Medical Necessity Guidelines
Designed to facilitate consistent medical necessity determinations for coverage of select services and supplies.
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
CCA Medical Necessity Guidelines
Active Water Circulation Pump with Cold Compression Pad
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Acupuncture
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Adult Day Health
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Adult Foster Care
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Air Conditioner
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Alzheimer Coaching
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Assisted Living Services (SPA/Group Adult Foster Care in Assisted Living Residences)
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Cardiac Rehabilitation
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CG-Drug 95 Belatacept (Nulojix)
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Chiropractic Services
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Chore Services
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Clinical Trials Routine Patient Care Costs
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Community Support Programs
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Community Support Programs for Chronically Homeless Individuals (CSP- CHI)
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Companion Services
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Complement Inhibitors – Eculizumab and Ravulizumab-cwvz
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Day Habilitation
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Day Services
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Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility
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Electronic Aids to Daily Living
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Excision of Excessive Skin & Subcutaneous Tissue
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Experimental and Investigational Services
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External Breast Prostheses
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Gender Affirming Surgery and Related Procedures
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Genetic and Molecular Testing
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Grocery Delivery
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Group Adult Foster Care
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Hearing Aid
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Home Based Wandering Response System
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Home Delivered Meals and Medically Tailored Meals
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Home Health Aide
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Home Health Services
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Home Modifications
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Home Oxygen Therapy
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Homemaker Services
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Hospital Beds
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Hyaluronic Acid Injection for Knee Osteoarthritis
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Intravenous Iron Infusion
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Laundry Services Delivery
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Massage Therapy
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Mattress- Non-HCPC Coded
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Mattress – HCPC Coded Pressure Reducing Support Surfaces
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Medical Necessity
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Medicare Part B Step Therapy
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Medicare Part B Step Therapy Preferred Drug List
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Modified T-Cell Therapy
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Non-Covered Benefit
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Non-Emergent Transportation
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Non-Preferred DME
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Out of Network Coverage
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Outpatient Part B COVID-19 Treatment
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Part B Drugs Requiring Prior Authorization
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Personal Care Agency
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Personal Care Attendant
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Personal Emergency Response System
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Power Seat Lift Chairs
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Program of Assertive Community Treatment
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Pulmonary Rehabilitation
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Radiofrequency Ablation for Lung Cancer
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Ramps
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Recommendations for Intermittent Skilled Therapy in a SNF
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Recovery Coach Services
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Recovery Support Navigator
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Repairs and Modifications of Durable Medical Equipment (DME)
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Skilled Nursing
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Skilled Nursing Facility (SNF) Services Under Medicare Part A
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Skin and Soft Tissue Substitutes
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Social Day Care
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Stair Lift
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Subacute Level of Care in a Skilled Nursing Facility (SNF) Under Medicare Part A
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Supportive Home Care Aide
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Vertical Platform (Wheelchair) Lift
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Wheelchair-Custom Fabricated Seat and Cushion
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Wheelchair-Power Seating
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