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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
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Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin

PW_AD083614
NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete a group-specific review requirement will be considered ‘Adopted’ for that group only and for the specific type of review required.  
Ancillary Services:  
CG-ANC-01 Ambulance Services Ground  
CG-ANC-04 Ambulance services Air and Water  
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-05 Recombinant Erythropoietin Products  
CG-DRUG-08 Pharmacotherapy for Gaucher Disease  
CG-DRUG-09 Intravenous Immune Globulin Therapy  
CG-DRUG-11 Infertility Drugs  
CG-DRUG-15 Gonadotropin Releasing Hormone  
CG-DRUG 16 White Blood Cell Growth Factors  
CG-DRUG-24 Repository Corticotropin Injection  
CG-DRUG-25 IV vs. Oral Drug Administration in the Outpatient and Home Setting  
CG-DRUG-28 Alglucosidase Alfa  
CG-DRUG-30 Oprelvekin (Neumega®)  
DME:  
CG-DME-01 External (Portable) Continuous Insulin Infusion Pump  
CG-DME-06 Pneumatic Compression Devices  
CG-DME-07 Augmentative and Alternative Communication  
CG-DME-11 Spinal Orthoses  
CG-DME -13 Lower Limb Prosthesis  
CG-DME-15 Hospital Beds and Accessories  
CG-DME-16 Pressure Reducing Support Surfaces  
CG-DME-24 Manual Wheeled Mobility Devices  
CG-DME-28 Myoelectric Upper Extremity Prosthetic Devices  
CG-DME-31 Wheeled Mobility Devices  
CG-DME-33 Manual Wheelchairs- Ultra Lightweight  
CG-DME-34- Wheelchair accessories  
Medicine:  
CG-MED-19 Custodial Care  
CG- MED-23 Home Health  
CG-MED-26- Neonatal Levels of Care  
CG-MED-29- Inpatient Subacute Care  
CG-MED-31-Skilled Nursing Facility Services  
CG-MED- 37- Pediatric Feeding Programs  
CG-MED-38 Inpatient Admission for Radiation Therapy  
Orthotics-Prosthetics:  
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces  
CG-OR-PR-03 Custom Made Knee Braces  
Rehabilitation:  
CG-REHAB-03 Pulmonary Rehabilitation  
CG-REHAB-04 Physical Therapy  
CG-REHAB-05 Occupational Therapy  
CG-REHAB-06 Speech Language Pathology  
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services  
CG-REHAB-08 Private Duty Nursing in the Home Setting  
CG-REHAB-09 Acute Inpatient Rehabilitation  
Surgery:  
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair and Brow Lift  
CG-SURG-05 MAZE Procedure 
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) and Craniomandibular Disorder (CMD)  
CG-SURG-12 Penile Prosthesis Implantatation  
CG SURG 18 –Septoplasty  
CG-SURG-24 Functional Endoscopic Sinus Surgery  
CG-SURG-27 Gender Reassignment  
CG-SURG-28- Transcatheter Uterine Artery Embolization  
CG-SURG-30- Tonsillectomy for Children  
CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID)  
Sleep Management Guidelines  
2012 AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines available at http://www.aimspecialtyhealth.com/gowebsleep.  
Note: The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty Health, Inc. (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment management services.  
Radiology Authorization Guidelines:  
AIM’s Diagnostic Imaging Clinical Guidelines are available at:  
Note: The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health, Inc., (AIM), a separate company. For certain health plan members, AIM also provides radiology utilization management services.  
Head & Neck Imaging:  
CTA of the Head: Cerebrovascular  
MRI of the Head  
MRA of the Head: Cerebrovascular  
CT of the Orbit, Sella Turcica, Posterior Fossa and the Temporal Bone, including Mastoids  
MRI of the Orbit, Face, Neck  
CT of the Paranasal Sinus Maxillofacial Area  
MRI of the Temporomandibular Joints  
CT of the Neck (Soft Tissue)  
CTA of the Neck  
MRA of the Neck  
Chest Imaging:  
CT of the Chest  
CTA of the Chest  
MRI of the Chest  
MRA of the Chest  
Cardiac Imaging:  
Nuclear Cardiology - Myocardial Perfusion Imaging  
Nuclear Cardiology - Cardiac Blood Pool Imaging  
Nuclear Cardiology - Infarct Imaging  
CT Cardiac (Structure)  
MRI – Cardiac  
Stress Echocardiography  
Transesophageal Echocardiography (TEE)  
Resting Transthoracic Echocardiography (TTE)  
Abdominal & Pelvic Imaging:  
CT of the Abdomen  
MRI of the Abdomen  
CTA/MRA of the Abdomen  
CTA of the Abdominal Aorta - Lower Extremity Run-off  
CT of the Pelvis  
MRI of the Pelvis  
CTA/MRA of the Pelvis  
CT of the Abdomen & Pelvis Combination  
Spine Imaging:  
CT of the Cervical Spine  
MRI of the Cervical Spine  
CT of the Thoracic Spine  
MRI of the Thoracic Spine  
CT of the Lumbar Spine  
MRI of the Lumbar Spine  
Upper Extremity Imaging:  
CT of the Upper Extremity  
MRI of the Upper Extremity (Any Joint)  
MRI of the Upper Extremity (Non-Joint)  
CTA/MRA Upper Extremity  
Lower Extremity Imaging:  
CT of the Lower Extremity  
MRI of the Lower Extremity (Joint & Non- Joint)  
CTA/MRA of the Lower Extremity  
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, 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 (excluding 30 counties in the Kansas City area): 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. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees 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. Use of the Anthem Web sites constitutes your agreement with our Terms of Use