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.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
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.