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. To see the full list of Clinical UM Guidelines, visit the Medical Policies and Clinical UM Guidelines page. Update to clinical guideline, Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry (CG-MED-39), was published January 30, 2018. Effective, January 30, 2018, this clinical guideline will apply to Medicaid lines of business. The clinical indication section specific to female screening of osteoporosis was revised to reflect that an initial (baseline) central (hip or spine) bone density measurement is considered medically necessary when conducted in postmenopausal individuals 65 years of age or older. The guideline also identifies other clinical indications when initial and repeat central bone mineral density measurements are medically necessary. Please note: For markets with pharmacy services carved out, the applicable listings below would be informational only. CG-ADMIN-01 CG-ADMIN-02 CG-ANC-03 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 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists Clinically Equivalent Cost Effective Services Targeted Immune Modulators Acupuncture 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 https://providers.healthybluela.com Healthy Blue is the trade name of Community Care Health Plan of Louisiana, Inc., an independent licensee of the Blue Cross and Blue Shield Association. BLAPEC-0680-17 April2018
CG-DME-03 CG-DME-04 CG-DME-05 CG-DME-06 CG-DME-07 CG-DME-08 CG-DME-09 CG-DME-10 CG-DME-12 CG-DME-13 CG-DME-15 Neuromuscular Stimulation in the Treatment of Muscle Atrophy Electrical Nerve Stimulation, Transcutaneous, Percutaneous Cervical Traction Devices for Home Use Pneumatic Compression Devices for Lymphedema Healthy Blue Page 2 of 7 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Infant Home Apnea Monitors Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Post-Operative Period Durable Medical Equipment Home Phototherapy Devices for Neonatal Hyperbilirubinemia Lower Limb Prosthesis Hospital Beds and Accessories CG-DME-16 Pressure Reducing Support Systems Groups 1, 2 & 3 CG-DME-18 CG-DME-19 CG-DME-20 CG-DME-21 CG-DME-22 CG-DME-23 CG-DME-24 CG-DME-25 CG-DME-26 CG-DME-30 CG-DME-31 CG-DME-33 CG-DME-34 CG-DME-35 CG-DME-36 CG-DME-37 CG DME-38 CG-DME-39 CG-DME-40 CG-DME-41 CG-DRUG-01 CG-DRUG-03 CG-DRUG-04 CG-DRUG-05 CG-DRUG-08 CG-DRUG-09 Home Oxygen Therapy Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes Orthopedic Footwear External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings Ankle-Foot & Knee-Ankle-Foot-Orthotics (Braces) Lifting Devices for Use in the Home Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight Seat Lift Mechanisms Back-Up Ventilators in the Home Setting Prothrombin Time Self-Monitoring Devices Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Wheeled Mobility Devices: Manual Wheelchairs Ultra Lightweight Wheeled Mobility Devices: Wheelchair Accessories Breastfeeding Pumps Pediatric Gait Trainers Air Conduction Hearing Aids Continuous Interstitial Glucose Monitoring Dynamic Low-Load Prolonged-Duration Stretch Devices Electrical Bone Growth Stimulation Ultraviolet Light Therapy Delivery Devices for Home Use Off-Label Drug and Approved Orphan Drug Use Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ), and Direct Thrombin Inhibitors in the Outpatient Setting Recombinant Erythropoietin Products Enzyme Replacement Therapy for Gaucher Disease Immune Globulin (Ig) Therapy
Page 3 of 7 CG-DRUG-11 CG-DRUG-13 CG-DRUG-14 CG-DRUG-16 CG-DRUG-18 CG-DRUG-19 CG-DRUG-20 CG-DRUG-21 CG-DRUG-24 CG-DRUG-25 CG-DRUG-27 CG-DRUG-28 CG-DRUG-29 CG-DRUG-31 CG-DRUG-33 CG-DRUG-34 CG-DRUG-38 CG-DRUG-40 CG-DRUG-41 CG-DRUG-42 CG-DRUG-43 CG-DRUG-44 CG-DRUG-45 CG-DRUG-46 CG-DRUG-47 CG-DRUG-48 CG-DRUG-49 CG-DRUG-50 CG-DRUG-51 CG-DRUG-52 CG-DRUG-53 CG-DRUG-54 CG-DRUG-55 CG-DRUG-56 CG-DRUG-57 CG-DRUG-58 CG-DRUG-59 CG-DRUG-60 CG-DRUG-61 Infertility Drugs Hepatitis B Interferon Antiviral Therapy Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults White Blood Cell Growth Factors Nesiritide (Natrecor ) Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women Enfuviritide (Fuzeon) Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid Dependence Repository Corticotropin Injection (H.P. Acthar Gel) Intravenous vs. Oral Drug Administration in the Outpatient and Home Setting Clostridial Collagenase Histolyticum Injection Alglucosidase alfa (Lumizyme, Myozyme ) Hyaluronan Injections in the Knee Oncology Drug Treatment Regimens for Adults Note: At this time, this guideline is not implemented for medical benefit determinations. Palonosetron (Aloxi ) Docetaxel (Docefrez, Taxotere ) Pemetrexed Disodium (Alimta ) Bortezomib (Velcade ) Zoledronic acid Asparagine Specific Enzymes (Asparaginase) Natalizumab (Tysabri ) Pegloticase (Krystexxa ) Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) Fosaprepitant (Emend ) Level of Care: Specialty Pharmaceuticals Azacitidine (Vidaza ) Doxorubicin Hydrochloride Liposome Injection Paclitaxel, protein-bound (Abraxane ) Romidepsin (Istodax ) Temsirolimus (Torisel ) Drug Dosage, Frequency, and Route of Administration Agalsidase beta (Fabrazyme ) Elosulfase alfa (Vimizim ) Galsulfase (Naglazyme ) Idurasufase (Elaprase ) Laronidase (Aldurazyme ) Testosterone, Injectable Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
Page 4 of 7 CG-DRUG-62 CG-DRUG-63 CG-DRUG-64 CG-DRUG-65 CG-DRUG-66 CG-DRUG-68 CG-DRUG-69 CG-DRUG-70 CG-DRUG-71 CG-DRUG-72 CG-DRUG-73 CG-DRUG-74 CG-DRUG-75 CG-DRUG-76 CG-DRUG-77 CG-DRUG-78 CG-DRUG-79 CG-DRUG-80 CG-DRUG-81 CG-GENE-01 CG-GENE-02 CG-GENE-03 CG-GENE-04 CG-LAB-03 CG-LAB-09 CG-LAB-10 CG-LAB-11 CG-MED-02 CG-MED-05 CG-MED-08 CG-MED-19 CG-MED-21 CG-MED-22 CG-MED-23 CG-MED-24 CG-MED-26 CG-MED-28 CG-MED-32 CG-MED-34 CG-MED-35 CG-MED-37 Fulvestrant (FASLODEX ) Levoleucovorin Calcium (Fusilev ) FDA-Approved Biosimilar Products Tumor Necrosis Factor Antagonists Panitumumab (Vectibix ) Bevacizumab (Avastin ) for Non-Ophthalmologic Indications Ustekinumab (Stelara ) Eribulin mesylate (Halaven ) Ziv-aflibercept (Zaltrap ) Pertuzumab (Perjeta ) Denosumab (Prolia, Xgeva ) Canakinumab (Ilaris ) Romiplostim (Nplate ) Plerixafor Injection (Mozobil ) Radium Ra 223 Dichloride (Xofigo ) Antihemophilic Factors and Clotting Factors Siltuximab (Sylvant ) Cabazitaxel (Jevtana ) Tocilizumab (Actemra ) Janus Kinase 2 (JAK2) V617F Gene Mutation Assay Analysis of KRAS Status BRAF Mutation Analysis Molecular Marker Evaluation of Thyroid Nodules Tropism Testing for HIV Management Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain Zika Virus Testing Screening for Vitamin D Deficiency in Average Risk Individuals Esophageal ph Monitoring Ketogenic Diet for Treatment of Intractable Seizures Home Enteral Nutrition Custodial Care Anesthesia Services and Moderate ("Conscious") Sedation Neuropsychological Testing Home Health Electromyography and Nerve Conduction Studies Neonatal Levels of Care Iontophoresis for Medical Indications Ancillary Services for Pregnancy Complications Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Retinal Telescreening Systems Intensive Programs for Pediatric Feeding Disorders
Page 5 of 7 CG-MED-38 CG-MED-39 CG-MED-40 CG-MED-41 CG-MED-42 CG-MED-44 CG-MED-45 CG-MED-46 CG-MED-47 CG-MED-48 CG-MED-49 CG-MED-50 CG-MED-51 CG-MED-52 CG-MED-53 CG-MED-54 CG-MED-55 CG-MED-56 CG-MED-57 CG-MED-58 CG-MED-59 CG-MED-61 CG-MED-62 CG-MED-63 CG-MED-64 CG-MED-65 CG-MED-66 CG-MED-67 CG-MED-68 CG-OR-PR-02 CG-OR-PR-03 CG-OR-PR-04 CG-OR-PR-05 CG-OR-PR-06 CG-REHAB-02 CG-REHAB-03 CG-REHAB-04 CG-REHAB-05 Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry External Ambulatory Event Monitors to Detect Cardiac Arrhythmias Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting Maternity Ultrasound in the Outpatient Setting Holter Monitors Transrectal Ultrasonography Ambulatory and Inpatient Video Electroencephalography Fundus Photography Scrotal Ultrasound Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders Visual, Somatosensory and Motor Evoked Potentials Three-Dimensional (3-D) Rendering of Imaging Studies Allergy Immunotherapy (Subcutaneous) Cervical Cancer Screening for Women Under 21 Years of Age Strapping Level of Care: Advanced Radiologic Imaging Non-Obstetrical Transvaginal Ultrasonography Cardiac Stress Testing with Electrocardiogram (ECG) Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI Upper Gastrointestinal Endoscopy for Diagnosis, Screening or Surveillance Preoperative Testing for Low Risk Invasive Procedures and Surgeries Resting Electrocardiogram Screening in Adults Treatment of Hyperhidrosis Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) Manipulation Under Anesthesia of the Spine and Joints other than the Knee Cryopreservation of Oocytes or Ovarian Tissue Melanoma Vaccines Therapeutic Apheresis Prefabricated and Prophylactic Knee Braces Custom-made Knee Braces Cranial Remodeling Bands and Helmets (Cranial Orthotics) Myoelectric Upper Extremity Prosthesis Devices Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar Outpatient Cardiac Rehabilitation Pulmonary Rehabilitation Physical Therapy Occupational Therapy
Page 6 of 7 CG-REHAB-06 CG-REHAB-07 CG-REHAB-08 CG-REHAB-10 CG-SURG-01 CG-SURG-03 CG-SURG-05 CG-SURG-07 CG-SURG-08 CG-SURG-09 CG-SURG-10 CG-SURG-11 CG-SURG-12 CG-SURG-15 CG-SURG-17 CG-SURG-18 CG-SURG-24 CG-SURG-25 CG-SURG-27 CG-SURG-28 CG-SURG-29 CG-SURG-30 CG-SURG-31 CG-SURG-32 CG-SURG-33 CG-SURG-34 CG-SURG-35 CG-SURG-36 CG-SURG-37 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 Speech-Language Pathology Services Skilled Nursing and Skilled Rehabilitation Services (Outpatient) Private Duty Nursing in the Home Setting Level of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services Colonoscopy Blepharoplasty, Blepharoptosis Repair and Brow Lift Maze Procedure Vertical Expandable Prosthetic Titanium Rib Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Temporomandibular Disorders Ambulatory or Outpatient Surgery Center Procedures Surgical Treatment for Dupuytren's Contracture Penile Prosthesis Implantation Endometrial Ablation Trigger Point Injections Septoplasty Functional Endoscopic Sinus Surgery (FESS) Injection Treatment for Morton's Neuroma Sex Reassignment Surgery Transcatheter Uterine Artery Embolization Lumbar Discography 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) Diagnostic Infertility Surgery Intracytoplasmic Sperm Injection (ICSI) Adenoidectomy Destruction of Pre-Malignant Skin Lesions 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
Page 7 of 7 CG-SURG-48 CG-SURG-49 CG-SURG-50 CG-SURG-51 CG-SURG-52 CG-SURG-53 CG-SURG-54 CG-SURG-55 CG-SURG-56 CG-SURG-57 CG-SURG-58 CG-SURG-59 CG-SURG-60 CG-SURG-61 CG-SURG-62 CG-SURG-63 CG-SURG-65 CG-SURG-66 CG-SURG-67 CG-SURG-68 CG-SURG-69 CG-THER-RAD- 01 CG-THER-RAD- 02 CG-TRANS-02 Elective Percutaneous Coronary Interventions (PCI) Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Assistant Surgeons Outpatient Cystourethroscopy Level of Care: Hospital-Based Ambulatory Surgical Procedures, including Endoscopic Procedures Elective Total Hip Arthroplasty Elective Total Knee Arthroplasty Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation Diagnostic Fiberoptic Flexible Laryngoscopy Diagnostic Nasal Endoscopy Radioactive Seed Localization of Nonpalpable Breast Lesions Vena Cava Filters Cervical Total Disc Arthroplasty Cryosurgical Ablation of Solid Tumors Outside the Liver Radiofrequency Ablation to Treat Tumors Outside the Liver Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Recombinant Human Bone Morphogenetic Protein Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) Treatment of Osteochondral Defects Surgical Treatment of Femoracetabular Impingement Syndrome Meniscal Allograft Transplantation of the Knee Fractionation and Radiation Therapy in the Treatment of Specified Cancers Special Radiation Physics Consult and Treatment Procedure Kidney Transplantation