Policy Updates Medical Policy & Clinical GuidelinesCommercialMay 1, 2019

MCG care guidelines 23rd Edition*

Effective August 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will upgrade to the 23rd edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC).

 

Goal Length of Stay (GLOS) changes for Inpatient & Surgical Care (ISC)

 

Guideline

MCG Number

23rd Edition GLOS

22nd Edition GLOS

Neurology- Traumatic Brain Injury, Nonsurgical Treatment

M-78

Ambulatory or 2 days

2 days

Orthopedics-Lumbar Fusion

S-820

2 days postoperative

3 days postoperative

 

 

New Optimal Recovery Guidelines (ORGs), Common Complications and Conditions (CCC) and Level of Care (LOC) Guidelines

 

Module

Guideline

Title

MCG Number

ISC

ORG

Anorexia Nervosa, Child or Adolescent

P-585

ISC

ORG

Substance-Related Disorders, Child or Adolescent

P-596

ISC

ORG

Left Atrial Appendage Closure, Percutaneous

M-333

ISC

ORG

Abdominal Pain, Undiagnosed, Pediatric

P-05

ISC

ORG

Craniotomy for Traumatic Brain Injury or Intracerebral Hemorrhage, Pediatric

P-414

ISC

ORG

Craniotomy, Supratentorial, Pediatric

P-411

ISC

ORG

Headaches, Pediatric

P-185

ISC

ORG

Hernia Repair (Non-Hiatal), Pediatric

P-1305

ISC

ORG

Inflammatory Bowel Disease, Pediatric

P-565

ISC

ORG

Pelvic Inflammatory Disease (PID), Acute, Pediatric

P-260

ISC

ORG

Spine, Scoliosis, Posterior Instrumentation, Pediatric

P-1056

ISC

ORG

Supraventricular Arrhythmias, Pediatric

P-510

ISC

CCC

Pain: Common Complications and Conditions

CCC-050

RFC

ORG

Degenerative Joint Disease (DJD)

M-7030

BHC

LOC

Obsessive-Compulsive and Related Disorders, Adult: Inpatient Care

B-030-IP

BHC

LOC

Obsessive-Compulsive and Related Disorders, Child or Adolescent: Inpatient Care

B-029-IP

BHC

LOC

Obsessive-Compulsive and Related Disorders: Residential Care

B-030-RES

BHC

LOC

Obsessive-Compulsive and Related Disorders: Partial Hospital Program

B-030-PHP

BHC

LOC

Obsessive-Compulsive and Related Disorders: Intensive Outpatient Program

B-030-IOP

BHC

LOC

Obsessive-Compulsive and Related Disorders: Acute Outpatient Care

B-030-AOP

 

 

Anthem Customizations to MCG care guideline 23rd Edition

 

Effective August 1, 2019, the following MCG care guideline 23rd edition customizations will be implemented.

  • Left Atrial Appendage Closure, Percutaneous (W0157) - customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) - customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

 

Available online is a more detailed summary of the Anthem customizations.

 

For questions, please contact the provider service number on the back of the member's ID card.


* Notice of Prior Authorization or Material Adverse Change

PUBLICATIONS: May 2019 Anthem Provider Newsletter - Missouri