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Clinical UM Guidelines 
 
The “Last Review Date” set forth in the clinical UM guideline is the most recent date the Medical Policy and Technology Assessment Committee has reviewed or revised the clinical UM guideline. This is not necessarily coincident with the “Current Effective Date" which is also shown on the clinical UM guideline. For example, we may require lead time in order to program a clinical UM guideline on our claims systems. In cases where a new or revised clinical UM guideline results in the denial of benefits for services which have historically been covered, we may opt to provide advance notice of the changes prior to the clinical UM guideline taking effect. To confirm the effective date of a particular clinical UM guideline for your state or region, please contact us.  
 
 
Ancillary, Miscellaneous  
CG-ANC-01 Ambulance Services: Ground
CG-ANC-03 Acupuncture
CG-ANC-04 Ambulance Services: Air and Water
 
Behavioral Health  
CG-BEH-01 Screening and Assessment Tools for Autism, Asperger’s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Development Disorder Not Otherwise Specified (NOS)
 
 
Durable Medical Equipment  
CG-DME-01 External (Portable) Continuous Insulin Infusion Pump
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
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
CG-DME-10 Durable Medical Equipment
CG-DME-11 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
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
CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthotics (Braces)
CG-DME-23 Patient Lifts
CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs-Standard, Heavy Duty, Lightweight
CG-DME-25 Seat Lift Mechanisms
CG-DME-26 Back-Up Ventilators in the Home Setting
CG-DME-27 Non-Invasive Positive Pressure Respiratory Assist Devices (BiPAP®)
CG-DME-28 Myoelectric Upper Extremity Prosthetic Devices
CG-DME-29 Ambulatory Event Monitors to Detect Cardiac Arrhythmias
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-32 Continuous Positive Airway Pressure (CPAP) for the Treatment of Obstructive Sleep Apnea in Adults and Children, and Related Devices for the Treatment of Obstructive Sleep Apnea in Adults
CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
 
 
Prescription Drugs  
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
CG-DRUG-03 Beta Interferons or Glatiramer Acetate for Treatment of Multiple Sclerosis
CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy and Fondiparinux (Arixtra®) in the Outpatient Setting
CG-DRUG-05 Recombinant Erythropoietin Products
CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy
CG-DRUG-08 Pharmacotherapy for Gaucher Disease
CG-DRUG-09 Intravenous Immune Globulin Therapy (IVIG)
CG-DRUG-11 Oral and Injectable 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-15 Gonadotropin Releasing Hormone (GnRH) Analogs
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 Dependence
CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel)
CG-DRUG-25 IV vs. Oral Drug Administration in the Outpatient and Home Setting
CG-DRUG-26 Alefacept (Amevive®)
 
 
Laboratory/Pathology  
CG-LAB-03 Tropism Testing for HIV Management
 
 
Medicine  
CG-MED-01 Polysomnography Studies in Adults and Children
CG-MED-02 Esophageal pH Monitoring
CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
CG-MED-08 Home Enteral Nutrition
CG-MED-09 Vision Therapy
CG-MED-18 Electroencephalography (EEG) Testing: Ambulatory and Video
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 (EMG/NCS)
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 Anesthesia Services for Gastrointestinal Endoscopic Procedures
CG-MED-35 Retinal Telescreening Systems
CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
 
Orthotics/Prosthetics  
CG-OR-PR-01 NeuroControl Freehand Neuroprosthesis
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
CG-OR-PR-03 Custom-made Knee Braces
 
 
Radiology  
CG-RAD-01 Ultrasound Evaluation of Breast Disease
CG-RAD-02 Endoscopic Ultrasonography (EUS)
CG-RAD-04 Ultrasound in Maternity Care in the Outpatient Setting
CT-RAD-05 CT Myelogram
CG-RAD-06 Lumbar Discography
CG-RAD-07 CT/MRI Upper Extremity
CG-RAD-08 CTA/MRA Head and Neck
CG-RAD-09 CTA/MRA of the Thorax Cavity, Abdomen, Pelvis and Extremities
CG-RAD-10 CT/MRI Abdomen, Pelvis and Kidney
CG-RAD-11 CT/MRI Brain and Head
CG-RAD-12 CT/MRI Face, Orbits, Sinuses, Temporomandibular Joint (TMJ), Neck Soft Tissue
CG-RAD-13 CT/MRI Lower Extremity
CG-RAD-14 CT/MRI of the Spine (Cervical, Thoracic, Lumbar)
CG-RAD-15 CT/MRI of the Thoracic Cavity and Heart
CG-RAD-16 Myocardial Perfusion Imaging in the Outpatient Setting
CG-RAD-18 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry
CG-RAD-19 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
CG-RAD-21 Transesophageal and Transthroacic Echocardiography in the Outpatient Setting
CG-RAD-22 Stress Echocardiography in the Outpatient Setting
CG-RAD-23 Cardiac Blood Pool and Infarct Imaging in the Outpatient Setting
 
 
Rehabilitation Therapy  
CG-REHAB-01 Vestibular Rehabilitation and Canalith Repositioning
CG-REHAB-02 Cardiac Rehabilitation (Outpatient)
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
 
 
Surgery  
CG-SURG-01 Colonoscopy
CG-SURG-02 Infrared Coagulation for the Treatment of Hemorrhoids
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib (VEPTR)
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
CG-SURG-09 Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ), Craniomandibular Disorder (CMD)
CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
CG-SURG-11 Dupuytren's Contracture Release
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-13 Circumcision
CG-SURG-15 Endometrial Ablation
CG-SURG-17 Trigger Point Injections
CG-SURG-18 Septoplasty
CG-SURG-19 Carpal Tunnel Release Surgery
CG-SURG-23 Arthroscopic Lavage and Arthroscopic Debridement as a Treatment for Osteoarthritis of the Knee
CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
CG-SURG-25 Injection Treatment for Morton’s Neuroma
CG-SURG-27 Gender Reassignment Surgery
CG-SURG-28 Transcatheter Uterine Artery Embolization
 
Transplant  
CG-TRANS-02 Kidney Transplantation
 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri (excluding 30 counties in the Kansas City area), Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use