Historical Medical Policies and Clinical UM 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 Medical Policies & Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
Historical Clinical 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 Medical Policies & Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
- CG-DME-16 Pressure Reducing Support Surfaces – Groups 1, 2 & 3
- CG-DME-31 Powered Wheeled Mobility Devices
- CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
- CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals
- CG-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies
- CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography
- 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