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CUSTOMIZATION TOCARE GUIDELINES25th EDITIONIssue Date:February 11, 2021Original Date:February 11, 2021This 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 11, 2021 for MCG care guidelines 25th edition and corresponding customizedguidelines.Issue Date: February 11, 2021 R1Page 1 of 11
Subject: Customizations toCare Guidelines 25th 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.MCG GuidelineISC Common Complicationsand Conditions Preoperative Days (W0130)ISC General Surgery –Mastectomy, Complete(W0002) 3.ISC General Surgery Mastectomy, Complete, withInsertion of Breast Prosthesisor Tissue Expander (W0022) 4.ISC General Surgery Mastectomy, Complete, withTissue Flap Reconstruction(W0023) Issue Date: February 11, 2021 R1CustomizationClinical Indications for Inpatient Care: For inpatient preoperative days, addedindication, bridging anticoagulation that requires inpatient treatmentReference: 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 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 postoperativeAdded 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: AddedPage 2 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS TO MCG CRITERIAInpatient & Surgical Care (ISC)5.6.MCG GuidelineISC General Surgery Mastectomy, Partial(Lumpectomy) (W0008)ISC Hematology - Oncology Chemotherapy (W0162) 7.8.9.ISC Neonatology –Newborn Care, Routine(W0087)ISC Neonatology –Newborn Care, Term, withSevere Illness or Abnormality(W0106)ISC OB / GYN Cesarean Delivery (W0045) 10.11.ISC OB / GYN Hysterectomy, Abdominal(W0109)ISC OB / GYN Hysterectomy, Laparoscopic 12.13.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) 14.ISC OB / GYN Laparotomy, for GynecologicSurgery, IncludingMyomectomy, Oophorectomy,and Salpingectomy (W0025)Issue Date: February 11, 2021 R1 CustomizationGoal 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 complex multiple-drug chemotherapy regimens requiringmore than 6 hours of continuous observation and drug administration withexamplesHospital Care Planning: Added Nutrition consultation to Consultation,assessment, and other services scheduling and completionReferences: 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 InfertilitySurgeryClinical Indications for Procedure: Revised criteria for oophorectomy neededPage 3 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS TO MCG CRITERIAInpatient & Surgical Care (ISC)15.MCG GuidelineISC OB / GYN Vaginal Delivery (W0047) 16.17. ISC OB / GYN Vaginal Delivery, Operative(W0048) ISC Pediatrics Diabetes, Pediatric (W0117)CustomizationClinical 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)1.2.MCG GuidelineBHG Level of CareGuidelines: OpioidManagement –MedicationsBHG Therapeutic Services –Transcranial MagneticStimulation (W0174)CustomizationRemoved 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-Naloxone Long-Acting Opioids Naltrexone Extended-Release Injection Naltrexone Implant Clinical Indications for Procedure: Added need for acute TMS treatment, up to 6weeks. Added acute treatment course needed as indicated by (a) Initial course oftreatment for major depressive disorder (severe), or (b) Relapse of symptoms afterremission. Added continuation of acute treatment, up to 6 months Added information for when TMS is considered not medically necessary Footnote: Updated footnote with definitions for acute (or index) course,maintenance treatment, remission, relapse, recovery and recurrence Reference: AddedReturn to IndexCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEIssue Date: February 11, 2021 R1Page 4 of 11
Subject: Customizations toCare Guidelines 25th 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 Aneurysm, Thoracic,Endovascular Repair (W0173)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 –Issue Date: February 11, 2021 R1Medical 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 TransectionCG-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 HyperhidrosisCG-SURG-59 Vena Cava FiltersClinical Indications forProcedureClinical Indications forProcedureClinical Indications forProcedureClinical Indications forProcedureClinical Indications forInpatient CarePage 5 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG Guideline17.18.Venous Thrombosis andPulmonary Embolism (W0136)ISC General Surgery –Fundoplasty, Esophagogastric,by Laparoscopy (W0158)ISC General Surgery –Gastric Restrictive Procedurewith Gastric BypassMedical Policy orClinical UM GuidelineCustomizationCG-SURG-92 Paraesophageal Hernia RepairClinical Indications forProcedureCG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityClinical Indications 30.31.32.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)Issue Date: February 11, 2021 R1CG-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 GuidelinesPage 6 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG Guideline33.34.35.36.37.38.39.ISC Orthopedics –Cervical Fusion, Anterior(W0111)ISC Orthopedics –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 GuidelineMusculoskeletal Program Clinical AppropriatenessGuidelines and Level of Care GuidelinesClinical Indications forProcedure and Level of CareMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedureSURG.00071 Percutaneous and Endoscopic SpinalSurgeryClinical Indications forProcedureMusculoskeletal 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 forProcedure and Level of CareClinical Indications forProcedure and Level of CareClinical Indications forProcedureCodesClinical Indications forProcedure and Level of CareSURG.00105 Bicompartmental Knee Arthroplasty40.41.42.43.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 Fusion44.45.46.ISC Orthopedics –Lumbar Laminectomy (W0100)ISC Orthopedics –Shoulder Arthroplasty (W0137)ISC Orthopedics –Issue Date: February 11, 2021 R1Musculoskeletal 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 forProcedurePage 7 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEInpatient & Surgical Care (ISC)MCG oulder Hemiarthroplasty(W0138)ISC Orthopedics –Spine, Scoliosis, PosteriorInstrumentation (W0116)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 GuidelineCustomizationMusculoskeletal Program Clinical AppropriatenessGuidelinesClinical Indications forProcedureCG-MED-46 Electroencephalography and VideoElectroencephalographic MonitoringClinical 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 FiltersIssue Date: February 11, 2021 R1Page 8 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEGeneral Recovery Care (GRG)MCG GuidelineMedical Policy orClinical UM GuidelineCustomizationCG-SURG-63 Cardiac ResynchronizationTherapy with or without an ImplantableCardioverter Defibrillator for the Treatment ofHeart FailureCG-SURG-97 Cardioverter DefibrillatorsSURG.00019 TransmyocardialRevascularizationSURG.00121 Transcatheter Heart ValveProcedures2.GRG Body System –General Surgery or Procedure GRG(W0142)SURG.00145 Mechanical Circulatory AssistDevices (Ventricular Assist Devices,Percutaneous Ventricular Assist Devices andArtificial Hearts)CG-SURG-27 Gender Reassignment SurgeryClinical Indications forProcedureCG-SURG-83 Bariatric Surgery and OtherTreatments for Clinically Severe ObesityCG-SURG-92 Paraesophageal Hernia RepairTRANS.00011 Pancreas Transplantation andPancreas Kidney Transplantation3.GRG Body System –Musculoskeletal Surgery or ProcedureGRG (W0118)TRANS.00013 Small Bowel, SmallBowel/Liver and Multivisceral TransplantationSURG.00105 Bicompartmental KneeArthroplastyClinical 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)Issue Date: February 11, 2021 R1Musculoskeletal Program ClinicalAppropriateness Guidelines and Level of CareGuidelinesMusculoskeletal Program ClinicalAppropriateness Guidelines and Level of CareGuidelinesCG-SURG-27 Gender Reassignment SurgeryCG-SURG-110 Lung Volume ReductionSurgerySURG.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)Clinical Indications forProcedureClinical Indications forProcedureClinical Indication forProcedureClinical Indications forProcedureClinical Indications forAdmission to Inpatient CarePage 9 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATIONS RELATED TO A MEDICAL POLICY OR GUIDELINEGeneral Recovery Care (GRG)MCG GuidelineMedical Policy orClinical UM Guidelinehematopoietic stem cell transplantation, see theapplicable clinical document, such as thefollowing:CustomizationCG-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 theLiverTRANS.00### Hematopoietic Stem CellTransplantation (for various conditions)Return 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)5.6.BHG Therapeutic Services –Vagus Nerve Stimulation, Implantable:Behavioral Health Care (W0166)BHG Therapeutic Services –Wilderness Therapy (W0172)SURG.00158 Implantable Peripheral NerveStimulation Devices as a Treatment for PainSURG.00007 Vagus Nerve StimulationMED.00122 Wilderness ProgramsClinical Indications forProcedureClinical Indications forProcedureReturn to IndexIssue Date: February 11, 2021 R1Page 10 of 11
Subject: Customizations toCare Guidelines 25th EditionCUSTOMIZATION HISTORYIssue DateActionReason02/11/2021Release document forCustomizations to MCGCare Guidelines 25thEditionNew document for Customizations to MCG Care Guidelines 25thEdition approved at the February 11, 2021 Medical Policy &Technology Assessment Committee (MPTAC) meeting.Return to IndexIssue Date: February 11, 2021 R1Page 11 of 11
ISC OB / GYN - Hysterectomy, Vaginal bleeding, leiomyoma ("fibroid"), pelvic organ prolapse (W0110) Clinical Indications for Procedure: Revised criteria for abnormal uterine Added information for when hysterectomy is considered not medically necessary 13. ISC OB / GYN - Laparoscopic Gynecologic Surgery, Including
