Medical Policies and Clinical Utilization Management Guidelines
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1 providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup* began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical Utilization Management (UM) Guidelines on May 1, The full list of Medical Policies and Clinical Utilization Management Guidelines are publicly available on the Amerigroup Medical Policy and Clinical UM Guideline subsidiary website 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 is used only for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. Anthem Behavioral Health Medical Policies and Clinical Utilization Management Guidelines will be used for all behavioral health reviews. 1 In all cases, Medicaid contracts or regulatory guidance, or Centers for Medicare & Medicaid Services requirements supersede both McKesson InterQual Level of Care and Anthem 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. 1 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behavioral health utilization management services and where the use of Anthem Behavioral Health UM Guidelines is not superseded by regulatory or contractual requirements. *In Louisiana, Amerigroup Louisiana, Inc. In Texas, Amerigroup members in the Medicaid Rural Service Area are served by Amerigroup Insurance Company; all other Amerigroup members are served by Amerigroup Texas, Inc. In Washington, Amerigroup Washington, Inc. PEC-ALL _FL_LA_MD_NV_NJ_TX_WA June 2016
2 Clinical Utilization Management Guidelines 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 effective February 29, Highlighted sections indicate a new or revised guideline. To see the full UM Guidelines on the Amerigroup website, visit the Amerigroup Medical Policy and Clinical UM Guideline subsidiary website. Please note: For markets with pharmacy services carved out, the applicable listings below would be informational only. 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-BEH-14 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 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) Intensive In-Home Behavioral Health Services 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 Page 2 of 5
3 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 Settings CG-DME-22 Ankle-Foot & Knee-Ankle-Foot-Orthotics (Braces) CG-DME-23 Lifting Devices for Use in the Home CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight CG-DME-25 Seat Lift Mechanisms CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories CG-DME-35 Breastfeeding Pumps CG DME-36 Pediatric Gait Trainers CG-DME-37 Air Conduction Hearing Aids CG DME-38 Continuous Interstitial Glucose Monitoring CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ), and Direct Thrombin Inhibitors in the Outpatient Setting CG-DRUG-05 Recombinant Erythropoietin Products CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy (Archived 04/05/16) CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease CG-DRUG-09 Immune Globulin (Ig) Therapy CG-DRUG-11 Infertility Drugs CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs CG-DRUG-16 White Blood Cell Growth Factors CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High- Risk Women CG-DRUG-20 Enfuviritide (Fuzeon) CG-DRUG-21 Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid Dependence CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar Gel) CG-DRUG-27 Clostridial Collagenase Histolyticum Injection CG-DRUG-28 Alglucosidase alfa (Lumizyme, Myozyme ) CG-DRUG-29 Hyaluronan Injections in the Knee CG-DRUG-30 Oprelvekin (Neumega) CG-DRUG-33 Palonosetron (Aloxi ) Page 3 of 5
4 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 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-MED-53 CG-MED-54 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 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 Drug Testing or Screening in the Context of Substance Use Disorder 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) Cervical Cancer Screening for Women Under 21 Years of Age Strapping 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 Page 4 of 5
5 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 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-SURG-52 CG SURG-53 CG SURG -54 CG-THER-RAD- 01 CG-THER-RAD- 02 CG-TRANS-02 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 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 Level of Care: Hospital-Based Ambulatory Surgical Procedures, including Endoscopic Procedures Elective Total Hip Arthroplasty Elective Total Knee Arthroplasty Fractionation and Radiation Therapy: Bone Metastases and Whole-Breast Irradiation Following Breast-Conserving Surgery Special Radiation Physics Consult and Treatment Procedure Kidney Transplantation Page 5 of 5
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