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.
- ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
- LAB.00039 Pooled Antibiotic Sensitivity Testing
- MED.00125 Biofeedback and Neurofeedback
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00121 Transcatheter Heart Valve Procedures
- TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
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.