The following codes for treatments and procedures applicable to this guideline are included
below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device …

• Treatment of primary immunodeficiencies, including:-Hypogammaglobulinemia;-
Congenital agammaglobulinemia (X-linked agammaglobulinemia);-Common variable …

1. Inadequate response to prior surgical therapy to correct the defect; and 2. Size of the
cartilage defect is greater than or equal to 1.5 square cm (ie length x width)* in total area …

Use of a circulating tumor DNA (ctDNA) test is considered medically necessary to guide
targeted cancer therapies in individuals with solid tumors when the mutation (s) meets …

Clinical UM Guideline Description Clinical Indications Page 1 Clinical UM Guideline Subject:
Rehabilitative and Habilitative Services: Physical Medicine/Physical Therapy Guideline # …

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue's
standard Medicaid benefit plan. When evaluating insurance coverage for the provision of …

A. Acute inflammatory demyelinating polyradiculoneuropathy/Guillain-Barre syndrome B.
Anti-glomerular basement membrane disease (Goodpasture's syndrome) when the …

Federal and State law, as well as contract language, and Medical Policy take precedence
over Clinical UM Guidelines. We reserve the right to review and update Clinical UM …

A. Acute inflammatory demyelinating polyradiculoneuropathy/Guillain-Barre syndrome B.
Anti-glomerular basement membrane disease (Goodpasture's syndrome) when the …

B. There is documentation from the provider that the beneficiary is receiving the scope and
intensity of services required to meet the program goals stated in the service description. C …