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.
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
- SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema
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.