
CG-MED-48 Scrotal Ultrasound
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otacoustic Emissions (OAEs) for Hearing Disorders
CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials
CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
CG-MED-52 Allergy Immunotherapy (Subcutaneous)
CG-MED-53 Cervical Cancer Screening and Human Papillomavirus Testing
CG-MED-54 Strapping
CG-MED-55 Level of Care: Advanced Radiologic Imaging
CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography
CG-MED-57 Cardiac Stress Testing with Electrocardiogram (ECG)
CG-MED-58 Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI
CG-MED-59 Upper Gastrointestinal Endoscopy
CG-MED-60 Anesthesia During Cataract Surgery
CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries
CG-MED-62 Resting Electrocardiogram Screening in Adults
CG-MED-63 Treatment of Hyperhidrosis
CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
CG-MED-65 Manipulation Under Anesthesia of the Spine and Joints other than the Knee
CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
CG-MED-67 Melanoma Vaccines
CG-MED-68 Therapeutic Apheresis
 
 
Orthotics/Prosthetics  
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
CG-OR-PR-03 Custom-made Knee Braces
CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
 
 
Radiology  
The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health (AIM), a separate company. For certain health plan members, AIM also provides radiology utilization management services. 
The health plan also develops Diagnostic Imaging Medical Policies which may address a service described in an AIM Diagnostic Imaging Clinical Guideline. Where such Medical Policy exists, the health plan Medical Policy supersedes the AIM Diagnostic Imaging Clinical Guideline.  
AIM's Diagnostic Imaging Clinical Guidelines are available at http://www.aimspecialtyhealth.com/marketing/guidelines/185/index.html
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us. 
 
 
Rehabilitation Therapy  
CG-REHAB-02 Outpatient Cardiac Rehabilitation
CG-REHAB-03 Pulmonary Rehabilitation
CG-REHAB-04 Physical Therapy
CG-REHAB-05 Occupational Therapy
CG-REHAB-06 Speech-Language Pathology Services
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
CG-REHAB-08 Private Duty Nursing in the Home Setting
CG-REHAB-09 Acute Inpatient Rehabilitation
CG-REHAB-10 Level of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
 
 
Surgery  
CG-SURG-01 Colonoscopy
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
CG-SURG-09 Temporomandibular Disorders
CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
CG-SURG-11 Surgical Treatment for Dupuytren's Contracture
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-15 Endometrial Ablation
CG-SURG-17 Trigger Point Injections
CG-SURG-18 Septoplasty
CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
CG-SURG-25 Injection Treatment for Morton’s Neuroma
CG-SURG-27 Sex Reassignment Surgery
CG-SURG-28 Transcatheter Uterine Artery Embolization
CG-SURG-29 Lumbar Discography
CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
CG-SURG-31 Treatment of Keloids and Scar Revision
CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar Facet Injections
CG-SURG-33 Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA)
CG-SURG-34 Diagnostic Infertility Surgery
CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
CG-SURG-36 Adenoidectomy
CG-SURG-37 Destruction of Pre-Malignant Skin Lesions
CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
CG-SURG-39 Pain Management: Epidural Steroid Injections
CG-SURG-40 Cataract Removal Surgery for Adults
CG-SURG-41 Surgical Strabismus Correction
CG-SURG-42 Cervical Fusion
CG-SURG-43 Knee Arthroscopy
CG-SURG-44 Coronary Angiography in the Outpatient Setting
CG-SURG-45 Bone Graft Substitutes
CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion
CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity
CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI)
CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
CG-SURG-50 Assistant Surgeons
CG-SURG-51 Outpatient Cystourethroscopy
CG-SURG-52 Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
CG-SURG-53 Elective Total Hip Arthroplasty
CG-SURG-54 Elective Total Knee Arthroplasty
CG-SURG-55 Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
CG-SURG-57 Diagnostic Nasal Endoscopy
CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions
CG-SURG-59 Vena Cava Filters
CG-SURG-60 Cervical Total Disc Arthroplasty
CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver
CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver
CG-SURG-63 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure
CG-SURG-65 Recombinant Human Bone Morphogenetic Protein
CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
CG-SURG-67 Treatment of Osteochondral Defects
CG-SURG-68 Surgical Treatment of Femoracetabular Impingement Syndrome
CG-SURG-69 Meniscal Allograft Transplantation of the Knee
 
 
THER-RAD  
CG-THER-RAD-01 Fractionation and Radiation Therapy in the Treatment of Specified Cancers
CG-THER-RAD-02 Special Radiation Physics Consult and Treatment Procedure
 
 
Transplant  
CG-TRANS-02 Kidney Transplantation
 
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