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.00025 Self-Operated Spinal Unloading Devices
- SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00165 Histotripsy
- TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
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-31 Powered Wheeled Mobility Devices
- CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals
- CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
- CG-MED-69 Inhaled Nitric Oxide
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention