CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Clinical UM Guideline

Subject: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
Guideline #: CG-ADMIN-01	Publish Date: 07/01/2026
Status: Reviewed	Last Review Date: 05/14/2026

Description

The Company reviews services provided, or proposed to be provided, to its members to determine benefits coverage based on whether the services are medically necessary or not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice, taking into account credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors, as they relate to the member's clinical circumstances.

This document provides guidance to be followed and a list of resources available to Company Medical Reviewers when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes noted in the table below in connection with a provider who is on pre-payment review. These services and corresponding codes may be modified when additional inappropriate use of services is identified; services and codes may be added to the table accordingly.

After Company Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system. Utilization Management departments will follow their standard procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.

NOTE: PLEASE SEE THE DEFINITIONS OF "MEDICALLY NECESSARY" OR "MEDICAL NECESSITY" AND "INVESTIGATIONAL" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Summary for Members and Families

This document describes clinical utilization management (UM) guideline for pre-payment review medical necessity determinations when no other clinical UM guideline exists. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

This document explains how the Company decides if a medical service is medically necessary and covered when there is no specific clinical guideline for that service. It outlines how medical reviewers use trusted medical research, expert recommendations, and their professional judgment to make fair decisions about coverage, especially for providers who are under pre-payment review. It also explains that decisions must follow the definitions of “medically necessary” in the member’s health plan.

The Company reviews medical services to decide if they meet generally accepted standards of medical practice. To do this, medical reviewers look at credible scientific studies published in peer reviewed medical journals. They also consider recommendations from physician specialty societies. These are national medical groups that represent doctors certified by boards recognized by the American Board of Medical Specialties. Reviewers may also consider the views of doctors who practice in the same clinical area as the requested service.

When there is no specific clinical guideline for a service, this document provides guidance and a list of possible resources to use. The list is not complete, and reviewers do not need to use every resource in every case. However, they should use more than one source when it makes sense. Reviewers are expected to use their professional judgment and to document both their decision and the resources they relied on. Standard procedures are followed to make sure decisions are made on time for urgent and non-urgent requests.

What are final decisions based on to determine medical necessity?

To decide whether a service is medically necessary, final decisions are based on:

The definitions of “medically necessary” or “medical necessity” in the person’s health plan; and
Credible scientific evidence; and
Expert recommendations; and
The individual’s specific medical situation.

Services that do not meet the plan’s definition of medically necessary are not clinically appropriate. Better studies are needed to know if these services improve health. Unnecessary or unproven tests or treatments can lead to treatment that does not help.

(Return to Description)

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT
71045	Radiologic examination, chest; single view
71046	Radiologic examination, chest, 2 views
71047	Radiologic examination, chest, 3 views
72020	Radiologic examination, spine, single view, specify level
72040	Radiologic examination, spine, cervical; 2 or 3 views
72050	Radiologic examination, spine, cervical; 4 or 5 views
72052	Radiologic examination, spine, cervical; 6 or more views
72070	Radiologic examination, spine; thoracic, 2 views
72074	Radiologic examination, spine; thoracic, minimum of 4 views
72082	Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views
72170	Radiologic examination, pelvis; 1 or 2 views
73030	Radiologic examination, shoulder; complete, minimum of 2 views
73060	Radiologic examination; humerus, minimum of 2 views
73070	Radiologic examination, elbow; 2 views
73080	Radiologic examination, elbow; complete, minimum of 3 views
73090	Radiologic examination; forearm, 2 views
73110	Radiologic examination, wrist; complete, minimum of 3 views
73130	Radiologic examination, hand; minimum of 3 views
73502	Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views
73503	Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views
73521	Radiologic examination, hips, bilateral, with pelvis when performed; 2 views
73522	Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views
73523	Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views
73560	Radiologic examination, knee; 1 or 2 views
73564	Radiologic examination, knee; complete, 4 or more views
73590	Radiologic examination, tibia and fibula, 2 views
73600	Radiologic examination, ankle; 2 views
73610	Radiologic examination, ankle; complete, minimum of 3 views
73620	Radiologic examination, foot; 2 views
73630	Radiologic examination, foot; complete, minimum of 3 views
73660	Radiologic examination; toe(s), minimum of 2 views
74021	Radiologic examination, abdomen; 3 or more views
76536	Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
76700	Ultrasound, abdominal, real time with image documentation; complete
76705	Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
76770	Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
76775	Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited
76881	Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures), real-time with image documentation
76882	Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscles[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation
93886	Transcranial Doppler study of the intracranial arteries; complete study
93888	Transcranial Doppler study of the intracranial arteries; limited study
93892	Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection
93893	Transcranial Doppler study of the intracranial arteries; venous-arterial shunt detection with intravenous microbubble injection
93896	Vasoreactivity study performed with transcranial Doppler study of intracranial arteries, complete
93897	Emboli detection without intravenous microbubble injection performed with transcranial Doppler study of intracranial arteries, complete
93898	Venous-arterial shunt detection with intravenous microbubble injection performed with transcranial Doppler study of intracranial arteries, complete
93975	Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
93976	Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
96365	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
96366	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
96367	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
96368	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
96369	Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)
96370	Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
96371	Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
96373	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial
96374	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
96375	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)
96376	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure
96377	Application of on-body injector (includes cannula insertion) for timed subcutaneous injection
96379	Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion

ICD-10 Diagnosis
	All diagnoses

**Note: In determining if there is a relevant Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is reported, the detailed description of service will be the determining factor.

Discussion/General Information

As noted above, this document provides guidance to be followed when the Company does not have a Clinical Utilization Management (UM) Guideline directly applicable to a particular medical necessity determination for a claim related to the above services and codes in connection with a provider who is on pre-payment review. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources that may be relevant to the decision at hand, but not necessarily use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.

Definitions

Physician Specialty Society: A United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.

References

Government Agency, Medical Society, and Other Authoritative Publications:

Agency for Healthcare Research and Quality (AHRQ) - Clinical Information. Available at: http://www.ahrq.gov/. Accessed on April 30, 2026.
American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2024. Available at: http://www.abms.org/member-boards/specialty-subspecialty-certificates/. Accessed on April 30, 2026
Centers for Disease Control and Prevention (CDC). Available at: http://www.cdc.gov. Accessed on April 30, 2026.
Centers for Medicare & Medicaid Services (CMS). Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on April 30, 2026.
National Library of Medicine - PUBMED^®. Available at: http://www.ncbi.nlm.nih.gov/sites/entrez. Accessed on April 30, 2026.
U.S. Food and Drug Administration (FDA). Available at: http://www.fda.gov. Accessed on April 30, 2026.
Physician specialty societies where publicly available:

General Certificate(s)	Specialty Society (+) Indicates Guidelines Publicly Available (-) Indicates Guidelines Not Publicly Available	Subspecialty Certificate(s)
Allergy and Immunology	American Academy of Asthma, Allergy and Immunology (AAAAI) (+) http://www.aaaai.org American College of Allergy, Asthma and Immunology (ACAAI) (-) https://acaai.org/	None
Anesthesiology	American Society of Anesthesiologists^® (ASA) (+) For additional information visit the ASA website: https://www.asahq.org/	Adult Cardiac Anesthesiology Critical Care Medicine Health Care Administration, Leadership, and Management Hospice and Palliative Medicine Neurocritical Care Pain Medicine Pediatric Anesthesiology Sleep Medicine
Colon and Rectal Surgery	American Society of Colon and Rectal Surgeons (ASCRS) (+) http://www.fascrs.org	None
Dermatology	American Academy of Dermatology (AAD) (+) http://www.aad.org	Dermatopathology Micrographic Dermatologic Surgery Pediatric Dermatology
Emergency Medicine	American College of Emergency Physicians^® (ACEP) (+) https://www.acep.org/	Anesthesiology Critical Care Medicine Emergency Medical Services Health Care Administration, Leadership, and Management Hospice and Palliative Medicine Internal Medicine- Critical Care Medicine Medical Toxicology Neurocritical Care Pain Medicine Pediatric Emergency Medicine Sports Medicine Undersea and Hyperbaric Medicine
Family Medicine	American Academy of Family Practice (AAFP) (-) http://www.aafp.org	Adolescent Medicine Geriatric Medicine Health Care Administration, Leadership, and Management Hospice and Palliative Medicine Pain Medicine Sleep Medicine Sports Medicine
Internal Medicine	American College of Physicians (ACP) (+) http://www.acponline.org	Adolescent Medicine Adult Congenital Heart Disease Advanced Heart Failure and Transplant Cardiology Allergy and Immunology Cardiovascular Disease Clinical Cardiac Electrophysiology Critical Care Medicine Endocrinology, Diabetes and Metabolism Gastroenterology Geriatric Medicine Hematology Hospice and Palliative Medicine Infectious Disease Interventional Cardiology Medical Oncology Nephrology Neurocritical Care Pulmonary Disease Rheumatology Sleep Medicine Sports Medicine Transplant Hepatology Women’s Health
Medical Genetics Clinical Biochemical Genetics Clinical Cytogenetics and Genomics Clinical Genetics and Genomics (MD) Clinical Molecular Genetics and Genomics Laboratory Genetics and Genomics	American College of Medical Genetics and Genomics (ACMG) (+) http://www.acmg.net	Medical Biochemical Genetics Molecular Genetic Pathology
Neurological Surgery	American Association of Neurological Surgeons (AANS) (+) For additional information visit the AANS website: https://www.aans.org/	Neurocritical Care
Nuclear Medicine	American College of Nuclear Medicine (ACNM) (-) http://www.acnmonline.org	None
Obstetrics and Gynecology	American Congress of Obstetricians and Gynecologists (ACOG) (+) http://www.acog.org	Complex Family Planning Critical Care Medicine Female Pelvic Medicine and Reconstructive Surgery Gynecologic Oncology Hospice and Palliative Medicine Maternal and Fetal Medicine Reproductive Endocrinology/ Infertility Urogynecology and Reconstructive Pelvic Surgery
Ophthalmology	American Academy of Ophthalmology (AAO) (+) For additional information visit the AAO website: https://www.aao.org/	None
Orthopaedic Surgery	American Academy of Orthopaedic Surgeons (AAOS) (+) http://www.aaos.org	Orthopaedic Sports Medicine Surgery of the Hand
Otolaryngology	American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+) http://www.entnet.org	Complex Pediatric Otolaryngology Neurotology Plastic Surgery Within the Head and Neck Sleep Medicine
Pathology Pathology-Anatomic/ Pathology-Clinical Pathology-Anatomic Pathology-Clinical	College of American Pathologists (CAP) (+) http://www.cap.org	Blood Banking/Transfusion Medicine Chemical Pathology Clinical Informatics Cytopathology Dermatopathology Hematopathology Neuropathology Pathology - Chemical Pathology - Forensic Pathology - Hematology Pathology - Medical Microbiology Pathology - Molecular Genetic Pathology - Pediatric
	American Society for Clinical Pathology (ASCP) (+) http://www.ascp.org
Pediatrics	American Academy of Pediatrics (AAP) (+) http://www.aap.org	Adolescent Medicine Child Abuse Pediatrics Developmental-Behavioral Pediatrics Hospice and Palliative Medicine Medical Toxicology Neonatal-Perinatal Medicine Pediatric Cardiology Pediatric Critical Care Medicine Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology-Oncology Pediatric Hospital Medicine Pediatric Infectious Diseases Pediatric Nephrology Pediatric Pulmonology Pediatric Rheumatology Pediatric Transplant Hepatology Sleep Medicine Sports Medicine
Physical Medicine and Rehabilitation	American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+) http://www.aapmr.org	Brain Injury Medicine Neuromuscular Medicine Pain Medicine Pediatric Rehabilitation Medicine Spinal Cord Injury Medicine Sports Medicine
Plastic Surgery	American Society of Plastic Surgeons^® (ASPS) (+) http://www.plasticsurgery.org	Plastic Surgery Within the Head and Neck Surgery of the Hand
Preventive Medicine Aerospace Medicine Occupational Medicine Public Health and General Preventive Medicine	American College of Preventive Medicine (ACPM) (+) http://www.acpm.org	Addiction Medicine Clinical Informatics Health Care Administration, Leadership, and Management Medical Toxicology Undersea and Hyperbaric Medicine
	American College of Occupational and Environmental Medicine (ACOEM) (+) http://www.acoem.org
Psychiatry and Neurology Psychiatry Neurology Neurology with Special Qualification in Child Neurology	American Psychiatric Association (APA) (+) https://www.psychiatry.org/ https://www.psychiatry.org/	Addiction Psychiatry Brain Injury Medicine Child and Adolescent Psychiatry Clinical Neurophysiology Consultation-Liaison Psychiatry Epilepsy Forensic Psychiatry Geriatric Psychiatry Neurocritical Care* Neurodevelopmental Disabilities Neuromuscular Medicine Pain Medicine Sleep Medicine Vascular Neurology
	American Academy of Child & Adolescent Psychiatry (AACAP) (+) http://www.aacap.org
	American Academy of Neurology^® (AAN) (+) http://www.aan.com Child Neurology Society (CNS) (-) http://www.childneurologysociety.org
Radiology Diagnostic Medical Physics Diagnostic Radiology Interventional Radiology and Diagnostic Radiology Nuclear Medical Physics Radiation Oncology Therapeutic Medical Physics	American College of Radiology (ACR^®) (+) http://www.acr.org NOTE: Do not confuse with American College of Rheumatology	Neuroradiology Nuclear Radiology Pain Medicine Pediatric Radiology
	American Society for Therapeutic Radiation and Oncology ASTRO (+) For additional information visit the ASTRO website: https://www.astro.org/
Surgery and Vascular Surgery	American College of Surgeons (ACS) (+) http://www.facs.org NOTE: Do not confuse with American Cancer Society.	Complex General Surgical Oncology Pediatric Surgery Surgical Critical Care Vascular Surgery
Thoracic and Cardiac Surgery	Society of Thoracic Surgeons (STS) (+) http://www.sts.org/	Congenital Cardiac Surgery
Urology	American Urological Association (AUA) (+) For additional information visit the AUA website: https://www.auanet.org/guidelines-and-quality/guidelines	Pediatric Urology Urogynecology and Reconstructive Pelvic Surgery

Subspecialty Societies

Subspecialty Certificate	Specialty Society (+) Indicates Guidelines Publicly Available (-) Indicates Guidelines Not Publicly Available
Cardiology	American College of Cardiology (ACC) (+) http://www.acc.org Society for Cardiovascular Angiography and Interventions (SCAI) (+) http://www.scai.org/Default.aspx
Clinical Cardiac Electrophysiology	Heart Rhythm Society (HRS) (+) (collaborative with ACC) http://www.hrsonline.org/
Critical Care Medicine	Society of Critical Care Medicine (SCCM) (+) For additional information visit the SCCM website: http://www.sccm.org/Home
Endocrinology, Diabetes and Metabolism	American Association of Clinical Endocrinologists AACE (+) http://www.aace.com
Endocrinology, Diabetes and Metabolism	Endocrine Society (+) https://www.endocrine.org/
Gastroenterology	American College of Gastroenterology (ACG) (+) https://gi.org/ American Gastroenterological Association (AGA) (+) http://www.gastro.org
Gastroenterology	Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (+) https://www.sages.org/
Geriatric Medicine	American Geriatrics Society (AGS) (+) http://www.americangeriatrics.org
Geriatric Psychiatry	American Association for Geriatric Psychiatry (AAGP) (-) http://www.aagponline.org/
Gynecologic Oncology	Society of Gynecologic Oncology (SGO) (+) http://www.sgo.org
Hematology	American Society of Hematology (ASH) (+) http://www.hematology.org
Hospice and Palliative Medicine	American Academy of Hospice and Palliative Medicine (AAHPM) (+) http://www.aahpm.org
Infectious Disease	Infectious Disease Society of America (IDSA) (+) http://www.idsociety.org
Medical Toxicology	American College of Medical Toxicology (ACMT) (+) http://www.acmt.net
Nephrology	American Society of Nephrology (ASN) (-) http://www.asn-online.org
Neuromuscular	American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) (+) http://www.aanem.org/Home.aspx
Neuroradiology	American Society of Neuroradiology (ASNR) (-) http://www.asnr.org
Oncology	American Society of Clinical Oncology (ASCO^®) (+) http://www.asco.org
Pain Medicine	American Chronic Pain Association (ACPA) (+) https://www.acpanow.com/
Pain Medicine	American Academy of Pain Medicine (AAPM) (+) https://painmed.org/
Pulmonary Disease	American College of Chest Physicians^® (CHEST) (+) http://www.chestnet.org
Reproductive Endocrinology/Infertility	American Society for Reproductive Medicine (ASRM) (+) http://www.asrm.org
Rheumatology	American College of Rheumatology (ACR) (+) For additional information visit the ACR website: http://www.rheumatology.org/ NOTE: Do not confuse with American College of Radiology
Sleep Medicine	American Academy of Sleep Medicine (AASM) (+) http://www.aasmnet.org
Sports Medicine	American Orthopaedic Society for Sports Medicine (AOSSM) (-) http://www.sportsmed.org
Surgery of the Hand	American Society for Surgery of the Hand (ASSH) (-) https://www.assh.org/
Transplant Hepatology	American Association for the Study of Liver Diseases (AASLD) (+) http://www.aasld.org
Transplant Hepatology	American Society of Transplantation (AST) (+) https://www.myast.org/
Undersea and Hyperbaric Medicine	Undersea and Hyperbaric Medical Society (UHMS) (+) https://www.uhms.org/
Vascular and Interventional Radiology	Society of Interventional Radiology (SIR) (+) http://www.sirweb.org
Vascular Surgery	Society for Vascular Surgery (SVS) (+) https://vascular.org/

Index

Radiograph
Ultrasound
X-Ray

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status	Date	Action
Reviewed	05/14/2026	Medical Policy & Technology Assessment Committee (MPTAC) review. Added “Summary for Members and Families” section. Revised Discussion/General Information and References section.
Reviewed	05/08/2025	MPTAC review. Revised References section. Revised Coding section to remove 72110, 72114 now addressed in CG-RAD-29.
	01/30/2025	Updated Coding section with 01/01/2025 CPT changes; added 93896, 93897, 93898, revised descriptor for 93893, removed 93890 deleted as of 01/01/2025.
Reviewed	05/09/2024	MPTAC review. Updated References section.
Reviewed	05/11/2023	MPTAC review. Updated References section.
	12/28/2022	Updated Coding section with 01/01/2023 CPT changes; revised descriptor for 76882.
Reviewed	05/12/2022	MPTAC review. Updated References.
Reviewed	05/13/2021	MPTAC review.
Reviewed	05/14/2020	MPTAC review. Updated References.
Revised	06/06/2019	MPTAC review. Revised Coding and References section to create separate sections. Updated References. Updated Coding section with CPT codes 96365-96379.
Revised	09/13/2018	MPTAC review. Added new entry and references for CPT codes 93886-93893. Added reference for AIUM practice guideline for the performance of ultrasound of the female pelvis to 93975 and 93976. Updated References.
Reviewed	02/27/2018	MPTAC review.
	01/01/2018	The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT changes; added codes 71045-71047 and 74021, removed codes 71010, 71020, 71021, and 74020 deleted 12/31/2017.
Revised	02/02/2017	MPTAC review. Updated document with references for added CPT codes 76881, 76882, 93975 and 93976.
New	08/04/2016	MPTAC review. Initial document development.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.