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The Commonwealth Care Alliance 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:

CCA Medical Necessity Guidelines

Active Water Circulation Pump with Cold Compression Pad


Adult Day Health

Adult Foster Care

Air Conditioner

Alzheimer Coaching

Assisted Living Services (SPA/Group Adult Foster Care in Assisted Living Residences)

Cardiac Rehabilitation

CG-Drug 95 Belatacept (Nulojix)

Chiropractic Services

Chore Services

Community Support Programs

Community Support Programs for Chronically Homeless Individuals (CSP- CHI)

Companion Services

Day Habilitation

Day Services

Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility


Electronic Aids to Daily Living

Excision of Excessive Skin & Subcutaneous Tissue

Experimental and Investigational Services

External Breast Prostheses

FDG PET for Dementia and Neurodegenerative Diseases

Gender Affirming Surgery and Related Procedures

Genetic and Molecular Testing

Grocery Delivery

Group Adult Foster Care

Hearing Aid

Home Based Wandering Response System

Home Delivered Meals and Medically Tailored Meals

Home Health Aide

Home Health Services

Home Modifications

Home Oxygen Therapy

Homemaker Services

Hospital Beds

Hyaluronic Acid Injection for Knee Osteoarthritis

Hyperbaric Oxygen Therapy

Iron Infusion

Laundry Services (Delivery)

Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

Massage Therapy

Mattress – HCPC Coded Pressure Reducing Support Surfaces

Medical Necessity

Medicare Part B Step Therapy

Medicare Part B Step Therapy Preferred Drug List

Modified T-Cell Therapy

Non-Covered Benefit

Non-Emergent Transportation

Non-Preferred DME

Osteogenesis Stimulators

Outpatient Part B COVID-19 Treatment

Personal Care Agency

Personal Care Attendant

Personal Emergency Response System

Program of Assertive Community Treatment

Pulmonary Rehabilitation

Radicava (Edaravone)

Radiofrequency Ablation for Lung Cancer

Recommendations for Intermittent Skilled Therapy in a SNF

Recovery Coach

Recovery Support Navigator

Repairs and Modifications of Durable Medical Equipment (DME)

Select Biologic Agents

Skilled Nursing

Skilled Nursing Facility (SNF) Services Under Medicare Part A

Skin and Soft Tissue Substitutes

Sleep Studies

Stair Lift

Subacute level of Care in a Skilled Nursing Facility (SNF) under Medicare Part A

Supportive Home Care Aide

Wheelchair-Custom Fabricated Seat and Cushion

Wheelchair-Power Seating

Vertical Platform (Wheelchair) Lift

Provider Services is here to help

8:00 am to 6:00 pm, Monday through Friday