MCG Care Guidelines 24th Edition Customization

Effective April 1, 2021, the following new customizations will be implemented:

 

• Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) – Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.

 

• Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) – Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.

 

To view a detailed summary of customizations:

 

• Go to Anthem’s Medical Policies & Clinical UM Guidelines page for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
  
  
• Scroll down to other criteria section and select Customizations to MCG Care Guidelines 24th Edition.

 

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

 

902-0121-PN-KY.MO