Search for Coverage Guidelines and Clinical UM Guidelines
To see a list of all coverage guidelines and clinical UM guidelines, visit our Full List page.
Coverage guidelines are used by all plans and lines of business unless Federal or State law—as well as contract language, including definitions and specific contract provisions or exclusions—take precedence over a coverage guideline. Those provisions will be considered first in determining eligibility for coverage before the coverage guideline is used to determine medical necessity.
Clinical UM Guidelines
The clinical utilization management (UM) guidelines published on this website are not always used by all plans or lines of business. Clinical UM guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Commercial or FEP plans or lines of business which determine there is not a need to adopt a clinical utilization management guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, please reference the listing provided below.
Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Virginia
In addition to the documents Anthem maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a coverage guideline that addresses a service also described in one of these other sets of criteria, Anthem’s coverage guideline supersedes.
Anthem licenses and utilizes MCG Care Guidelines to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG Care Guidelines licensed include:
- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic Care
- Behavioral Health Care
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 24th Edition (Publish date January 20, 2021).Customizations to MCG Care Guidelines 24th Edition
This document provides a summary of customizations to the MCG Care Guidelines 25th Edition (Publish date August 19, 2021).
Customizations to MCG Care Guidelines 25th Edition
This document provides a summary of customizations to the MCG Care Guidelines 26th Edition (Publish date December 9, 2022).
Customizations to MCG Care Guidelines 26th Edition
This document provides a summary of customizations to the MCG Care Guidelines 27th Edition (Publish date March 1, 2023).
Customizations to MCG Care Guidelines 27th Edition
Our health plans may use guidelines developed by Carelon Medical Benefits Management, Inc. to perform utilization management services for some procedures and certain members.
Carelon Medical Benefits Management guidelines applicable to Anthem programs are maintained by Carelon Medical Benefits Management. Updates to these guidelines can be found on their website.
CarelonRx is an independent company providing pharmacy benefit management services. The pharmacy clinical criteria for injectable, infused or implanted prescription drugs and therapies covered under the medical benefit are available for commercial plans and certain Medicare/Medicaid markets.
There are several different dates that may be associated with a coverage guideline or clinical utilization management (UM) guideline.
Publish Date — the date a coverage guideline or clinical UM guideline was made available on our public websites
Last Review Date — the date a coverage guideline or clinical UM guideline was reviewed and approved
Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.