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.00026 Systems Pathology Testing for Prostate Cancer
- LAB.00039 Pooled Antibiotic Sensitivity Testing
- LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00140 Gene Therapy for Beta Thalassemia
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00097 Scoliosis Surgery
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- 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.
- CG-DME-42 Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-DME-50 Automated Insulin Delivery Systems
- CG-GENE-13 Genetic Testing for Inherited Diseases
- CG-GENE-18 Genetic Testing for TP53 Mutations
- CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing
- CG-MED-68 Therapeutic Apheresis
- CG-MED-94 Vestibular Function Testing
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-70 Gastric Electrical Stimulation
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-94 Keratoprosthesis
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention