Clinical Utilization Management Guidelines
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1 Provider Bulletin This is an update about information in the provider manual. For access to the latest manual, go online to Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division effective September 1, Highlighted sections indicate a new or revised guideline. To see the full list of Clinical UM Guidelines, visit the Coverage Guidelines and Clinical UM Guidelines page. The Medical Operations Committee also adopted the Interqual Coronary Bypass Procedures Criteria for use in review of the 1-2 vessel coronary artery bypass grafting (CABG) procedures on September 11, Guideline number CG-ADMIN- 01 CG-ANC-04 CG-ANC-05 CG-ANC-06 CG-BEH-01 CG-BEH-02 CG-BEH-03 CG-BEH-04 CG-BEH-05 CG-BEH-07 CG-BEH-09 CG-BEH-10 CG-BEH-11 CG-BEH-12 CG-BEH-13 CG-BEH-14 CG-DME-01 CG-DME-03 CG-DME-05 CG-DME-07 CG-DME-08 CG-DME-09 Clinical UM Guideline name/title Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists Ambulance Services: Air and Water Ambulance Services: Ground; Emergent Ambulance Services: Ground; Non-Emergent Assessment for Autism Spectrum Disorders and Rett Syndrome Adaptive Behavioral Treatment for Autism Spectrum Disorder Psychiatric Disorder Treatment Substance-Related and Addictive Disorder Treatment Eating and Feeding Disorder Treatment Psychological Testing Assertive Community Treatment (ACT) Basic Skills Training/Social Skills Training Mental Health Support Services Psychosocial Rehabilitation Services Targeted Case Management (TCM) Intensive In-Home Behavioral Health Services External (Portable) Continuous Insulin Infusion Pump Neuromuscular Stimulation in the Treatment of Muscle Atrophy Cervical Traction Devices for Home Use Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Infant Home Apnea Monitors Continuous Local Delivery of Analgesia to Operative Sites using an HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. WEBPAVA
2 Page 2 of 5 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 Systems 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-Orthotics (Braces) CG-DME-23 Lifting Devices for Use in the Home CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight CG-DME-25 Seat Lift Mechanisms 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 Breastfeeding 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 CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ) and CG-DRUG-04 Direct Thrombin Inhibitors in the Outpatient Setting CG-DRUG-05 Recombinant Erythropoietin Products CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy (Archived 04/05/16) 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-15 Gonadotropin Releasing Hormone Analogs CG-DRUG-16 White Blood Cell Growth Factors Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk CG-DRUG-19 Women CG-DRUG-20 Enfuviritide (Fuzeon) Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid CG-DRUG-21 Dependence CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar Gel)
3 Page 3 of 5 CG-DRUG-27 Clostridial Collagenase Histolyticum Injection CG-DRUG-28 Alglucosidase alfa (Lumizyme, Myozyme ) CG-DRUG-29 Hyaluronan Injections in the Knee CG-DRUG-30 Oprelvekin (Neumega) CG-DRUG-33 Palonosetron (Aloxi ) 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-59 Testosterone, Injectable Drug Testing or Screening in the Context of Substance Use Disorder and CG-LAB-09 Chronic Pain CG-MED-08 Home Enteral Nutrition 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-28 Iontophoresis for Medical Indications CG-MED-32 Ancillary Services for Pregnancy Complications CG-MED-38 Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer CG-MED-42 Maternity Ultrasound in the Outpatient Setting CG-MED-44 Holter Monitors CG-MED-45 Transrectal Ultrasonography CG-MED-46 Ambulatory and Inpatient Video Electroencephalography CG-MED-47 Fundus Photography CG-MED-48 Scrotal Ultrasound Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions CG-MED-49 (OAEs) for Hearing Disorders CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
4 Page 4 of 5 CG-MED-52 CG-MED-53 CG-MED-54 CG-MED-55 CG-OR-PR- 04 CG-OR-PR CG-SURG-03 CG-SURG-05 CG-SURG-08 CG-SURG-09 CG-SURG-12 CG-SURG-18 CG-SURG-24 CG-SURG-25 CG-SURG-27 CG-SURG-30 CG-SURG-31 CG-SURG-32 CG-SURG-33 CG-SURG-36 CG-SURG-38 CG-SURG-39 CG-SURG-40 CG-SURG-41 CG-SURG-42 CG-SURG-43 CG-SURG-44 CG-SURG-45 CG-SURG-46 CG-SURG-47 Allergy Immunotherapy (Subcutaneous) Cervical Cancer Screening for Women Under 21 Years of Age Strapping Level of Care: Advanced Radiologic Imaging Cranial Remodeling Bands and Helmets (Cranial Orthotics) Myoelectric Upper Extremity Prosthesis Devices Pulmonary Rehabilitation Physical Therapy Occupational Therapy Speech-Language Pathology Services Private Duty Nursing in the Home Setting Blepharoplasty, Blepharoptosis Repair and Brow Lift Maze Procedure Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Temporomandibular Disorders Penile Prosthesis Implantation Septoplasty Functional Endoscopic Sinus Surgery (FESS) Injection Treatment for Morton's Neuroma Sex Reassignment Surgery Tonsillectomy with or without Adenoidectomy for Children Treatment of Keloids and Scar Revision Pain Management: Cervical, Thoracic & Lumbar Facet Injections Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) Adenoidectomy Lumbar Laminectomy, Hemi-laminectomy, Laminectomy and/or Discectomy Pain Management: Epidural Steroid Injections Cataract Removal Surgery for Adults Surgical Strabismus Correction Cervical Fusion Knee Arthroscopy Coronary Angiography in the Outpatient Setting Bone Graft Substitutes Myringotomy and Tympanostomy Tube Insertion Surgical Interventions for Scoliosis and Spinal Deformity
5 Page 5 of 5 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, including Endoscopic Procedures 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-57 Diagnostic Nasal Endoscopy CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions 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 CG-TRANS- 02 Kidney Transplantation
BadgerCare Plus. Ambulance services: air and water Ambulance services: ground; nonemergent
Clinical Utilization Management (UM) Guidelines Effective June 15, 2016, the Clinical UM Guidelines listed below were adopted by the medical operations committee for the Government Business Division. To
Clinical Utilization Management Guidelines
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Clinical Utilization Management Guidelines
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Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
Provider Newsletter. Table of Contents. Reimbursement Policy: Improve member medication regimen. Page 2
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Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
Your Responsibilities. $2,600 per family. $6,000 per individual $12,000 per family $200 copayment per visit
Security Administrative Services certifies that you and any covered dependents have coverage as described in your Summary Plan Description and Schedule of Benefits as of the effective date shown on the