Medical Policies | Providers – Amerigroup

Medical Policies

As a wholly owned subsidiary of WellPoint, Inc. (WellPoint), Amerigroup adopted WellPoint’s nationally recognized, evidence-based medical policies and clinical utilization management guidelines effective May 1, 2013.1

These policies are publicly available at WellPoint’s 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, 20142, McKesson InterQual Level of Care criteria will be used only for medical necessity review for medical inpatient concurrent review, inpatient site of service appropriateness, home health and outpatient rehabilitation. WellPoint’s Behavioral Health Medical Policies and Clinical Utilization Management Guidelines will be used for all behavioral health reviews.3In all cases, Medicaid contracts or regulatory guidance, or 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.4

1These policies took effect on April 1, 2013, for HealthPlus, an Amerigroup Company.
2Effective January 1, 2014, for Amerigroup Community Care in Georgia: WellPoint Behavioral Health Medical Policies and Clinical Utilization Management Guidelines are used for all behavioral health reviews.
3This change applies only to states, covered populations and services for which Amerigroup provides behavioral health utilization management services and where the use of WellPoint’s Behavioral Health UM Guidelines is not superseded by regulatory or contractual requirements.
4Tennessee providers should also consult TennCare Rule 1200-13-16 for state-specific medical necessity criteria.

Clinical Utilization Management Guidelines

Approved and Adopted Effective May 28, 2014

The Clinical Utilization Management Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. Because of local practice patterns, claims systems and benefit designs vary; a local health plan may choose whether to implement a particular Clinical UM Guideline.

To see the full utilization management guidelines on the Amerigroup website, click the link above.

Guideline Number Clinical UM Guidelines name/title
CG-ANC-01 Ambulance Services: Ground
CG-ANC-04 Ambulance Services: Air and Water
CG-ANC-05 Ambulance Services: Ground; Emergent
CG-ANC-06 Ambulance Services: Ground; Non-Emergent
CG-BEH-01 Assessment 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 Abuse Treatment
CG-BEH-05 Eating Disorder Treatment
CG-BEH-06 Psychiatric Outpatient Treatment
CG-BEH-07 Psychological Testing
CG-DME-01 External (Portable) Continuous Insulin Infusion Pump
CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
CG-DME-05 Cervical Traction Devices for Home Use
CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
 CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric
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 Systems Groups 1, 2 &3
CG-DME-18 Home Oxygen Therapy
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-31 Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
CG-DME-33 Ultralight Wheelchair
CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
CG-DME-35 Breastfeeding Pumps
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-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 Collegenase (Xiaflex)
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®)
CG-DRUG-34 Docetaxel (Taxotere®)
CG-DRUG-38 Pemetrexed Disodium (Alimta®)
CG-DRUG-40 Bortezomib (Velcade®)
CG-DRUG-41 Zoledronic Acid
CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase)
CG-DRUG-45 Bone Graft Substitutes
CG-MED-08 Home Enteral Nutrition
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 (EMG/NCS)
CG-MED-28 Iontophoresis for Medical Indications
CG-MED-32 Ancillary Services for Pregnancy Complications
CG-MED-38 Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer
CG-MED-42 Maternity Ultrasound in the Outpatient Setting
CG-MED-43 Multiple Sleep Latency Testing (MLST) 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 Otoacoustic Emissions (OAEs) for Screening and Diagnosis of Hearing Disorders
CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials
CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
CG-OR-PR-05 Myoelectric Upper Extremity Prosthesis Devices
CG-REHAB-03 Pulmonary Rehabilitation
CG-REHAB-04 Physical Therapy
CG-REHAB-05 Occupational Therapy
CG-REHAB-06 Speech-Language Pathology Services
CG-REHAB-08 Private Duty Nursing in the Home Setting
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair and Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
CG-SURG-09 Temporomandibular Disorders
CG-SURG-12 Penile Prosthesis Implantation
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-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 Intervertebral Disc (LAID)
CG-SURG-36 Adenoidectomy
CG-SURG-38 Lumbar Laminectomy, Hemi-laminectomy, Laminectomy 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-TRANS-02
Kidney Transplantation