Medical Necessity Guidelines

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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CCA Medical Necessity Guidelines

Acupuncture

Adult Day Health

Aduhelm™ (aducanumab-avwa)

Adult Foster Care

Air Conditioner

Assisted Living Services (Specialized Personal Assistance (SPA))

Bed and Mattress Non-HCPCS Coded MNG 103

Chimeric Antigen Receptor (CAR) T-Cell Therapy

Chiropractic Services

Chromosomal Microarray Analysis

Chore Services

Clinical Trials, Routine Patient Care Costs

Community Crisis Stabilization (CCS)

Community Support Programs and Specialized Community Support Programs (CSP)

Companion Services

Complement Inhibitors – Eculizumab and Ravulizumab-cwvz

Continuous Glucose Monitors (CGM)

Day Habilitation and Day Habilitation Individualized Staffing Supports

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

Gender Affirming Surgery and Related Procedures

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

Genetic and Molecular Testing

Grocery Shopping and Delivery Service

Group Adult Foster Care

Home Delivered Meals and Medically Tailored Meals

Home Accessibility Adaptations

Home Health Services – Medicare Advantage

Homemaker Services

Hospital Beds

Hyaluronic Acid Injection for Knee Osteoarthritis

Intravenous Iron Infusion

Laundry Services Delivery

Leqembi (lecanemab-irmb)

Massage Therapy

Maternal Cell-Free Fetal DNA Testing

Medical Necessity

Medicare Part B Step Therapy

New-to-Market Part B Medications

Non-Certified Home Health Aide

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

Power Seat Lift Chairs

Pressure Reducing Support Surfaces – Group 2 and Group 3

Program of Assertive Community Treatment

Radiofrequency Ablation for Lung Cancer

Recommendations for Intermittent Skilled Therapy in a Nursing Facility (NF)

Recommendations for Skilled Nursing

Recovery Coach Services

Recovery Support Navigator (RSN)

Repairs and Modifications of Durable Medical Equipment (DME)

Rhinoplasty and Septoplasty

Senior Care Option and One Care Products – Certified Home Health Services

Skilled Nursing Facility (SNF) Services Under Medicare Part A

Skin and Soft Tissue Substitutes

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

Supportive Day Program

Supportive Home Care Aide

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