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.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
- SURG.00121 Transcatheter Heart Valve Procedures
- TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
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-LAB-21 Serum Iron Testing
- CG-MED-40 External Ambulatory Cardiac Monitors
- CG-MED-68 Therapeutic Apheresis
- CG-MED-101 Home Hospice
- CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
- CG-SURG-90 Mohs Micrographic Surgery
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-126 Tibial Nerve Stimulation
- CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses