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.
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00071 Percutaneous and Endoscopic Spinal Surgery
- SURG.00120 Internal Rib Fixation Systems
- SURG.00126 Irreversible Electroporation
- SURG.00142 Genicular Procedures for Treatment of Knee Pain
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-MED-26 Neonatal Levels of Care
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity