Medicare AdvantageJune 1, 2021
MCG Care Guidelines 25th Edition
Effective September 1, 2021, Anthem Blue Cross and Blue Shield will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.
Goal length of stay (GLOS) for inpatient and surgical care (ISC)
Guideline |
MCG Code |
24th Edition GLOS |
25th Edition GLOS |
Aortic Coarctation, Angioplasty |
S-152 |
Ambulatory or 1 day postoperative |
Ambulatory |
Cardiac Septal Defect: Atrial, Transcatheter Closure |
W0016 |
Ambulatory or 1 day postoperative |
Ambulatory |
Esophageal Diverticulectomy, Endoscopic |
S-445 |
Ambulatory or 1 day postoperative |
Ambulatory |
Gastrectomy, Partial - Billroth I or II |
S-510 |
4 or 6 days postoperative |
5 days postoperative |
Hernia Repair (Non-Hiatal) |
S-1305 |
Ambulatory or 1 day postoperative |
Ambulatory |
Pancreatectomy |
S-1200 |
5 or 7 days postoperative |
6 days postoperative |
Pyloroplasty and Vagotomy |
S-990 |
4 or 6 days postoperative |
4 days postoperative |
Cervical Laminectomy |
W0097 |
2 days postoperative |
Ambulatory or 2 days postoperative |
Lumbar Diskectomy, Foraminotomy, or Laminotomy |
W0091 |
Ambulatory or 1 day postoperative |
Ambulatory |
Removal of Posterior Spinal Instrumentation |
S-530 |
1 day postoperative |
Ambulatory or 1 day postoperative |
Shoulder Hemiarthroplasty |
W0138 |
1 day postoperative |
Ambulatory or 1 day postoperative |
Spine, Scoliosis, Posterior Instrumentation, Pediatric |
W0156 |
4 days postoperative |
3 days postoperative |
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent |
S-190 |
5 or 6 days postoperative |
5 days postoperative |
Prostatectomy, Transurethral Resection (TURP) |
S-970 |
Ambulatory or 1 day postoperative |
Ambulatory |
Urethroplasty |
S-1172 |
Ambulatory or 1 day postoperative |
Ambulatory |
New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)
Body System |
Guideline Title |
MCG - Code |
Withdrawal Management |
Withdrawal Management, Adult: Inpatient Care |
B-031-IP |
Withdrawal Management |
Withdrawal Management, Adult: Intensive Outpatient Program |
B-031-IOP |
Withdrawal Management |
Withdrawal Management, Adult: Outpatient Care |
B-031-AOP |
Withdrawal Management |
Withdrawal Management, Adult: Partial Hospital Program |
B-031-PHP |
Withdrawal Management |
Withdrawal Management, Adult: Residential Care |
B-031-RES |
Cardiology |
Hypertension |
M-5197 |
Cardiology |
Peripheral Vascular Disease (PVD) |
M-7087 |
Nephrology |
Rhabdomyolysis |
M-7095 |
Nephrology |
Encephalopathy |
M-7100 |
Thoracic Surgery |
Rib Fracture |
M-5545 |
Customizations to MCG care guidelines 25th edition
Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:
- Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
- Need for acute TMS treatment, up to six weeks
- Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
- Continuation of acute treatment, up to six months
- TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
- Maintenance TMS treatment
- Continuation of acute TMS treatment for longer than six months
- TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.
To view a detailed summary of customizations, visit this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.
For questions, please contact the provider services at the number on the back of the member’s ID card.
PUBLICATIONS: June 2021 Anthem Provider News - Missouri
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