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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:

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

Certified Home Health Services

CG-Drug 95 Belatacept (Nulojix)

Chiropractic Services

Chromosomal Microarray Analysis

Chore Services

Clinical Trials Routine Patient Care Costs

Community Crisis Stabilization (CCS)

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

Community Support Program (CSP) MNG

Community Support Program for Individuals with Justice Involvement (CSP-JI) MNG

Companion Services

Complement Inhibitors – Eculizumab and Ravulizumab-cwvz

Day Habilitation

Day Services

Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility

Eating Disorder Acute Residential Treatment

Electronic Aids to Daily Living

Excision of Excessive Skin & Subcutaneous Tissue

Experimental and Investigational Services

External Breast Prostheses

Gender Affirming Surgery and Related Procedures

Genetic Testing BRCA-Related Breast and/or Ovarian Cancer Syndrome

Genetic and Molecular Testing

Grocery Delivery

Group Adult Foster Care

Home Based Wandering Response System

Home Delivered Meals and Medically Tailored Meals

Home Health Aide

Home Health Services – Medicare Advantage

Home Modifications

Home Oxygen Therapy

Homemaker Services

Hospital Beds

Hyaluronic Acid Injection for Knee Osteoarthritis

Intravenous Iron Infusion

Laundry Services Delivery

Massage Therapy

Maternal Cell-Free Fetal DNA Testing

Mattress – HCPC Coded Pressure Reducing Support Surfaces

Mattress Non-HCPCS Coded MNG 103

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

Oral Liquid Nutrition Supplements

Out of Network Coverage

Part B Drugs Requiring Prior Authorization

Personal Care Agency

Personal Care Attendant

Personal Emergency Response System

Power Seat Lift Chairs

Program of Assertive Community Treatment

Pulmonary Rehabilitation

Radiofrequency Ablation for Lung Cancer

Recommendations for Intermittent Skilled Therapy in a SNF

Recommendations for Skilled Nursing

Recovery Coach Services

Recovery Support Navigator (RSN)

Repairs and Modifications of Durable Medical Equipment (DME)

Skilled Nursing Facility (SNF) Services Under Medicare Part A

Skin and Soft Tissue Substitutes

Social Day Care

Stair Lift

Subacute Level of Care in a Skilled Nursing Facility (SNF) Under Medicare Part A

Supportive Home Care Aide

Vertical Platform (Wheelchair) Lift

Wheelchair-Custom Fabricated Seat and Cushion

Wheelchair-Power Seating

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