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

Adult Foster Care

Air Conditioner

Assisted Living Services-Specialized Personal Assistance (SPA)

Balloon Dilation of the Eustachian Tube

Bed and Mattress Non-HCPCS Coded

BRCA/PALB2 Related Breast and/or Ovarian Cancer Syndrome

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

Continuous Glucose Monitors (CGM)

Day Habilitation

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 and Molecular Testing

Grocery Shopping and Delivery Service

Group Adult Foster Care

Home Delivered Meals and Medically Tailored Meals

Home Accessibility Adaptations

Home Health Aide Services Provided by Non-Certified Agency

Home Health Services Certified: Senior Care Options and One Care

Homemaker Services – Agency-Delivered

Hospital Beds

Inpatient Rehabilitation Facility

Intermittent Skilled Therapy in a Nursing Facility (NF)

Intravenous Iron Infusion

Laundry Services Delivery

Leqembi (lecanemab-irmb)

Manual Wheelchair Power Accessories

Massage Therapy

Maternal Cell-Free Fetal DNA Testing

Medical Necessity

Medicare Part B Step Therapy

MyoPro Upper Limb Compensatory Device

New-to-Market Part B Medications

Non-Covered Benefit

Non-Emergent Transportation (Supplemental Benefit)

Non-Preferred Durable Medical Equipment and Supplies

Oral Liquid Nutrition Supplements

Out of Network Coverage

Outpatient Medications: 2025 Part B Preferred Drug List

Outpatient Medications: 2026 Part B Preferred Drug List

Part B Drugs Requiring Prior Authorization

Peroral Endoscopic Myotomy (POEM)

Personal Care Services (Agency Delivered)

Personal Care Attendant (PCA) Program (Consumer/Self Directed Care)

Power Operated Vehicle

Power Seat Lift Chairs

Pressure Reducing Support Surfaces – Group 2 and Group 3

Program of Assertive Community Treatment

Pulmonary Artery Pressure Monitoring (CardioMEMS)

Recovery Coach Services

Recovery Support Navigator (RSN)

Repairs and Modifications of Durable Medical Equipment (DME)

Rhinoplasty and Septoplasty

Skilled Nursing Facility (SNF) Services Under Medicare Part A

Skin and Soft Tissue Substitutes

Supportive Day Program

Supportive Home Care Aide

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