Medical Necessity Guidelines

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:

• 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