Historical Medical Policies and Clinical Utilization Management Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Utilization Management Clinical Criteria List – this document lists the North Carolina Healthy Blue utilization management criteria that has been adopted. Implementation dates of the most current versions vary per state notification requirements.
- LAB.00045 Selected Tests for the Evaluation and Management of Infertility
- MED.00145 Digital Therapy Devices for Treatment of Amblyopia
- OR-PR.00008 Osseointegrated Limb Prostheses
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
- SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- TRANS.00008 Liver Transplantation
Historical Clinical Utilization Management (UM) Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Utilization Management Clinical Criteria List – this document lists the North Carolina Healthy Blue utilization management criteria that has been adopted. Implementation dates of the most current versions vary per state notification requirements.