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Clinical UM Guidelines 
 
The “Last Review Date” set forth in the clinical UM guideline is the most recent date the Medical Policy and Technology Assessment Committee has reviewed or revised the clinical UM guideline. This is not necessarily coincident with the “Current Effective Date" which is also shown on the clinical UM guideline. For example, we may require lead time in order to program a clinical UM guideline on our claims systems. In cases where a new or revised clinical UM guideline results in the denial of benefits for services which have historically been covered, we may opt to provide advance notice of the changes prior to the clinical UM guideline taking effect. To confirm the effective date of a particular clinical UM guideline for your state or region, please contact us.  
 
 
Ancillary, Miscellaneous  
CG-ANC-03 Acupuncture
CG-ANC-04 Ambulance Services: Air and Water
CG-ANC-05 Ambulance Services: Ground; Emergent
CG-ANC-06 Ambulance Services: Ground; Non-Emergent
 
Behavioral Health  
CG-BEH-01 Screening and Testing for Autism Spectrum Disorders and Rett Syndrome
CG-BEH-02 Applied Behavioral Analysis for Autism Spectrum Disorder
CG-BEH-03 Psychiatric Disorder Treatment
CG-BEH-04 Substance-Related and Addictive Disorder Treatment
CG-BEH-05 Feeding and Eating Disorder Treatment
CG-BEH-07 Psychological Testing
CG-BEH-09 Assertive Community Treatment (ACT)
CG-BEH-10 Basic Skills Training/Social Skills Training
CG-BEH-11 Mental Health Support Services
CG-BEH-12 Psychosocial Rehabilitation Services
CG-BEH-13 Targeted Case Management (TCM)
 
Durable Medical Equipment  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
2012 AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines available at http://www.aimspecialtyhealth.com/gowebsleep  
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.  
 
CG-DME-01 External (Portable) Continuous Insulin Infusion Pump
CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
CG-DME-05 Cervical Traction Devices for Home Use
CG-DME-06 Pneumatic Compression Devices for Lymphadema
CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
CG-DME-08 Infant Home Apnea Monitors
CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump During the Post-Operative Period
CG-DME-10 Durable Medical Equipment
CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia
CG-DME-13 Lower Limb Prosthesis
CG-DME-15 Hospital Beds and Accessories
CG-DME-16 Pressure Reducing Support Surfaces - 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
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-26 Back-Up Ventilators in the Home Setting
CG-DME-30 Prothrombin Time Self-Monitoring Devices
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
 
 
Prescription Drugs  
CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use
CG-DRUG-03 Beta Interferons or 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
CG-DRUG-08 Pharmacotherapy 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-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults
CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs
CG-DRUG-16 White Blood Cell Growth Factors
CG-DRUG-18 Nesiritide (Natrecor®)
CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women
CG-DRUG-20 Enfuvirtide (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-25 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
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-31 Oncology Drug Treatment Regimens for Adults **NOTE: At this time, this guideline is not implemented for medical benefit determinations
CG-DRUG-32 HCV and HIV-AIDS Anti-Viral Drug Treatment Regimens **NOTE: At this time, this guideline is not implemented for medical benefit determinations
 
 
Laboratory/Pathology  
CG-LAB-03 Tropism Testing for HIV Management
CG-LAB-09 Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain
 
 
Medicine  
The health plan uses sleep diagnostic and treatment guidelines developed by AIM Specialty HealthSM (AIM), a separate company. For certain health plan members, AIM also provides sleep diagnostic and treatment utilization management services.  
2012 AIM Obstructive Sleep Apnea Diagnostic & Treatment Management Guidelines available at http://www.aimspecialtyhealth.com/gowebsleep  
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.  
 
CG-MED-02 Esophageal pH Monitoring
CG-MED-05 Ketogenic Diet for Treatment of Intractable Seizures
CG-MED-08 Home Enteral Nutrition
CG-MED-19 Custodial Care
CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
CG-MED-22 Neuropsychological Testing
CG-MED-23 Home Health
CG-MED-24 Electromyography and Nerve Conduction Studies
CG-MED-26 Neonatal Levels of Care
CG-MED-28 Iontophoresis for Medical Indications
CG-MED-29 Inpatient Subacute Care
CG-MED-31 Skilled Nursing Facility Services
CG-MED-32 Ancillary Services for Pregnancy Complications
CG-MED-34 Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
CG-MED-35 Retinal Telescreening Systems
CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry
CG-MED-40 Ambulatory Event Monitors to Detect Cardiac Arrhythmias
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CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
CG-MED-42 Maternity Ultrasound in the Outpatient Setting
CG-MED-43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT)
CG-MED-44 Holter Monitors
CG-MED-45 Transrectal Ultrasonography
CG-MED-46 Ambulatory Electroencephalography
CG-MED-47 Fundus Photography
CG-MED-48 Scrotal Ultrasound
CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otacoustic Emissions (OAEs) for Hearing Disorders
CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials
 
 
Orthotics/Prosthetics  
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
CG-OR-PR-03 Custom-made Knee Braces
CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
 
 
Radiology  
The health plan uses diagnostic imaging management guidelines developed by AIM Specialty Health (AIM), a separate company. For certain health plan members, 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 http://www.aimspecialtyhealth.com/marketing/guidelines/185/index.html
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. 
 
 
Rehabilitation Therapy  
CG-REHAB-02 Cardiac Rehabilitation (Outpatient)
CG-REHAB-03 Pulmonary Rehabilitation
CG-REHAB-04 Physical Therapy
CG-REHAB-05 Occupational Therapy
CG-REHAB-06 Speech-Language Pathology Services
CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
CG-REHAB-08 Private Duty Nursing in the Home Setting
CG-REHAB-09 Acute Inpatient Rehabilitation
 
 
Surgery  
CG-SURG-01 Colonoscopy
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib (VEPTR)
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
CG-SURG-09 Temporomandibular Disorders
CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
CG-SURG-11 Surgical Treatment for Dupuytren's Contracture
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-15 Endometrial Ablation
CG-SURG-17 Trigger Point Injections
CG-SURG-18 Septoplasty
CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
CG-SURG-25 Injection Treatment for Morton’s Neuroma
CG-SURG-27 Gender Reassignment Surgery
CG-SURG-28 Transcatheter Uterine Artery Embolization
CG-SURG-29 Lumbar Discography
CG-SURG-30 Tonsillectomy for Children
CG-SURG-31 Treatment of Keloids and Scar Revision
CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar Facet Injections
CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intevertebral Disc (LAID)
CG-SURG-34 Diagnostic Infertility Surgery
CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
CG-SURG-36 Adenoidectomy
CG-SURG-37 Destruction of Pre-Malignant Skin Lesions
CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
CG-SURG-39 Pain Management: Epidural Injections for Pain Relief
CG-SURG-40 Cataract Removal Surgery for Adults
CG-SURG-41 Surgical Strabismus Correction
CG-SURG-42 Cervical Fusion
CG-SURG-43 Knee Arthroscopy
CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the Outpatient Setting
 
Transplant  
CG-TRANS-02 Kidney Transplantation
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Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.