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CUSTOMIZATION TOCARE GUIDELINES24th EDITIONIssue Date:January 20, 2021Original Date:February 21, 2020This document provides a high level summary of customizations and modifications to MCG CareGuidelines, collectively, “customized guidelines.”1234 The five (5) MCG products licensed include thefollowing: Behavioral Health Care (BHG) Chronic Care (CCG) General Recovery Care (GRG) Inpatient & Surgical Care (ISC) Recovery Facility Care (RFC)INDEX (CTRL Click to follow link)CUSTOMIZATIONS – BACKGROUND INFORMATIONCUSTOMIZATIONS TO MCG CRITERIA Inpatient & Surgical Care (ISC) General Recovery Care (GRG) Behavioral Health Care (BHG)CUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINE Inpatient & Surgical Care (ISC) General Recovery Care (GRG) Behavioral Health Care (BHG)CUSTOMIZATION HISTORY1Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in thecustomized guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan,including specific exclusions and limitations, as well as applicable state and/or federal law. The customizedguidelines do not constitute plan authorization or a guarantee of payment, nor are they an explanation of benefits.2We reserve the right to review and modify the MCG care guidelines or customized guidelines at any time.3No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by anymeans, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.4Original Issue Date: February 21, 2020 for MCG care guidelines 24th edition and corresponding customizedguidelines.Issue Date: January 20, 2021 R3Page 1 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS – BACKGROUND INFORMATIONTypes of CustomizationsCustomizations are most often done to align with existing medical policy documents or to refer a user tothird party guidelines, such as AIM Specialty Health. Original MCG criteria may be customized when aseparate medical policy document is not appropriate.In addition to customization in clinical criteria, other changes may be made to MCG care guidelines such asadding references, revising coding, or noting length of stay based on mandates.Review and Approval of CustomizationsThe Medical Policy & Technology Assessment Committee (MPTAC) reviews and approves new editions ofMCG care guidelines and customizations to revise MCG clinical indications.DisclaimerCustomized guidelines include a disclaimer at the top of the guideline after the guideline title indicating:This guideline contains custom content that has been modified from the standard care guidelines and hasnot been reviewed or approved by MCG Health, LLC.Guideline HistoryCustomized guidelines include a “Guideline History” section that provides (1) the date of the Medical Policy& Technology Assessment Committee (MPTAC) meeting review and approval of the customization, and(2) a summary of the customization to the MCG care guidelines.Return to IndexCUSTOMIZATIONS TO MCG CRITERIACUSTOMIZATIONS TO MCG CRITERIAInpatient & Surgical Care (ISC)1.2.3.4.MCG GuidelineISC Common Complicationsand Conditions Preoperative Days (W0130)ISC Gastroenterology Gastrointestinal Bleeding,Upper (W0170)ISC GastroenterologyObservation Care GuidelinesGastrointestinal Bleeding,Upper: Observation Care(W0171)ISC General Surgery –Mastectomy, Complete(W0002) 5.ISC General Surgery Mastectomy, Complete, withInsertion of Breast Prosthesisor Tissue Expander (W0022)Issue Date: January 20, 2021 R3 CustomizationClinical Indications for Inpatient Care: For inpatient preoperative days, addedindication, bridging anticoagulation that requires inpatient treatmentReference: AddedClinical Indications for Admission to Inpatient Care: Revised the Hemoglobin;Systolic blood pressure; Pulse; Melena; Orthostatic hypotension; and BUNcriteriaReference and Footnote: AddedObservation Care Admission Criteria: Revised the systolic blood pressure andhemoglobin criteria. Added melena or hematochezia and suspected history ofbleeding.Clinical Indications for Procedure: For risk-reduction mastectomy andsignificantly elevated risk of breast cancer, added indicationsGoal Length of Stay: Revised Goal Length of Stay (GLOS) to indicate 2 dayspostoperative rather than AmbulatoryAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableReferences: AddedClinical Indications for Procedure: For risk-reduction mastectomy andsignificantly elevated risk of breast cancer, added indicationsGoal Length of Stay: Revised Goal Length of Stay (GLOS) to indicate 2 dayspostoperative rather than Ambulatory or 1 day postoperativePage 2 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS TO MCG CRITERIAInpatient & Surgical Care (ISC)MCG Guideline 6.7.8.9.10.11.ISC General Surgery Mastectomy, Complete, withTissue Flap Reconstruction(W0023)ISC General Surgery Mastectomy, Partial(Lumpectomy) (W0008)ISC Hematology - Oncology Chemotherapy (W0162)ISC Neonatology –Newborn Care, Routine(W0087)ISC Neonatology –Newborn Care, Term, withSevere Illness or Abnormality(W0106)ISC OB / GYN Cesarean Delivery (W0045) 12.13.ISC OB / GYN Hysterectomy, Abdominal(W0109)ISC OB / GYN Hysterectomy, Laparoscopic 14.15.Title change to:Hysterectomy, Laparoscopic;Hysterectomy, Vaginal,Laparoscopically-Assisted(W0010)ISC OB / GYN Hysterectomy, Vaginal(W0110)ISC OB / GYN Laparoscopic GynecologicSurgery, IncludingMyomectomy, Oophorectomy,and Salpingectomy (W0026) Issue Date: January 20, 2021 R3CustomizationAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableReferences: AddedClinical Indications for Procedure: For risk-reduction mastectomy andsignificantly elevated risk of breast cancer, added indicationsAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableReferences: AddedGoal Length of Stay: Revised Goal Length of Stay (GLOS) to indicate 2 dayspostoperative rather than AmbulatoryAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableClinical Indications for Admission: Added examples for aggressive hydrationneeds that cannot be managed in an infusion center, prolonged marrowsuppression. Added Regimens that cannot be managed as an outpatient withexamplesReferences: AddedFootnotes: AddedAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableClinical Indications for Admission to Inpatient Care: Changed “Higher-levelneonatal care (ie, other than Level I nursery)” is needed to indicate “Inpatientneonatal care” is neededSee CG-MED-26 Neonatal Levels of Care to determine nursery level forneonates meeting admission and continued stay criteriaClinical Indications for Procedure: Added clinical indications for early electivecesarean delivery. Revised MCG clinical indications for elective cesareandeliveryAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableReferences: AddedCodes: Additional ICD-10 diagnosis codes may applyClinical Indications for Procedure: Revised criteria for abnormal uterinebleeding, leiomyoma (“fibroid”), pelvic organ prolapseAdded information for when hysterectomy is considered not medicallynecessaryClinical Indications for Procedure: Revised criteria for abnormal uterinebleeding, leiomyoma (“fibroid”), pelvic organ prolapseAdded information for when hysterectomy is considered not medicallynecessaryClinical Indications for Procedure: Revised criteria for abnormal uterinebleeding, leiomyoma (“fibroid”), pelvic organ prolapseAdded information for when hysterectomy is considered not medicallynecessaryClinical Indications for Procedure: Revised criteria for oophorectomy orexcision of adnexal mass neededFor laparoscopic surgical ablation of uterine fibroids, see SURG.00077 UterineFibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image GuidedTechniques.For the evaluation of infertility, see CG-SURG-34 Diagnostic InfertilitySurgeryPage 3 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS TO MCG CRITERIAInpatient & Surgical Care (ISC)16.17.MCG GuidelineISC OB / GYN Laparotomy, for GynecologicSurgery, IncludingMyomectomy, Oophorectomy,and Salpingectomy (W0025)ISC OB / GYN Vaginal Delivery (W0047) 18.19. ISC OB / GYN Vaginal Delivery, Operative(W0048) ISC Pediatrics –Diabetes, Pediatric (W0117)CustomizationClinical Indications for Procedure: Revised criteria for oophorectomy neededClinical Indications for Procedure: Added clinical indications for electiveinduction of labor. Added clinical indications for early elective induction oflaborAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableReferences: AddedCodes: Additional ICD-10 diagnosis codes may applyClinical Indications for Procedure: For early elective vaginal delivery, seeW0047 Vaginal DeliveryAdded information regarding Federal or State mandates will supersede theguideline Length of Stay when applicableExtended Stay: Added minimal stay extension for need to receivecomprehensive patient, parent or caregiver education and comprehensivediabetic education programs are not available on an outpatient basis in thecommunity; Obtain verbal or written attestation from provider regarding lack ofoutpatient diabetic education resourcesReturn to IndexCUSTOMIZATIONS TO MCG CRITERIAGeneral Recovery Care (GRG)1.MCG GuidelineGRG General RecoveryGuidelines Tools Section Inpatient Palliative CareCriteria (W0086) CustomizationAlternatives to Admission: For Home hospice added the following:o Outpatient: Continuous Home Care (CHC)o Outpatient: Routine Home Careo Patients who may benefit from hospice careo Nursing careReference: AddedReturn to IndexCUSTOMIZATIONS TO MCG CRITERIABehavioral Health Care (BHG)1.MCG GuidelineBHG Level of CareGuidelines: OpioidManagement –MedicationsCustomizationRemoved the MCG Behavioral Health Level of Care: Opioid Management –Medication guidelines listed below. Guidelines for medications addressed by othersources, such as IngenioRx. Buprenorphine Extended-Release Injection Buprenorphine Implant Buprenorphine-Naloxone Long-Acting Opioids Naltrexone Extended-Release Injection Naltrexone ImplantReturn to IndexCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEIssue Date: January 20, 2021 R3Page 4 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG C Cardiology Angioplasty, PercutaneousCoronary Intervention (W0120)ISC Cardiology Atrial Fibrillation (W0114)ISC Cardiology Electrophysiologic Study andImplantable CardioverterDefibrillator (ICD) Insertion(W0011)ISC Cardiology Electrophysiologic Study andIntracardiac Catheter Ablation(W0012)ISC Cardiology Left Atrial Appendage Closure,Percutaneous (W0157)ISC Cardiovascular Surgery Abdominal Aortic Aneurysm,Endovascular Repair (W0084)ISC Cardiovascular Surgery Aortic Valve Replacement,Transcatheter (W0133)ISC Cardiovascular Surgery Cardiac Septal Defect: Atrial,Transcatheter Closure (W0016)ISC Cardiovascular Surgery Cardiac Septal Defect:Ventricular, Repair (W0093)ISC Cardiovascular Surgery Cardiac Valve Replacement orRepair (W0089)ISC Cardiovascular Surgery –Carotid Artery Stenting (W0165)ISC Cardiovascular Surgery Heart Transplant (W0017)ISC Cardiovascular Surgery Percutaneous Revascularization,Lower Extremity (W0121)ISC Cardiovascular Surgery Sympathectomy byThoracoscopy or Laparoscopy(W0044)ISC Common Complicationsand Conditions Venous Thrombosis andPulmonary Embolism (W0136)ISC General Surgery Fundoplasty, Esophagogastric,by Laparoscopy (W0158)Issue Date: January 20, 2021 R3Medical Policy orClinical UM GuidelineCardiology Program Clinical GuidelinesCG-MED-64 Transcatheter Ablation ofArrhythmogenic Foci in the Pulmonary Veins as aTreatment of Atrial Fibrillation or Atrial Flutter(Radiofrequency and Cryoablation)CG-SURG-63 Cardiac Resynchronization Therapywith or without an Implantable CardioverterDefibrillator for the Treatment of Heart FailureCustomizationClinical Indications forProcedureClinical Indications forAdmission to Inpatient CareClinical Indications forProcedureCG-SURG-97 Cardioverter DefibrillatorsCG-SURG-55 Intracardiac ElectrophysiologicalStudies (EPS) and Catheter AblationClinical Indications forProcedureCG-MED-64 Transcatheter Ablation ofArrhythmogenic Foci in the Pulmonary Veins as aTreatment of Atrial Fibrillation or Atrial Flutter(Radiofrequency and Cryoablation)SURG.00032 Patent Foramen Ovale and Left AtrialAppendage Closure Devices for Stroke PreventionClinical Indications forProcedureCG-SURG-86 Endovascular/Endoluminal Repair ofAortic Aneurysms, Aortoiliac Disease, AorticDissection and Aortic TransectionSURG.00121 Transcatheter Heart Valve ProceduresClinical Indications forProcedureSURG.00032 Patent Foramen Ovale and Left AtrialAppendage Closure Devices for Stroke PreventionClinical Indications forProcedureSURG.00123 Transmyocardial/PerventricularDevice Closure of Ventricular Septal DefectsClinical Indications forProcedureSURG.00121 Transcatheter Heart Valve ProceduresClinical Indications forProcedureCG-SURG-76 Carotid, Vertebral and IntracranialArtery Stent Placement with or without AngioplastyTRANS.00026 Heart/Lung TransplantationClinical Indications forProcedureClinical Indications forProcedureTRANS.00033 Heart TransplantationCG-SURG-49 Endovascular Techniques(Percutaneous or Open Exposure) for ArterialRevascularization of the Lower ExtremitiesCG-MED-63 Treatment of HyperhidrosisClinical Indications forProcedureClinical Indications forProcedureClinical Indications forProcedureCG-SURG-59 Vena Cava FiltersClinical Indications forInpatient CareCG-SURG-92 Paraesophageal Hernia RepairClinical Indications forProcedurePage 5 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG Guideline17.ISC General Surgery –Gastric Restrictive Procedurewith Gastric BypassMedical Policy orClinical UM GuidelineCG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityCustomizationClinical Indications 29.30.31.32.33.Title change to:Gastric Restrictive Procedurewith or without Gastric Bypass(W0054)ISC General Surgery –Gastric Restrictive Procedurewith Gastric Bypass byLaparoscopy (W0014)ISC General Surgery –Gastric Restrictive Procedurewithout Gastric Bypass byLaparoscopy (W0033)ISC General Surgery –Gastric Restrictive Procedure,Sleeve Gastrectomy, byLaparoscopy (W0102)ISC General Surgery –Hiatal Hernia Repair,Abdominal (W0159)ISC General Surgery –Hiatal Hernia Repair,Transthoracic (W0160)ISC General Surgery –Liver Transplant (W0034)ISC Neonatal Facility Levelsand Intensity of Care CriteriaISC Neonatology –Sepsis, Neonatal, Confirmed(W0107)ISC Neonatology –Sepsis, Neonatal, Suspected, NotConfirmed (W0108)ISC Neurology –EEG, Video Monitoring(W0115)ISC Orthopedics –Acromioplasty and Rotator CuffRepair (W0139)ISC Orthopedics –Ankle Arthroscopy (W0155)ISC Orthopedics –Bunionectomy (W0168)ISC Orthopedics –Cervical Diskectomy orMicrodiskectomy,Foraminotomy, Laminotomy(W0071)ISC Orthopedics –Cervical Fusion, Anterior(W0111)ISC Orthopedics –Issue Date: January 20, 2021 R3CG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityClinical Indications forProcedureCG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityCodesClinical Indications forProcedureCG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityClinical Indications forProcedureCG-SURG-92 Paraesophageal Hernia RepairClinical Indications forProcedureCG-SURG-92 Paraesophageal Hernia RepairClinical Indications forProcedureTRANS.00008 Liver TransplantationClinical Indications forProcedureRemoved MCG guidelinesCG-MED-26 Neonatal Levels of CareCG-MED-26 Neonatal Levels of CareClinical Indications forAdmission to Inpatient CareCG-MED-26 Neonatal Levels of CareClinical Indications forAdmission to Inpatient CareCG-MED-46 Electroencephalography and VideoElectroencephalographic MonitoringClinical Indications forProcedureMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesSURG.00071 Percutaneous and Endoscopic SpinalSurgeryClinical Indications forProcedure and Level of CareClinical Indications forProcedure and Level of CareClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedurePage 6 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG Guideline34.35.36.37.38.Cervical Fusion, Posterior(W0112)ISC Orthopedics –Cervical Laminectomy (W0097)ISC Orthopedics –Hip Arthroplasty (W0105)ISC Orthopedics –Hip Arthroscopy (W0096)ISC Orthopedics –Hip Resurfacing (W0098)ISC Orthopedics –Knee Arthroplasty, Total(W0081)Medical Policy orClinical UM GuidelineSURG.00071 Percutaneous and Endoscopic SpinalSurgeryMusculoskeletal Program Clinical AppropriatenessGuidelinesSURG.00082 Computer-Assisted MusculoskeletalSurgical Navigational Orthopedic Procedures of theAppendicular SystemMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesCG-SURG-85 Hip ResurfacingSURG.00082 Computer-Assisted MusculoskeletalSurgical Navigational Orthopedic Procedures of theAppendicular SystemCustomizationClinical Indications forProcedureClinical Indications forProcedure and Level of CareClinical Indications forProcedure and Level of CareClinical Indications forProcedureCodesClinical Indications forProcedure and Level of CareSURG.00105 Bicompartmental Knee Arthroplasty39.40.41.42.ISC Orthopedics –Knee Arthroscopy (W0113)ISC Orthopedics –Knee Arthrotomy (W0140)ISC Orthopedics –Lumbar Diskectomy,Foraminotomy, or Laminotomy(W0091)ISC Orthopedics –Lumbar Fusion (W0072)Musculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesSURG.00071 Percutaneous and Endoscopic SpinalSurgeryClinical Indications forProcedure and Level of CareClinical Indications forProcedure and Level of CareClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesSURG.00071 Percutaneous and Endoscopic SpinalSurgeryClinical Indications forProcedureSURG.00111 Axial Lumbar Interbody Fusion43.44.45.46.ISC Orthopedics –Lumbar Laminectomy (W0100)ISC Orthopedics –Shoulder Arthroplasty (W0137)ISC Orthopedics –Shoulder Hemiarthroplasty(W0138)ISC Orthopedics –Spine, Scoliosis, PosteriorInstrumentation (W0116)Issue Date: January 20, 2021 R3Musculoskeletal Program Clinical AppropriatenessGuidelinesSURG.00071 Percutaneous and Endoscopic SpinalSurgeryClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelinesMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedureClinical Indications forProcedureMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedurePage 7 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG Guideline47.48.49.50.51.52.53.54.55.56.57.58.ISC Pediatrics –EEG, Video Monitoring,Pediatric (W0122)ISC Pediatrics –Fundoplasty, Esophagogastric,by Laparoscopy, Pediatric(W0161)ISC Pediatrics –Heart Transplant, Pediatric(W0123)ISC Pediatrics –Liver Transplant, Pediatric(W0124)ISC Pediatrics –Lung Transplant, Pediatric(W0125)ISC Pediatrics –Renal Transplant, Pediatric(W0126)ISC Pediatrics –Spine, Scoliosis, PosteriorInstrumentation, Pediatric(W0156)ISC Thoracic Surgery andPulmonary Disease Deep Venous Thrombosis ofLower Extremities (W0135)ISC Thoracic Surgery andPulmonary Disease Lung Transplant (W0076)ISC Thoracic Surgery andPulmonary Disease Pulmonary Embolism (W0134)ISC Urology –Prostatectomy, Transurethral,Alternatives to StandardResection (W0029)ISC Urology –Renal Transplant (W0027)Medical Policy orClinical UM GuidelineCG-MED-46 Electroencephalography and VideoElectroencephalographic MonitoringCustomizationClinical Indications forProcedureCG-SURG-92 Paraesophageal Hernia RepairClinical Indications forProcedureTRANS.00026 Heart/Lung TransplantationClinical Indications forProcedureTRANS.00033 Heart TransplantationTRANS.00008 Liver TransplantationTRANS.00009 Lung and Lobar TransplantationTRANS.00026 Heart/Lung TransplantationCG-TRANS-02 Kidney TransplantationClinical Indications forProcedureClinical Indications forProcedureClinical Indications forProcedureMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedureCG-SURG-59 Vena Cava FiltersClinical Indications forAdmission to Inpatient CareTRANS.00009 Lung and Lobar TransplantationClinical Indications forProcedureTRANS.00026 Heart/Lung TransplantationCG-SURG-59 Vena Cava FiltersClinical Indications forAdmission to Inpatient CareCG-SURG-107 Surgical and Minimally InvasiveTreatments for Benign Prostatic Hyperplasia (BPH)Clinical Indications forProcedureCG-TRANS-02 Kidney TransplantationClinical Indications forProcedureReturn to IndexCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEGeneral Recovery Care (GRG)MCG Guideline1.GRG Body System Cardiovascular Surgery or ProcedureGRG (W0099)Medical Policy orClinical UM GuidelineFor cardiovascular surgeries or procedures, seethe applicable clinical document, such as thefollowing:CustomizationClinical Indications forProcedureCG-SURG-59 Vena Cava FiltersCG-SURG-63 Cardiac ResynchronizationTherapy with or without an ImplantableCardioverter Defibrillator for the Treatment ofHeart FailureIssue Date: January 20, 2021 R3Page 8 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEGeneral Recovery Care (GRG)MCG GuidelineMedical Policy orClinical UM GuidelineCustomizationCG-SURG-97 Cardioverter DefibrillatorsSURG.00019 TransmyocardialRevascularizationSURG.00121 Transcatheter Heart ValveProcedures2.3.GRG Body System General Surgery or Procedure GRG(W0142)GRG Body System Musculoskeletal Surgery or ProcedureGRG (W0118)SURG.00145 Mechanical Circulatory AssistDevices (Ventricular Assist Devices,Percutaneous Ventricular Assist Devices andArtificial Hearts)CG-SURG-27 Gender Reassignment SurgerySURG.00105 Bicompartmental KneeArthroplastyClinical Indications forProcedureClinical Indications forProcedure and Level of CareSURG.00127 Sacroiliac Joint Fusion4.5.6.7.8.GRG Body System Neurosurgery or Procedure GRG(W0119)GRG Body System Obstetric and Gynecologic Surgery orProcedure GRG (W0143)GRG Body System Thoracic Surgery or Procedure GRG(W0169)GRG Body System Urologic Surgery or Procedure GRG(W0141)GRG Problem Oriented Medical Oncology GRG (W0074)Musculoskeletal Program ClinicalAppropriateness Guidelines and Level of CareGuidelinesMusculoskeletal Program ClinicalAppropriateness Guidelines and Level of CareGuidelinesCG-SURG-27 Gender Reassignment SurgerySURG.00022 Lung Volume Reduction SurgerySURG.00119 Endobronchial Valve DevicesCG-SURG-27 Gender Reassignment SurgeryCG-SURG-103 Male CircumcisionFor (a) chimeric antigen receptor (CAR) T-celltherapy, (b) transcatheter arterialchemoembolization, (c) high-dose radioactiveiodine or radioactive implant treatmentsneeding inpatient admission, and (d)hematopoietic stem cell transplantation, see theapplicable clinical document, such as thefollowing:Clinical Indications forProcedureClinical Indications forProcedureClinical Indication forProcedureClinical Indications forProcedureClinical Indications forAdmission to Inpatient CareCG-MED-38 Inpatient Admission for RadiationTherapy for Cervical or Thyroid CancerCG-SURG-78 Locoregional and SurgicalTechniques for Treating Primary and MetastaticLiver MalignanciesRAD.00059 Catheter-based EmbolizationProcedures for Malignant Lesions Outside theLiverIssue Date: January 20, 2021 R3Page 9 of 11
Subject: Customizations toCare Guidelines 24th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEGeneral Recovery Care (GRG)MCG GuidelineMedical Policy orClinical UM GuidelineTRANS.00### Hematopoietic Stem CellTransplantation (for various conditions)CustomizationReturn to IndexCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEBehavioral Health Care (BHG)MCG Guideline1.BHG Testing Procedures Urine Toxicology Testing (W0150)2.BHG Therapeutic Services Applied Behavioral Analysis (W0153)BHG Therapeutic Services Deep Brain Stimulation (DBS):Behavioral Health Care (W0164)BHG Therapeutic Services Trigeminal Nerve Stimulation,Transcutaneous: Behavioral HealthCare3.4.Medical Policy orClinical UM GuidelineCG-LAB-09 Drug Testing or Screening in theContext of Substance Use Disorder and ChronicPainCG-BEH-02 Adaptive Behavioral TreatmentCustomizationClinical Indications forProcedureSURG.00026 Deep Brain, Cortical, andCerebellar StimulationClinical Indications forProcedureClinical Indications forProcedureSee related documents, such as the following:Removed MCG guidelineCG-DME-04 Electrical Nerve Stimulation,Transcutaneous, PercutaneousDME.00011 Electrical Stimulation as aTreatment for Pain and Other Conditions:Surface and Percutaneous DevicesSURG.00112 Implantation of Occipital,Supraorbital or Trigeminal Nerve StimulationDevices (and Related Procedures)5.BHG Therapeutic Services Vagus Nerve Stimulation, Implantable:Behavioral Health Care (W0166)SURG.00158 Implantable Peripheral NerveStimulation Devices as a Treatment for PainSURG.00007 Vagus Nerve StimulationClinical Indications forProcedureReturn to IndexCUSTOMIZATION HISTORYIssue DateActionReason01/20/2021Release updateddocumentUpdated Issue Date reflects addition of the following new or updatedcustomizations approved at the November 5, 2020 MPTAC meeting. ISCo W0170 Gastrointestinal Bleeding, Uppero W0171 Gastrointestinal Bleeding, Upper: ObservationCare BHGo W0153 Applied Behavioral Analysis11/03/2020Release updateddocumentUpdated Issue Date reflects addition of the following new or updatedcustomizations approved at the August 13, 2020 MPTAC meeting. ISCIssue Date: January 20, 2021 R3Page 10 of 11
Subject: Customizations toCare Guidelines 24th EditionIssue DateReasonActiono W0026 Laparoscopic Gynecologic Surgery, IncludingMyomectomy, Oophorectomy, and Salpingectomyo W0072 Lumbar Fusiono W0097 Cervical Laminectomyo W0112 Cervical Fusion, Posterioro W0116 Spine, Scoliosis, Posterior Instrumentationo W0137 Shoulder Arthroplastyo W0138 Shoulder Hemiarthroplastyo W0156 Spine, Scoliosis, Posterior Instrumentation,Pediatrico W0168 BunionectomyGRGo W0118 Musculoskeletal Surgery or Procedure GRGo W0169 Thoracic Surgery or Procedure GRGUpdated format for Customizations to MCG Care Guidelines.02/21/2020Release document forCustomizations to MCGCare Guidelines 24thEditionNew document for Customizations to MCG Care Guidelines 24thEdition approved at the February 20, 2020 Medical Policy &Technology Assessment Committee (MPTAC) meeting.Return to IndexIssue Date: January 20, 2021 R3Page 11 of 11
ISC OB / GYN - Hysterectomy, Abdominal (W0109) Clinical Indications for Procedure: Revised criteria for abnormal uterine bleeding, leiomyoma ("fibroid"), pelvic organ prolapse Added information for when hysterectomy is considered not medically necessary 13. ISC OB / GYN - Hysterectomy, Laparoscopic Title change to:
