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.
- DME.00044 Wheelchair Mounted Robotic Arm
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
- SURG.00079 Nasal Valve Suspension
- SURG.00119 Endobronchial Valve Devices
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
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.
- CG-DME-13 Lower Limb Prosthesis
- CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses
- CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-GENE-13 Genetic Testing for Inherited Diseases
- CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
- CG-SURG-01 Colonoscopy