UM Guidelines

PW_AD089438

Clinical Guidelines Applicable for New York

NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered ‘Adopted’ for that ASO group only and for the specific type of review required.
Clinical Guidelines - New York
(updated 10/17/2014)
Date First Implemented Implementation Date of Current Version
CG-ANC-04 Ambulance Services: Air and Water 
5/1/11 
4/15/14 
CG-BEH-02 Applied Behavioral Analysis for Autism Spectrum Disorder 
3/1/14 
7/1/14 
CG-BEH-03 Psychiatric Disorder Treatment  
10/8/13  
10/14/14  
CG-BEH-04 Substance-Related and Addictive Disorder Treatment 
10/8/13  
10/14/14 
CG-BEH-05 Feeding and Eating Disorder Treatment  
10/8/13  
10/14/14  
CG-BEH-07 Psychological Testing  
10/8/13  
10/14/14  
CG-DME-06 Pneumatic Compression Devices for Lymphedema 
11/17/06 
5/17/14 
CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) 
9/17/11 
10/14/14  
CG-DME-10 Durable Medical Equipment 
5/7/07 
4/15/14 
CG-DME-31 Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems, and Power Operated Vehicles (POVs)s 
7/2/07 
4/15/14 
CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight 
4/21/10 
4/15/14 
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use 
7/2/07 
4/15/14 
CG-DRUG-03 Beta Interferons or Glatiramer Acetate for Treatment of Multiple Sclerosis 
5/17/14 
10/14/14 
CG-DRUG-05 Recombinant Erythropoietin Products 
4/25/08 
10/18/14 
CG-DRUG-08 Pharmacotherapy for Gaucher Disease 
7/2/07 
7/15/14 
CG-DRUG-09 Immune Globulin (Ig) Therapy  
8/24/07 
7/19/14 
CG-DRUG-11 Oral, Injectable and Topical Infertility Drugs 
1/23/10 
10/14/14 
CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs 
1/23/10 
ECD 11/15/14 
CG-DRUG-16 White Blood Cell Growth Factors 
5/7/10 
7/15/14 
CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel) 
10/24/08 
10/14/14 
CG-DRUG-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting 
10/24/08 
7/15/14 
CG-DRUG-27 Clostridial Collagenase Histolyticum Injection  
5/1/11 
7/15/14 
CG-DRUG-28 Alglucosidase alfa (Lumizyme®, Myozyme®)  
5/1/11 
10/14/14 
CG-MED-19 Custodial Care 
7/13/07 
4/15/14 
CG-MED-29 Inpatient Subacute Care 
7/13/07 
7/15/14 
CG-MED-31 Skilled Nursing Facility 
7/13/07 
10/14/14 
CG-MED-37 Intensive Programs for Pediatric Feeding Disorders 
1/23/10 
7/15/14 
CG-MED-43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) 
4/16/13 
7/19/14 
CG-MED-46 Ambulatory Electroencephalography 
11/9/13 
7/15/14 
CG-OR-PR-05 (was CG-DME-28) Myoelectric Upper Extremity Prosthetic Devices 
5/18/07 
4/15/14 
CG-REHAB-04 Physical Therapy 
12/15/06 
7/19/14 
CG-REHAB-05 Occupational Therapy 
3/9/07 
7/19/14 
CG-REHAB-06 Speech-Language Pathology Services [As of 07/16/11, National Account Members only]  
8/24/07 
5/19/14 
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) 
5/7/07 
4/15/14 
CG-REHAB-08 Private Duty Nursing in the Home Setting 
7/13/07 
4/15/14 
CG-REHAB-09 Acute Inpatient Rehabilitation  
7/2/07 
10/14/14  
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift 
5/18/07 
4/15/14 
CG-SURG-05 Maze Procedure 
12/8/12 
10/14/14  
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury 
9/17/11 
10/14/14 
CG-SURG-09 Temporomandibular Disorders 
9/17/11 
1/14/14 
CG-SURG-12 Penile Prosthesis Implantation 
8/24/07 
1/14/14 
CG-SURG-18 Septoplasty 
5/7/07 
8/16/14 
CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) 
5/1/11 
10/14/14 
CG-SURG-27 Gender Reassignment 
7/18/09 
10/14/14 
CG-SURG-28 Transcatheter Uterine Artery Embolization 
5/7/07 
2/15/14 
CG-SURG-30 Tonsillectomy for Children 
7/14/12 
1/14/14 
CG-SURG-33 Lumbar Fusion or Lumbar Intervertebral Disc (LAID) 
5/13/13 
4/15/14 
CG-SURG-34 Diagnostic Infertility Surgery  
5/1/14 
10/14/14 
CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)  
5/1/14 
10/14/14 
CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy 
1/1/14 
ECD 2/14/15 
CG-SURG-42 Cervical Fusion 
1/1/15 
1/1/15 
CG-TRANS-02 Kidney Transplantation 
11/17/06 
1/14/14 
     
Outpatient Sleep Testing and Therapy Services 
   
Effective 3/1/2013, the health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty Health, Inc. (AIM), a separate company. AIM’s Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines are available at http://www.aimspecialtyhealth.com/gowebsleep. For certain health plan members, AIM also provides sleep diagnostic and treatment management services.  
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us. 
Radiology  
   
The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health (AIM), a separate company. For certain health plan members as of 01/01/2011, AIM also provides radiology utilization management services. 
The health plan also develops Diagnostic Imaging Medical Policies which may address a service described in an AIM Diagnostic Imaging Clinical Guideline. Where such Medical Policy exists, the health plan Medical Policy supersedes the AIM Diagnostic Imaging Clinical Guideline. 
AIM's Diagnostic Imaging Clinical Guidelines are available at 
By clicking on the link to AIM above, you are now leaving our site and linking to a site created and/or maintained by AIM ("External Site"). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Site. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Site. The information contained on the External Site should not be interpreted as medical advice or treatment provided by us. 
 
Head & Neck Imaging 
   
CT of the Head 
4/1/11 
 
CTA of the Head: Cerebrovascular 
4/1/11 
 
MRI of the Head 
4/1/11 
 
MRA of the Head: Cerebrovascular 
4/1/11 
 
CT of the Orbit, Sella Turcica, Posterior Fossa and the Temporal Bone, including Mastoids 
4/1/11 
 
MRI of the Orbit, Face, Neck 
4/1/11 
 
CT of the Paranasal Sinus Maxillofacial Area 
4/1/11 
 
MRI of the Temporomandibular Joints 
4/1/11 
 
CT of the Neck (Soft Tissue) 
4/1/11 
 
CTA of the Neck 
4/1/11 
 
MRA of the Neck 
4/1/11 
 
     
Chest Imaging 
CT of the Chest 
4/1/11 
 
CTA of the Chest 
4/1/11 
 
MRI of the Chest 
4/1/11 
 
MRA of the Chest 
4/1/11 
 
     
Cardiac Imaging 
   
Nuclear Cardiology - Myocardial Perfusion Imaging 
4/1/11 
 
Nuclear Cardiology - Cardiac Blood Pool Imaging 
4/1/11 
 
Nuclear Cardiology - Infarct Imaging 
4/1/11 
 
Stress Echocardiography 
3/1/12 
 
Transesophageal Echocardiography (TEE) 
3/1/12 
 
Resting Transthoracic Echocardiography 
3/1/12 
 
CT Cardiac (Structure) 
4/1/11 
 
MRI – Cardiac 
4/1/11 
 
     
Abdominal & Pelvic Imaging 
   
CT of the Abdomen 
4/1/11 
 
MRI of the Abdomen 
4/1/11 
 
CTA/MRA of the Abdomen 
4/1/11 
 
CTA of the Abdominal Aorta - Lower Extremity Run-off 
4/1/11 
 
CT of the Pelvis 
4/1/11 
 
MRI of the Pelvis 
4/1/11 
 
CTA/MRA of the Pelvis 
4/1/11 
 
CT of the Abdomen & Pelvis Combination 
4/1/11 
 
     
Spine Imaging 
   
CT of the Cervical Spine 
4/1/11 
 
MRI of the Cervical Spine 
4/1/11 
 
CT of the Thoracic Spine 
4/1/11 
 
MRI of the Thoracic Spine 
4/1/11 
 
CT of the Lumbar Spine 
4/1/11 
 
MRI of the Lumbar Spine 
4/1/11 
 
     
Upper Extremity Imaging 
   
CT of the Upper Extremity 
4/1/11 
 
MRI of the Upper Extremity (Any Joint) 
4/1/11 
 
MRI of the Upper Extremity (Non-Joint) 
4/1/11 
 
CTA/MRA Upper Extremity 
4/1/11 
 
     
Lower Extremity Imaging 
   
CT of the Lower Extremity 
4/1/11 
 
MRI of the Lower Extremity (Joint & Non- Joint) 
4/1/11 
 
CTA/MRA of the Lower Extremity 
4/1/11 
 
     
 
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