Medi-Cal Managed Care
L.A. Care
Medi-Cal Access Program
Major Risk Medical Insurance Program
Clinical Utilization Management (UM) Guidelines
Effective [August 1, 2016], the Clinical Utilization Management Guidelines listed below were
adopted by the medical operations committee for the Government Business Division.
To see the full UM Guidelines, visit the Medical Policies and Clinical UM Guidelines page.
Guideline number:
CG-ANC-04
CG-ANC-05
CG-ANC-06
CG-BEH-01
CG-BEH-02
CG-BEH-03
CG-BEH-04
CG-BEH-05
CG-BEH-07
CG-BEH-09
CG-BEH-10
CG-BEH-11
CG-BEH-12
CG-BEH-13
CG-BEH-14
CG-DME-01
CG-DME-03
CG-DME-05
CG-DME-07
CG-DME-08
CG-DME-09
CG-DME-10
CG-DME-12
CG-DME-13
CG-DME-15
CG-DME-16
CG-DME-18
CG-DME-19
CG-DME-20
CG-DME-21
Clinical UM Guidelines name/title:
Ambulance services: air and water
Ambulance services: ground; emergent
Ambulance services: ground; nonemergent
Assessment for autism spectrum disorders and Rett Syndrome
Adaptive behavioral treatment for autism spectrum disorder
Psychiatric disorder treatment
Substance-related and addictive disorder treatment
Eating and feeding disorder treatment
Psychological testing
Assertive community treatment (ACT)
Basic skills training/social skills training
Mental health support services
Psychosocial rehabilitation services
Targeted case management (TCM)
Intensive in-home behavioral health services
External (portable) continuous insulin infusion pump
Neuromuscular stimulation in the treatment of muscle atrophy
Cervical traction devices for home use
Augmentative and alternative communication (AAC) devices/speech
generating devices (SGD)
Infant home apnea monitors
Continuous local delivery of analgesia to operative sites using an elastomeric
infusion pump during the post-operative period
Durable medical equipment
Home phototherapy devices for neonatal hyperbilirubinemia
Lower limb prosthesis
Hospital beds and accessories
Pressure reducing support systems groups one, two and three
Home oxygen therapy
Therapeutic shoes, inserts or modifications for individuals with diabetes
Orthopedic footwear
External infusion pumps for the administration of drugs in the home or
residential care settings
https://mediproviders.anthem.com/ca
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are
independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue
Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan
to provide Medi-Cal Managed Care services in Los Angeles County.
WEBPACA-0014-16 August 2016
Anthem Blue Cross
UM guidelines
August 2016
Page 2 of 5
Guideline number:
CG-DME-22
CG-DME-23
CG-DME-24
CG-DME-25
CG-DME-31
CG-DME-33
CG-DME-34
CG-DME-35
CG DME-36
CG-DME-37
CG DME-38
CG-DME-39
CG-DRUG-01
CG-DRUG-03
CG-DRUG-04
CG-DRUG-05
CG-DRUG-07
CG-DRUG-08
CG-DRUG-09
CG-DRUG-11
CG-DRUG-13
CG-DRUG-15
CG-DRUG-16
CG-DRUG-19
CG-DRUG-20
CG-DRUG-21
CG-DRUG-24
CG-DRUG-27
CG-DRUG-28
CG-DRUG-29
CG-DRUG-30
CG-DRUG-33
CG-DRUG-34
CG-DRUG-38
Clinical UM Guidelines name/title:
Ankle-foot orthotics and knee-ankle-foot orthotics (braces)
Lifting devices for use in the home
Wheeled mobility devices: manual wheelchairs – lightweight, standard or
heavy duty
Seat lift mechanisms
Wheeled mobility devices: wheelchairs – powered/motorized, with or
without power seating systems and power operated vehicles (POVs)
Wheeled mobility devices: manual wheelchairs – ultra lightweight
Wheeled mobility devices: wheelchair accessories
Breastfeeding pumps
Pediatric gait trainers
Air conduction hearing aids
Continuous interstitial glucose monitoring
Dynamic low-load prolonged-duration stretch
Off-label drug and approved orphan drug use
Beta interferons and glatiramer acetate for treatment of multiple sclerosis
Use of low molecular weight heparin therapy, fondaparinux (Arixtra®) and
direct thrombin inhibitors in the outpatient setting
Recombinant erythropoietin products
Hepatitis C pegylated interferon antiviral therapy (archived April 5, 2016)
Enzyme replacement therapy for Gaucher disease
Immune globulin (Ig) therapy
Infertility drugs
Hepatitis B interferon antiviral therapy
Gonadotropin releasing hormone analogs
White blood cell growth factors
Progesterone therapy as a technique to prevent preterm delivery in high-risk
women
Enfuviritide (Fuzeon)
Naltrexone (Vivitrol®) injections for the treatment of alcohol and opioid
dependence
Repository corticotropin injection (H.P. Acthar® gel)
Clostridial collagenase histolyticum injection
Alglucosidase alfa (Lumizyme®, Myozyme®)
Hyaluronan injections in the knee
Oprelvekin (Neumega)
Palonosetron (Aloxi®)
Docetaxel (Docefrez™, Taxotere®)
Pemetrexed disodium (Alimta®)
Anthem Blue Cross
UM guidelines
August 2016
Page 3 of 5
Guideline number:
CG-DRUG-40
CG-DRUG-41
CG-DRUG-42
CG-DRUG-43
CG-DRUG-44
CG-DRUG-45
CG-DRUG-46
CG-DRUG-47
CG-DRUG-48
CG-DRUG-49
CG-DRUG-50
CG-DRUG-51
CG-DRUG-52
CG-DRUG-53
CG-LAB-09
CG-MED-08
CG-MED-21
CG-MED-22
CG-MED-23
CG-MED-24
CG-MED-28
CG-MED-32
CG-MED-38
CG-MED-42
CG-MED-44
CG-MED-45
CG-MED-46
CG-MED-47
CG-MED-48
CG-MED-49
CG-MED-50
CG-MED-51
CG-MED-52
CG-MED-53
CG-MED-54
CG-OR-PR-04
CG-OR-PR-05
Clinical UM Guidelines name/title:
Bortezomib (Velcade®)
Zoledronic acid
Asparagine-specific enzymes (Asparaginase)
Natalizumab (Tysabri®)
Pegloticase (Krystexxa®)
Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
Fosaprepitant (Emend®)
Level-of-care: specialty pharmaceuticals
Azacitidine (Vidaza®)
Doxorubicin hydrochloride liposome injection
Paclitaxel, protein-bound (Abraxane®)
Romidepsin (Istodax®)
Temsirolimus (Torisel®)
Drug dosage, frequency and route of administration
Drug testing or screening in the context of substance use disorder and
chronic pain
Home enteral nutrition
Anesthesia services and moderate (conscious) sedation
Neuropsychological testing
Home health
Electromyography and nerve conduction studies
Iontophoresis for medical indications
Ancillary services for pregnancy complications
Inpatient admission for radiation therapy for cervical or thyroid cancer
Maternity ultrasound in the outpatient setting
Holter monitors
Transrectal ultrasonography
Ambulatory and inpatient video electroencephalography
Fundus photography
Scrotal ultrasound
Auditory brainstem responses (ABRs) and evoked otoacoustic emissions
(OAEs) for hearing disorders
Visual, somatosensory and motor evoked potentials
Three-dimensional rendering of imaging studies
Allergy immunotherapy (subcutaneous)
Cervical cancer screening for women under 21 years of age
Strapping
Cranial remodeling bands and helmets (cranial orthotics)
Myoelectric upper extremity prosthesis devices
Anthem Blue Cross
UM guidelines
August 2016
Page 4 of 5
Guideline number:
CG-REHAB-03
CG-REHAB-04
CG-REHAB-05
CG-REHAB-06
CG-REHAB-08
CG-SURG-03
CG-SURG-05
CG-SURG-09
CG-SURG-12
CG-SURG-18
CG-SURG-24
CG-SURG-25
CG-SURG-27
CG-SURG-30
CG-SURG-31
CG-SURG-32
CG-SURG-33
CG-SURG-36
CG-SURG-38
CG-SURG-39
CG-SURG-40
CG-SURG-41
CG-SURG-42
CG-SURG-43
Clinical UM Guidelines name/title:
Pulmonary rehabilitation
Physical therapy
Occupational therapy
Speech-language pathology services
Private duty nursing in the home setting
Blepharoplasty, blepharoptosis repair and brow lift
Maze procedure
Sacral nerve stimulation as a treatment of neurogenic bladder secondary to
spinal cord injury
Temporomandibular disorders
Penile prosthesis implantation
Septoplasty
Functional endoscopic sinus surgery (FESS)
Injection treatment for Morton's neuroma
Sex reassignment surgery
Tonsillectomy, with or without adenoidectomy for children
Treatment of keloids and scar revision
Pain management: cervical, thoracic and lumbar facet injections
Lumbar fusion and lumbar total disc arthroplasty (TDA)
Adenoidectomy
Lumbar laminectomy, hemi-laminectomy, laminectomy and/or discectomy
Pain management: epidural steroid injections
Cataract removal surgery for adults
Surgical strabismus correction
Cervical fusion
Knee arthroscopy
CG-SURG-44
Coronary angiography in the outpatient setting
CG-SURG-45
CG-SURG-46
CG-SURG-47
CG-SURG-48
Bone graft substitutes
Myringotomy and tympanostomy tube insertion
Surgical interventions for scoliosis and spinal deformity
Elective percutaneous coronary interventions (PCI)
Endovascular techniques (percutaneous or open exposure) for arterial
revascularization of the lower extremities
Assistant surgeons
Outpatient cystourethroscopy
Level-of-care: hospital-based ambulatory surgical procedures, including
endoscopic procedures
Elective total hip arthroplasty
Elective total knee arthroplasty
CG-SURG-08
CG-SURG-49
CG-SURG-50
CG-SURG-51
CG-SURG-52
CG SURG-53
CG SURG -54
Anthem Blue Cross
UM guidelines
August 2016
Page 5 of 5
Guideline number:
CG-SURG-55
CG-THER-RAD-01
CG-THER-RAD-02
CG-TRANS-02
Clinical UM Guidelines name/title:
Intracardiac electrophysiological studies (EPS) and catheter ablation
Fractionation and radiation therapy in the treatment of specified cancers
Special radiation physics consult and treatment procedure
Kidney transplantation