Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Colorado Form

Carelon Health, Inc. is a separate company providing care management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CO-BCBS-CM-009482-26-S2727 April 2026

Colorado Adopted Clinical Guidelines as of: May 1, 2026 NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered ‘Adopted’ for that ASO group only and for the specific type of review required.

Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.
State Clinical Guideline number
Clinical Guideline name

Original implementation date by Colorado
Special notes CO CG-ANC-04 Ambulance Services: Air and Water Ancillary/Miscellaneous 4/16/2013

CO CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome Behavioral Health 6/28/2018

CO CG-DME-06 Compression Devices for Lymphedema Durable Medical Equipment 4/15/2026

CO CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Durable Medical Equipment 4/1/2024

CO CG-DME-10 Durable Medical Equipment Durable Medical Equipment 7/1/2013

CO CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Durable Medical Equipment 3/1/2023

CO CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight Durable Medical Equipment 4/1/2024

CO CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
Durable Medical Equipment 5/1/2018

CO CG-DME-45 Ultrasound Bone Growth Stimulation Durable Medical Equipment 9/20/2018

CO CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting Durable Medical Equipment 12/1/2019

CO CG-DME-57 Lower Extremity Pressure Gradient Compression Stockings Durable Medical Equipment 11/1/2025 CO CG-DME-59 Self-Operated Spinal Unloading Devices Durable Medical Equipment 4/15/2026

CO CG-LAB-13 Skin Nerve Fiber Density Testing Laboratory 1/1/2023

CO CG-MED-26 Neonatal Levels of Care Medicine 8/12/2013

CO CG-MED-37 Intensive Programs for Pediatric Feeding Disorders Medicine 4/1/2017

CO CG-MED-59 Upper Gastrointestional Endoscopy in Adults Medicine 11/1/2018

CO CG-MED-65 Manipulation Under Anesthesia
Medicine 12/27/2017

CO CG-MED-68 Therapeutic Apheresis Medicine 12/27/2017

CO CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Medicine 9/20/2018

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Colorado
Special notes CO CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Medicine 1/1/2026 CO CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures Medicine 10/1/2024

CO CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing System Medicine 1/1/2019

CO CG-MED-81 Ultrasound Ablation for Oncologic Indications Medicine 5/1/2023

CO CG-MED-83 Site of Care: Specialty Pharmaceuticals Medicine 4/23/2019

CO CG-MED-89 Home Parenteral Nutrition Medicine 11/1/2021

CO CG-MED-97 Biofeedback and Neurofeedback Medicine 12/1/2024

CO CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease Medicine 6/1/2025 CO CG-MED-99 Intradialytic Parenteral Nutrition Medicine 11/1/2025

CO CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine Medicine 11/1/2025

CO CG-MED-101 Home Hospice Medicine 11/1/2025

CO CG-MED-102 Dichoptic Digital Therapy for Amblyopia Previously Titled: Digital Therapy Devices for Treatment of Amblyopia Medicine 11/1/2025

CO CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices Orthotics/Prosthetics 4/15/2014

CO CG-RAD-29 X-rays for Low Back Pain Radiology 1/1/2026 CO CG-RAD-30 Non-Obstetrical Transvaginal Ultrasonography Radiology 4/15/2026

CO CG-RAD-31 Three-Dimensional (3-D) Rendering of Imaging Studies Radiology 4/15/2026

CO CG-RAD-32 Bone Mineral Density Testing Measurement Radiology 4/15/2026

CO CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
Rehabilitation 4/16/2013

CO CG-REHAB-08 Private Duty Nursing in the Home Setting Rehabilitation 4/16/2013

CO CG-SURG-12 Penile Prosthesis Implantation
Surgery 1/8/2013

CO CG-SURG-29 Lumbar Discography
Surgery 5/13/2013

CO CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver Surgery 12/27/2017

CO CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018

CO CG-SURG-79 Implantable Infusion Pumps
Surgery 6/28/2018

CO CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
Surgery 9/20/2018

CO CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
Surgery 9/20/2018

CO CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/2018

CO CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Surgery 1/1/2023

CO CG-SURG-88 Mastectomy for Gynecomastia
Surgery 9/20/2018

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Colorado
Special notes CO CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
Surgery 8/29/2018

CO CG-SURG-92 Paraesophageal Hernia Repair Surgery 6/1/2020

CO CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Surgery 3/21/2019

CO CG-SURG-99
Panniculecomy and Abdominoplasty Surgery 5/9/2019

CO CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus Surgery 9/4/2019

CO CG-SURG-105 Corneal Collagen Cross-Linking Surgery 2/5/2020

CO CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone Surgery 2/5/2020

CO CG-SURG-108 Stereotactic Radiofrequency Pallidotomy Surgery 4/15/2020

CO CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) Surgery 10/1/2024

CO CG-SURG-120 Vagus Nerve Stimulation Surgery 10/1/2024

CO CG-SURG-125 Canaloplasty Surgery 9/1/2025 CO CG-SURG-126 Tibial Nerve Stimulation Surgery 11/1/2025

CO CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses Surgery 11/1/2025

CO CG-SURG-129 Internal Rib Fixation Systems Surgery 1/1/2026

CO CG-TRANS-02 Kidney Transplantation Transplants 1/8/2013

THIRD PARTY CRITERIA ADOPTED: The health plan may use guidelines developed by third parties to perform utilization management services of some procedures for certain health plan members. Carelon Medical Benefits Management
To view Carelon Medical Benefits Management Guidelines, please visit the Carelon Specialty Health® site that contains links to Anthem programs: https://guidelines.carelonmedicalbenefitsmanagement.com
You may also call Carelon Medical Benefits Management Guidelines toll-free: 877-291-0366, 9 am to 7 pm CST, Monday to Friday.
Health Plan implementation of Carelon Specialty Health Guidelines are listed below. By clicking on the Carelon link above, you will be linked to a site created and/or maintained by another separate entity (“External Site”). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites.

Carelon Medical Benefits Management Guideline Health Plan
Implementation Date

CO Carelon Medical Benefits Management Carelon Site of Service Medical Necessity Reviews for upper and lower endoscopy procedures 6/1/2020

CO Carelon Medical Benefits Management Carelon Rehabilitative Services 4/1/2020

CO Carelon Medical Benefits Management Carelon Clinical Appropriateness Guidelines for Radiology (Adult & Pediatric)
9/1/2017

CO Carelon Medical Benefits Management Carelon Clinical Appropriateness Guidelines for Sleep Disorder Management
11/1/2012

CO Carelon Medical Benefits Management Carelon Musculoskeletal Clinical Appropriateness Guidelines: Spine Surgery, Joint Surgery, and Interventional Pain Management
1/1/2019

CO Carelon Medical Benefits Management Carelon Level of Care Guidelines for Musculoskeletal Surgery and Procedures
1/1/2019

CO Carelon Medical Benefits Management Carelon Preoperative Admission Guidelines for Musculoskeletal Surgery and Procedures
1/1/2019

CO Carelon Medical Benefits Management Carelon Cardiology Clinical Appropriateness Guidelines: Advanced
Imaging of the Heart, Arterial Ultrasound, Percutaneous Coronary
Intervention, and Diagnostic Coronary Angiography
3/1/2016

CO Carelon Medical Benefits Management Carelon Radiation Oncology Clinical Appropriateness Guidelines: Radiation Oncology includes brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS)
11/1/2012

CO Carelon Medical Benefits Management Carelon Sleep Clinical Appropriateness Guidelines 11/1/2012

CO Carelon Medical Benefits Management Surgical Clinical Site of Care 12/1/2020

CO Carelon Medical Benefits Management Rehabilitation Clinical Site of Care 8/1/2021

CO Carelon Medical Benefits Management Carelon Musculoskeletal Program Site of Care 1/1/2022

CO MCG Care Guidelines MCG Care Guidelines: Anthem licenses and utilizes MCG care guidelines to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving precertification, inpatient review, level of care, discharge planning and retrospective review. The MCG care guidelines licensed include:
(1) Inpatient & Surgical Care (ISC) (2)
General Recovery Care (GRG) (3)
Recovery Facility Care (RFC) (4)
Chronic Care (CC) (5)
Behavioral Health Care Guidelines (BHG)

• Original Implementation Date by state - this is the original implementation date by the health plan For a complete listing of Anthem Medical Policies and Clinical UM Guidelines, please go to: Anthem Provider site > select your state> Scroll down page, click “See Policies and Guidelines”