Medical Policies and Clinical Utilization Management Guidelines
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1 providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Iowa, Inc. uses nationally recognized, evidence-based Medical Policies and Clinical Utilization Management (UM) Guidelines. The full list of Medical Policies and Clinical Utilization Management Guidelines are publicly available on the Amerigroup website, under Medical Policy and Clinical UM Guidelines their purpose is to help you provide quality care by reducing inappropriate use of medical resources. Effective March 1, 2014, McKesson InterQual Level of Care criteria will be used for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. Anthem Behavioral Health Medical Policies, Clinical Utilization Management Guidelines and American Society of Addiction Medicine Guidelines will be used for all behavioral health reviews. In all cases, Medicaid contracts, regulatory guidance and Centers for Medicare & Medicaid Services requirements supersede both McKesson InterQual Level of Care and Amerigroup medical policy criteria. Determinations of medical necessity are made on a case-by-case basis in accordance with the definition of medical necessity. If the request does not meet established criteria guidelines, it will then be referred to the licensed physician with the appropriate clinical expertise for review. This change applies only to states, covered populations and services for which Amerigroup provides behavioral health utilization management services and where the use of Anthem Behavioral Health UM Guidelines is not superseded by regulatory or contractual requirements. WEBPIA December 2015
2 Clinical Utilization Management Guidelines Guideline number CG-ANC-04 CG-ANC-05 CG-ANC-06 CG-BEH-01 CG-BEH-02 CG-BEH-03 CG-BEH-04 CG-BEH-05 CG-BEH-07 CG-BEH-09 CG_BEH-10 CG-BEH-11 CG-BEH-12 CG-BEH-13 CG-DME-01 CG-DME-03 CG-DME-05 CG-DME-07 CG-DME-08 CG-DME-09 CG-DME-10 CG-DME-12 CG-DME-13 CG-DME-15 Effective August 18, 2015, the Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list of UM Guidelines on the Amerigroup website, select the link above. Clinical UM Guidelines name/title Ambulance Services: Air and Water Ambulance Services: Ground; Emergent Ambulance Services: Ground; Non-Emergent Assessment for Autism Spectrum Disorders and Rett Syndrome Adaptive Behavioral Treatment for Autism Spectrum Disorder Psychiatric Disorder Treatment Substance-Related and Addictive Disorder Treatment Eating and Feeding Disorder Treatment Psychological Testing Assertive Community Treatment (ACT) Basic Skills Training/Social Skills Training Mental Health Support Services Psychosocial Rehabilitation Services Targeted Case Management (TCM) External (Portable) Continuous Insulin Infusion Pump Neuromuscular Stimulation in the Treatment of Muscle Atrophy Cervical Traction Devices for Home Use Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Infant Home Apnea Monitors Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Post-Operative Period Durable Medical Equipment Home Phototherapy Devices for Neonatal Hyperbilirubinemia Lower Limb Prosthesis Hospital Beds and Accessories CG-DME-16 Pressure Reducing Support Systems 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 for the Administration of Drugs in the Home or Residential Care
3 CG-DME-22 CG-DME-23 CG-DME-24 CG-DME-25 CG-DME-31 CG-DME-33 CG-DME-34 CG-DME-35 CG DME-36 CG-DRUG-01 CG-DRUG-03 CG-DRUG-04 CG-DRUG-05 CG-DRUG-07 CG-DRUG-08 CG-DRUG-09 CG-DRUG-11 CG-DRUG-13 CG-DRUG-15 CG-DRUG-16 CG-DRUG-19 CG-DRUG-20 CG-DRUG-21 CG-DRUG-24 CG-DRUG-27 CG-DRUG-28 CG-DRUG-29 CG-DRUG-30 CG-DRUG-33 CG-DRUG-34 CG-DRUG-38 CG-DRUG-40 CG-DRUG-41 CG-DRUG-42 CG-DRUG-43 CG-DRUG-44 CG-DRUG-45 CG-DRUG-46 CG-DRUG-47 Settings Ankle-Foot & Knee-Ankle-Foot-Orthotics (Braces) Lifting Devices for Use in the Home Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight Seat Lift Mechanisms Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Wheeled Mobility Devices:Manual Wheelchairs-Ultra Lightweight Wheeled Mobility Devices: Wheelchair Accessories Breastfeeding Pumps Pediatric Gait Trainers Off-Label Drug and Approved Orphan Drug Use Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ), and Direct Thrombin Inhibitors in the Outpatient Setting Recombinant Erythropoietin Products Hepatitis C Pegylated Interferon Antiviral Therapy Enzyme Replacement Therapy for Gaucher Disease Immune Globulin (Ig) Therapy Infertility Drugs Hepatitis B Interferon Antiviral Therapy Gonadotropin Releasing Hormone (GnRH) Analogs White Blood Cell Growth Factors Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women Enfuviritide (Fuzeon) Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid Dependence Repository Corticotropin Injection (H.P. Acthar Gel) Clostridial Collagenase Histolyticum Injection Alglucosidase alfa (Lumizyme, Myozyme ) Hyaluronan Injections in the Knee Oprelvekin (Neumega) Palonosetron (Aloxi ) Docetaxel (Taxotere ) Pemetrexed Disodium (Alimta ) Bortezomib (Velcade ) Zoledronic acid Asparagine Specific Enzymes (Asparaginase) Natalizumab (Tysabri ) Pegloticase (Krystexxa ) Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) Fosaprepitant (Emend ) Level of Care: Specialty Pharmaceuticals
4 CG-LAB-09 CG-MED-08 CG-MED-21 CG-MED-22 CG-MED-23 CG-MED-24 CG-MED-28 CG-MED-32 CG-MED-38 CG-MED-42 CG-MED-44 CG-MED-45 CG-MED-46 CG-MED-47 CG-MED-48 CG-MED-49 CG-MED-50 CG-MED-51 CG-MED-52 CG-OR-PR-04 CG-OR-PR-05 CG-REHAB-03 CG-REHAB-04 CG-REHAB-05 CG-REHAB-06 CG-REHAB-08 CG-SURG-03 CG-SURG-05 CG-SURG-08 CG-SURG-09 CG-SURG-12 CG-SURG-18 CG-SURG-24 CG-SURG-25 CG-SURG-27 CG-SURG-30 CG-SURG-31 CG-SURG-32 CG-SURG-33 CG-SURG-36 Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain Home Enteral Nutrition Anesthesia Services and Moderate ("Conscious") Sedation Neuropsychological Testing Home Health Electromyography and Nerve Conduction Studies Iontophoresis for Medical Indications Ancillary Services for Pregnancy Complications Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer Maternity Ultrasound in the Outpatient Setting Holter Monitors Transrectal Ultrasonography Ambulatory and Inpatient Video Electroencephalography Fundus Photography Scrotal Ultrasound Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders Visual, Somatosensory and Motor Evoked Potentials Three-Dimensional (3-D) Rendering of Imaging Studies Allergy Immunotherapy (Subcutaneous) Cranial Remodeling Bands and Helmets (Cranial Orthotics) Myoelectric Upper Extremity Prosthesis Devices Pulmonary Rehabilitation Physical Therapy Occupational Therapy Speech-Language Pathology Services Private Duty Nursing in the Home Setting Blepharoplasty, Blepharoptosis Repair and Brow Lift Maze Procedure Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Temporomandibular Disorders Penile Prosthesis Implantation Septoplasty Functional Endoscopic Sinus Surgery (FESS) Injection Treatment for Morton's Neuroma Gender Reassignment Surgery Tonsillectomy with or without Adenoidectomy for Children Treatment of Keloids and Scar Revision Pain Management: Cervical, Thoracic & Lumbar Facet Injections Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) Adenoidectomy
5 CG-SURG-38 CG-SURG-39 CG-SURG-40 CG-SURG-41 CG-SURG-42 CG-SURG-43 CG-SURG-44 CG-SURG-45 CG-SURG-46 CG-SURG-47 CG-SURG-48 CG-SURG-49 CG-SURG-50 CG-SURG-51 CG-TRANS-02 Lumbar Laminectomy, Hemi-laminectomy, Laminectomy and/or Discectomy Pain Management: Epidural Steroid Injections Cataract Removal Surgery for Adults Surgical Strabismus Correction Cervical Fusion Knee Arthroscopy Coronary Angiography and Cardiac Catheterization in the Outpatient Setting Bone Graft Substitutes Myringotomy and Tympanostomy Tube Insertion Surgical Interventions for Scoliosis and Spinal Deformity Elective Percutaneous Coronary Interventions (PCI) Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Assistant Surgeons Outpatient Cystourethroscopy Kidney Transplantation
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