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.
- LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00112 Autonomic Testing
- MED.00140 Gene Therapy for Beta Thalassemia
- RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00157 Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
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.