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Full list of Medical Policies and Clinical Guidelines

WEBMedical Policy. Administrative. ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical …

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CG-SURG-83 Bariatric Surgery and Other Treatments for

WEBBariatric Surgery to Treat Indications Other than Obesity. The rates of metabolic diseases, such as diabetes and nonalcoholic fatty liver diseases (NAFLD) …

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CG-DME-10 Durable Medical Equipment

WEBDME must meet the following definitions of “durable” and “medical equipment”: Durable. --An item is considered durable if it can withstand repeated use, …

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Medical Policies and Clinical UM Guidelines

WEBThe MCG guidelines we are licensed to use include ( (1) Inpatient & Surgical Care (ISC), (2) General Recovery Care (GRG), (3) Recovery Facility Care (RFC), (4) Chronic Care (CC) …

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ADMIN.00006 Review of Services for Benefit Determinations in the

WEBSubject: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline …

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CG-DME-35 Electric Breast Pumps

WEBAn electric, heavy-duty, hospital-grade breast pump is recommended for mothers who are dependent on the expression of pumped breast milk (initiation or …

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MED.00110 Silver-based Products for Wound and Soft Tissue

WEBDefinitions. Antimicrobial silver wound dressing (e.g., Acticoat, Actisorb, and Silversorb): A technology proposed to prevent wound adhesion, limit nosocomial …

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CUSTOMIZATION TO CARE GUIDELINES 27th EDITION

WEBFebruary 16, 2023. This document provides a high-level summary of customizations and modifications to MCG Care Guidelines, collectively, “customized guidelines.”1234 The …

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CG-MED-19 Custodial Care

WEBThis document defines custodial care, a type of care that generally provides assistance in performing activities of daily living (ADL); for example, assistance walking, …

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CUSTOMIZATION TO CARE GUIDELINES 26th EDITION

WEBFebruary 17, 2022. This document provides a high level summary of customizations and modifications to MCG Care Guidelines, collectively, “customized guidelines.”1234 The …

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CG-ADMIN-01 Clinical Utilization Management (UM) Guideline

WEBSubject: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists …

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CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography …

WEBMedically Necessary:. Non-obstetric, gynecologic, duplex ultrasonography of the abdomen or pelvis, in the outpatient setting, is considered medically necessary when …

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CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the

WEBMedically Necessary:. Noninvasive electrical bone growth stimulation is considered medically necessary when all of the following criteria are met: . Treatment is …

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SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial …

WEBThe use of drug-eluting devices for maintaining sinus ostial patency or the treatment of nasal polyps is considered investigational and not medically necessary for …

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ADMIN.00004 Medical Necessity Criteria

WEBSubject: Medical Necessity Criteria. Document #: ADMIN.00004. Publish Date: 06/28/2023. Status: Reviewed. Last Review Date: 05/11/2023. THESE CRITERIA …

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ADMIN.00002 Preventive MediWellslines

WEBMedical Policy. Subject: Preventive MediWellslines. Document #: ADMIN.00002. Publish Date: 06/28/2023. Status: Reviewed. Last Review Date: …

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RAD.00064 Myocardial Sympathetic Innervation Imaging with or …

WEBThis document addresses use of the radiopharmaceutical tracer 123 iodine meta-iodobenzylguanidine (also known as 123 I-MIBG or MIBG, or AdreView ™) for …

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