May 2025 Clinical Utilization Management Guidelines Form

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. INBCBS-CD-095125-25-CPN94067 | December 2025 Clinical Utilization Management Criteria

Indiana | Anthem Blue Cross and Blue Shield | Serving Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging

Attached is a list of the Clinical Utilization Management (UM) Criteria Anthem has adopted. Non-customized national clinical guidelines (MCG) will continue to be the primary source of UM criteria.

The list of adopted Medical Policies and Clinical UM Guidelines is publicly available on the Medical Policy and Clinical UM Guideline subsidiary website. Their purpose is to help you provide quality care by reducing inappropriate use of medical resources.

The Anthem Clinical UM Guideline hierarchy for Medicaid in Indiana can be found here.

Note: We make determinations of medical necessity on a case-by-case basis in accordance with the Medicaid Clinical UM Guideline hierarchy for Indiana. If the request does not meet established criteria guidelines, it will be referred to the licensed physician reviewer for Indiana with the appropriate clinical expertise to make a decision.

The Clinical Utilization Management Criteria below, that are indicated as new, were adopted by the Medical Operations Committee for Medicaid members.

To view the criteria below, select the link in the Criteria Title column. For additional information regarding our Medical Policies and Clinical UM Guidelines, visit Provider Medical Policies | Anthem.com.

Criteria number
Criteria title
New item
CG-ANC -04 Ambulance Services: Air and Water

CG-ANC -07 Inpatient Interfacility Transfers

CG-DME-10 Durable Medical Equipment

Clinical Utilization Management Criteria Page 2 of 2

Criteria number
Criteria title
New item
CG-DME-13 Lower Limb Prosthesis

CG-DME-26 Back -Up Ventilators in the Home Setting

CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

New
CG-MED-69 Inhaled Nitric Oxide

CG-SURG -82 Bone -Anchored and Bone Conduction Hearing Aids

CG-SURG -95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence

CG-SURG -120 Vagus Nerve Stimulation

CG-SURG -121 Fetal Surgery for Prenatally Diagnosed Malformations

CG-SURG -127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

New
ADMIN.00006
Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline

ANC.00007
Cosmetic and Reconstructive Services: Skin Related

ANC.00009
Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

LAB.00046
Testing for Biochemical Markers for Alzheimer’s Disease

New
RAD.00034
Dynamic Spinal Visualization (Including Digital Motion X - ray and Cineradiography/ Videofluoroscopy)