Medical Necessity Guidelines
Designed to facilitate consistent medical necessity determinations for coverage of select services and supplies.
The Commonwealth Care Alliance (CCA) Medical Necessity Guidelines are used for requests for coverage of select medical and behavioral health services and supplies, such as durable medical equipment (DME), select elective surgical procedures, pharmaceuticals, oral surgery, transplants, and other services. The guidelines are:
- Scientifically derived and evidence-based
- Developed or adopted with input and instructions from CCA physicians, specialty consultants, and actively practicing specialty physicians
- Developed in accordance with standards adopted by national accreditation organizations and regulatory and government entities
- Reviewed on an annual basis with input from appropriate actively practicing physicians and other providers
- Updated as new treatments, applications, and technologies are adopted as generally accepted professional medical practice
- Applied in a manner that considers the individual healthcare needs of the patient and characteristics of the local delivery system
- Evaluated at least annually for consistency with current policies for determination of coverage applied by the Utilization Review department at CCA
CCA Medical Necessity Guidelines
Acupuncture
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Adult Day Health
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Adult Foster Care
Assisted Living Services-Specialized Personal Assistance (SPA)
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Balloon Dilation of the Eustachian Tube
Bed and Mattress Non-HCPCS Coded
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BRCA/PALB2 Related Breast and/or Ovarian Cancer Syndrome
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Chimeric Antigen Receptor (CAR) T-Cell Therapy
Chiropractic Services
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Chromosomal Microarray Analysis
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Clinical Trials, Routine Patient Care Costs
Community Crisis Stabilization (CCS)
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Community Support Programs and Specialized Community Support Programs (CSP)
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Continuous Glucose Monitors (CGM)
Day Habilitation
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Eating Disorder Acute Residential Treatment
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Excision of Excessive Skin & Subcutaneous Tissue
Experimental and Investigational Services
Gender Affirming Surgery and Related Procedures
Genetic and Molecular Testing
Group Adult Foster Care
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Home Health Aide Services Provided by Non-Certified Agency
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Home Health Services Certified: Senior Care Options and One Care
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Hospital Beds
Inpatient Rehabilitation Facility
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Intermittent Skilled Therapy in a Nursing Facility (NF)
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Intravenous Iron Infusion
Leqembi (lecanemab-irmb)
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Manual Wheelchair Power Accessories
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Maternal Cell-Free Fetal DNA Testing
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Medicare Part B Step Therapy
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Medical Necessity
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MyoPro Upper Limb Compensatory Device
New-to-Market Part B Medications
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Non-Covered Benefit
Non-Emergency Ground Ambulance Transportation
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Non-Emergent Transportation (Supplemental Benefit)
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Non-Preferred Durable Medical Equipment and Supplies
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One Care Flexible Benefits
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Oral Liquid Nutrition Supplements
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Out of Network Coverage
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Outpatient Medications: 2025 Part B Preferred Drug List
Outpatient Medications: 2026 Part B Preferred Drug List
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Part B Drugs Requiring Prior Authorization
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Peroral Endoscopic Myotomy (POEM)
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Personal Care Attendant (PCA) Program (Consumer/Self Directed Care)
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Power Operated Vehicle
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Power Seat Lift Chairs
Pressure Reducing Support Surfaces – Group 2 and Group 3
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Program of Assertive Community Treatment
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Pulmonary Artery Pressure Monitoring (CardioMEMS)
Recovery Coach Services
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Recovery Support Navigator (RSN)
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Repairs and Modifications of Durable Medical Equipment (DME)
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Rhinoplasty and Septoplasty
SCO Home and Community Based Services (HCBS)
Skilled Nursing Facility (SNF) Services Under Medicare
Skin and Soft Tissue Substitutes
Part B Pharmacy Policies
Alpha1-Proteinase Inhibitor Products UM Medical Policy
Alzheimer’s Disease – Amyloid Beta-Directed Antibodies – Kisunla Utilization Management
Alzheimer’s Disease – Amyloid Beta-Directed Antibodies – Leqembi Intravenous and Leqembi IQLIK Utilization Management
Amvuttra™ (vutrisiran subcutaneous injection − Alnyam)
Amyloidosis – Onpattro
Amyloidosis – Tegsedi
Antiemetics – Palonosetron Intravenous Products
Bone Modifiers – Denosumab Products (Prolia)
Bone Modifiers – Denosumab Products (Xgeva)
Bone Modifiers – Evenity
Bone Modifiers – Ibandronate Intravenous
Bone Modifiers – Zoledronic Acid (Reclast)
Bone Modifiers – Zoledronic Acid (Zometa)
Botulinum Toxins – Botox
Botulinum Toxins – Daxxify
Botulinum Toxins – Dysport
Botulinum Toxins – Myobloc
Botulinum Toxins – Xeomin
Chemoprotective Agent – Pedmark
Colony Stimulating Factors – Filgrastim Products
Colony Stimulating Factors – Granix
Colony Stimulating Factors – Leukine
Colony Stimulating Factors – Pegfilgrastim Products
Colony Stimulating Factors – Rolvedon
Colony Stimulating Factors – Ryzneuta
Complement Inhibitors – Veopoz
Complement Inhibitors – Eculizumab Products
Complement Inhibitors – PiaSky
Complement Inhibitors – Ultomiris
Coronavirus Disease – Evusheld
Coronavirus Disease – Veklury
Corticosteroids (Intraarticular) – Zilretta
Crysvita
Dermatology – Gene Therapy – Vyjuvek
Dermatology – Gene Therapy – Zevaskyn
Dermatology – Ycanth
Diabetes – Tzield
Enzyme Replacement Therapy – Aldurazyme
Enzyme Replacement Therapy – Elaprase
Enzyme Replacement Therapy – Elfabrio
Enzyme Replacement Therapy – Fabrazyme
Enzyme Replacement Therapy – Kanuma
Enzyme Replacement Therapy – Lamzede
Enzyme Replacement Therapy – Mepsevii
Enzyme Replacement Therapy – Naglazyme
Enzyme Replacement Therapy – Revcovi
Enzyme Replacement Therapy – Vimizim
Enzyme Replacement Therapy – Xenpozyme
Erythropoiesis-Stimulating Agents – Aranesp
Erythropoiesis-Stimulating Agents – Epoetin Alfa Products
Erythropoiesis-Stimulating Agents – Mircera
Gamifant
Gaucher Disease – Enzyme Replacement Therapy – Cerezyme
Gaucher Disease – Enzyme Replacement Therapy – Elelyso
Gaucher Disease – Enzyme Replacement Therapy – Vpriv
Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty
Gonadotropin-Releasing Hormone Agonists – Implants
Gonadotropin-Releasing Hormone Agonists – Lupron Depot
Gout – Krystexxa
Graft-Versus-Host Disease – Niktimvo
Graft-Versus-Host Disease – Ryoncil
Hematology – Adzynma
Hematology – Aphexda
Hematology – Cablivi
Hematology – Ceprotin
Hematology – Coagadex
Hematology – Corifact
Hematology – Enjaymo
Hematology – Fibrinogen Products
Hematology – Gene Therapy – Casgevy
Hematology – Gene Therapy – Lyfgenia
Hematology – Gene Therapy – Zynteglo
Hematology – Omisirge
Hematology – Reblozyl
Hematology – Ryplazim
Hematology – Rytelo
Hematology – Tretten
Hematology – Vonvendi
Hemophilia – Altuviiio
Hemophilia – Eptacog Products – NovoSeven RT
Hemophilia – Eptacog Products – Sevenfact
Hemophilia – Factor IX Products
Hemophilia – Factor VIII Products
Hemophilia – FEIBA
Hemophilia – Gene Therapy – Hemgenix
Hemophilia – Gene Therapy – Roctavian
Hemophilia – Non-Factor Routine Prophylaxis Products
Hepatology – Givlaari
Hepatology – Panhematin
Hereditary Angioedema – Andembry
Hereditary Angioedema – C1 Esterase Inhibitors (Intravenous)
Hereditary Angioedema – C1 Esterase Inhibitors (Subcutaneous)
Hereditary Angioedema – Dawnzera
Hereditary Angioedema – Icatibant
Hereditary Angioedema – Kalbitor
Hereditary Angioedema – Takhzyro
Homozygous Familial Hypercholesterolemia – Evkeeza
Human Immunodeficiency Virus – Apretude
Human Immunodeficiency Virus – Cabenuva
Human Immunodeficiency Virus – Sunlenca
Human Immunodeficiency Virus – Trogarzo
Human Immunodeficiency Virus – Yeztugo
Hyaluronic Acid Derivatives (Intraarticular)
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