Medical Necessity Guidelines
Designed to facilitate consistent medical necessity determinations for coverage of select services and supplies.
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
view:
Adult Day Health (ADH)
Adult Foster Care
Assisted Living Services-Specialized Personal Assistance (SPA)
view:
Balloon Dilation of the Eustachian Tube
BRCA/PALB2 Related Breast and/or Ovarian Cancer Syndrome
view:
Chimeric Antigen Receptor (CAR) T-Cell Therapy
Chiropractic Services
view:
Chromosomal Microarray Analysis
Clinical Trials, Routine Patient Care Costs
Community Crisis Stabilization (CCS)
view:
Community Support Programs and Specialized Community Support Programs (CSP)
Continuous Glucose Monitors (CGM)
Day Habilitation
view:
Eating Disorder Acute Residential Treatment
Excision of Excessive Skin & Subcutaneous Tissue
Experimental and Investigational Services
Gender Affirming Surgery and Related Procedures
Genetic and Molecular Testing
Group Adult Foster Care
Home Health Aide Services Provided by Non-Certified Agency
Home Health Services Certified: Senior Care Options and One Care
view:
Hospital Beds
Inpatient Rehabilitation Facility
view:
Intermittent Skilled Therapy in a Nursing Facility (NF)
view:
Manual Wheelchair Power Accessories
view:
Maternal Cell-Free Fetal DNA Testing
view:
Medical Necessity
view:
MyoPro Upper Limb Compensatory Device
Non-Covered Benefit
Non-Emergency Ground Ambulance Transportation
view:
Non-Emergent Transportation (Supplemental Benefit)
view:
Non-Preferred Durable Medical Equipment and Supplies
view:
One Care Flexible Benefits
view:
Oral Liquid Nutrition Supplements
view:
Out of Network Coverage
view:
Outpatient Medications: 2026 Part B Preferred Drug List
view:
Peroral Endoscopic Myotomy (POEM)
view:
Personal Care Attendant Program Consumer Directed
Power Operated Vehicle
view:
Power Seat Lift Chairs
Pressure Reducing Support Surfaces – Group 2 and Group 3
Program of Assertive Community Treatment
view:
Pulmonary Artery Pressure Monitoring (CardioMEMS)
Recovery Coach Services
view:
Recovery Support Navigator (RSN)
Repairs and Modifications of Durable Medical Equipment (DME)
view:
Rhinoplasty and Septoplasty
SCO Home and Community Based Services (HCBS)
Skilled Nursing Facility (SNF) Services Under Medicare
Skin and Soft Tissue Substitutes
Medical Necessity Guidelines
Part B Pharmacy Policies
Alpha1-Proteinase Inhibitor Products UM Medical Policy
Alzheimer’s Disease – Amyloid Beta-Directed Antibodies – Kisunla
Alzheimer’s Disease – Amyloid Beta-Directed Antibodies – Leqembi Intravenous and Leqembi IQLIK
Amvuttra™ (vutrisiran subcutaneous injection − Alnyam)
Amyloidosis – Onpattro
Amyloidosis – Tegsedi
Antiemetics – Palonosetron Intravenous Products
Bone Modifiers – Denosumab Products (Prolia)
Bone Modifiers – Denosumab Products (Xgeva)
Bone Modifiers – Evenity
Bone Modifiers – Ibandronate Intravenous
Bone Modifiers – Zoledronic Acid (Reclast)
Bone Modifiers – Zoledronic Acid (Zometa)
Botulinum Toxins – Botox
Botulinum Toxins – Daxxify
Botulinum Toxins – Dysport
Botulinum Toxins – Myobloc
Botulinum Toxins – Xeomin
Chemoprotective Agent – Pedmark
Colony Stimulating Factors – Filgrastim Products
Colony Stimulating Factors – Granix
Colony Stimulating Factors – Leukine
Colony Stimulating Factors – Pegfilgrastim Products
Colony Stimulating Factors – Rolvedon
Colony Stimulating Factors – Ryzneuta
Complement Inhibitors – Veopoz
Complement Inhibitors – Eculizumab Products
Complement Inhibitors – PiaSky
Complement Inhibitors – Ultomiris
Coronavirus Disease – Evusheld
Coronavirus Disease – Veklury
Corticosteroids (Intraarticular) – Zilretta
Crysvita
Dermatology – Gene Therapy – Vyjuvek
Dermatology – Gene Therapy – Zevaskyn
Dermatology – Ycanth
Diabetes – Tzield
Enzyme Replacement Therapy – Aldurazyme
Enzyme Replacement Therapy – Elaprase
Enzyme Replacement Therapy – Elfabrio
Enzyme Replacement Therapy – Fabrazyme
Enzyme Replacement Therapy – Kanuma
Enzyme Replacement Therapy – Lamzede
Enzyme Replacement Therapy – Mepsevii
Enzyme Replacement Therapy – Naglazyme
Enzyme Replacement Therapy – Revcovi
Enzyme Replacement Therapy – Vimizim
Enzyme Replacement Therapy – Xenpozyme
Erythropoiesis-Stimulating Agents – Aranesp
Erythropoiesis-Stimulating Agents – Epoetin Alfa Products
Erythropoiesis-Stimulating Agents – Mircera
Gamifant
Gaucher Disease – Enzyme Replacement Therapy – Cerezyme
Gaucher Disease – Enzyme Replacement Therapy – Elelyso
Gaucher Disease – Enzyme Replacement Therapy – Vpriv
Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty
Gonadotropin-Releasing Hormone Agonists – Implants
Gonadotropin-Releasing Hormone Agonists – Lupron Depot
Gout – Krystexxa
Graft-Versus-Host Disease – Niktimvo
Graft-Versus-Host Disease – Ryoncil
Hematology – Adzynma
Hematology – Aphexda
Hematology – Cablivi
Hematology – Ceprotin
Hematology – Coagadex
Hematology – Corifact
Hematology – Enjaymo
Hematology – Fibrinogen Products
Hematology – Gene Therapy – Casgevy
Hematology – Gene Therapy – Lyfgenia
Hematology – Gene Therapy – Zynteglo
Hematology – Omisirge
Hematology – Reblozyl
Hematology – Ryplazim
Hematology – Rytelo
Hematology – Tretten
Hematology – Vonvendi
Hemophilia – Altuviiio
Hemophilia – Eptacog Products – NovoSeven RT
Hemophilia – Eptacog Products – Sevenfact
Hemophilia – Factor IX Products
Hemophilia – Factor VIII Products
Hemophilia – FEIBA
Hemophilia – Gene Therapy – Hemgenix
Hemophilia – Gene Therapy – Roctavian
Hemophilia – Non-Factor Routine Prophylaxis Products – Hemlibra
Hepatology – Givlaari
Hepatology – Panhematin
Hereditary Angioedema – Andembry
Hereditary Angioedema – C1 Esterase Inhibitors (Intravenous)
Hereditary Angioedema – C1 Esterase Inhibitors (Subcutaneous)
Hereditary Angioedema – Dawnzera
Hereditary Angioedema – Icatibant
Hereditary Angioedema – Kalbitor
Hereditary Angioedema – Takhzyro
Homozygous Familial Hypercholesterolemia – Evkeeza
Human Immunodeficiency Virus – Apretude
Human Immunodeficiency Virus – Cabenuva
Human Immunodeficiency Virus – Sunlenca
Human Immunodeficiency Virus – Trogarzo
Human Immunodeficiency Virus – Yeztugo
Hyaluronic Acid Derivatives (Intraarticular)
Immune Globulin – Atgam
Immune Globulin – Cytogam
Immune Globulin – Intravenous
Immune Globulin – Subcutaneous
Immunologicals – Cinqair
Immunologicals – Exdensur
Immunologicals – Fasenra
Immunologicals – Nucala
Immunologicals – Tezspire
Immunologicals – Xolair
Inflammatory Conditions – Cimzia
Inflammatory Conditions – Cosentyx Intravenous
Inflammatory Conditions – Entyvio Intravenous
Inflammatory Conditions – Ilaris
Inflammatory Conditions – Ilumya
Inflammatory Conditions – Infliximab Intravenous Products
Inflammatory Conditions – Omvoh Intravenous
Inflammatory Conditions – Orencia Intravenous
Inflammatory Conditions – Simponi Aria
Inflammatory Conditions – Skyrizi Intravenous
Inflammatory Conditions – Spevigo Intravenous
Inflammatory Conditions – Tocilizumab Intravenous Products
Inflammatory Conditions – Tremfya Intravenous
Inflammatory Conditions – Ustekinumab Intravenous Products
Iron Replacement – Ferumoxytol
Iron Replacement – INFeD
Iron Replacement – Injectafer
Iron Replacement – Iron Sucrose
Iron Replacement – Monoferric
Iron Replacement – Sodium Ferric Gluconate
Lupus – Benlysta Intravenous
Lupus – Saphnelo
Metabolic Disorders – Imcivree
Metabolic Disorders – Nulibry
Metabolic Disorders – Primary Hyperoxaluria – Oxlumo
Metabolic Disorders – Primary Hyperoxaluria – Rivfloza
Migraine – Calcitonin Gene-Related Peptide Inhibitors – Vyepti
Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Briumvi
Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Ocrevus Zunovo
Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Ocrevus Zunovo
Multiple Sclerosis (Injectable – Other) – Lemtrada
Multiple Sclerosis and Crohn’s Disease (Injectable – Other) – Natalizumab Products
Muscular Dystrophy – Amondys 45
Muscular Dystrophy – Exondys 51
Muscular Dystrophy – Gene Therapy – Elevidys
Muscular Dystrophy – Viltepso
Muscular Dystrophy – Vyondys 53
Neurology – Brineura
Neurology – Edaravone Intravenous
Neurology – Gene Therapy – Kebilidi
Neurology – Gene Therapy – Lenmeldy
Neurology – Gene Therapy – Skysona
Neurology – Imaavy
Neurology – Qalsody
Neurology – Rystiggo
Neurology – Vyvgart Hytrulo
Neurology – Vyvgart Intravenous
Oncology (Injectable – Alkylating agent) – Zepzelca
Oncology (Injectable – Anti-GD2 Antibody) – Danyelza
Oncology (Injectable – Anti-GD2 Antibody) – Unituxin
Oncology (Injectable – Antibody-Drug Conjugate – c-Met) – Emrelis
Oncology (Injectable – Antibody – Drug Conjugate – Trop-2) – Datroway
Oncology (Injectable – Antibody – Drug Conjugate – Trop-2) – Trodelvy
Oncology (Injectable – Antibody-Drug Conjugate – HER2) – Enhertu
Oncology (Injectable – Antibody-Drug Conjugate – HER2) – Kadcyla
Oncology (Injectable – Asparaginase) – Asparlas
Oncology (Injectable – Asparaginase) – Oncaspar
Oncology (Injectable – Asparaginase) – Rylaze
Oncology (Injectable – Bispecific – BCMA-Directed) – Lynozyfic
Oncology (Injectable – Bispecific – BCMA-Directed) – Tecvayli
Oncology (Injectable – Bispecific – CD20-Directed) – Columvi
Oncology (Injectable – Bispecific – CD20-Directed) – Epkinly
Oncology (Injectable – Bispecific – CD20-Directed) – Lunsumio
Oncology (Injectable – Bispecific – GPRC5D-Directed) – Talvey
Oncology (Injectable – Bispecific – BCMA-Directed) – Elrexfio
Oncology (Injectable – CAR-T) – Abecma
Oncology (Injectable – CAR-T) – Aucatzyl
Oncology (Injectable – CAR-T) – Breyanzi
Oncology (Injectable – CAR-T) – Carvykti
Oncology (Injectable – CAR-T) – Kymriah
Oncology (Injectable – CAR-T) – Tecartus
Oncology (Injectable – CAR-T) – Yescarta
Oncology (Injectable – CD20-Directed Antibody) – Gazyva
Oncology (Injectable – CD20-Directed Antibody) – Rituxan
Oncology (Injectable – CD38 – Directed Cytolytic Antibody) – Darzalex Faspro
Oncology (Injectable – CD38 – Directed Cytolytic Antibody) – Darzalex Intravenous
Oncology (Injectable – CD38-Directed Cytolytic Antibody) – Sarclisa
Oncology (Injectable – CTLA-4 Antibody) – Imjudo
Oncology (Injectable – CTLA-4 Antibody) – Yervoy
Oncology (Injectable – Epidermal Growth Factor Receptor Exon 20 Mutation Agent) – Rybrevant
Oncology (Injectable – Epidermal Growth Factor Receptor Exon 20 Mutation Agent) – Rybrevant Faspro
Oncology (Injectable – Epidermal Growth Factor Receptor Inhibitor) – Erbitux
Oncology (Injectable – Epidermal Growth Factor Receptor Inhibitor) – Vectibix
Oncology (Injectable – HER2 Antagonist) – Herceptin Hylecta
Oncology (Injectable – HER2 Antagonist) – Perjeta
Oncology (Injectable – HER2 Antagonist) – Phesgo
Oncology (Injectable – HER2 Antagonist) – Trastuzumab Products
Oncology (Injectable – Histone Deacetylase Inhibitor) – Beleodaq
Oncology (Injectable – Histone Deacetylase Inhibitor) – Romidepsin Products
Oncology (Injectable – Microtubule Inhibitor) – Halaven
Oncology (Injectable – Microtubule Inhibitor) – Ixempra
Oncology (Injectable – Microtubule Inhibitor) – Jevtana
Oncology (Injectable – Microtubule Inhibitor) – Paclitaxel Albumin-Bound Products
Oncology (Injectable – mTOR Inhibitor) – Fyarro
Oncology (Injectable – mTOR Inhibitor) – Torisel
Oncology (Injectable – Programmed Death Receptor-1) – Jemperli
Oncology (Injectable – Programmed Death Receptor-1) – Keytruda Qlex
Oncology (Injectable – Programmed Death Receptor-1) – Keytruda
Oncology (Injectable – Programmed Death Receptor-1) – Libtayo
Oncology (Injectable – Programmed Death Receptor-1) – Loqtorzi
Oncology (Injectable – Programmed Death Receptor-1) – Opdivo Qvantig
Oncology (Injectable – Programmed Death Receptor-1) – Opdivo
Oncology (Injectable – Programmed Death Receptor-1) – Opdualag
Oncology (Injectable – Programmed Death Receptor-1) – Tevimbra
Oncology (Injectable – Programmed Death Receptor-1) – Zynyz
Oncology (Injectable – Programmed Death-Ligand 1) – Bavencio
Oncology (Injectable – Programmed Death-Ligand 1) – Imfinzi
Oncology (Injectable – Programmed Death-Ligand 1) – Tecentriq Hybreza
Oncology (Injectable – Programmed Death-Ligand 1) – Tecentriq
Oncology (Injectable – Programmed Death-Ligand 1) – Unloxcyt
Oncology (Injectable – Proteasome Inhibitor) – Bortezomib Products
Oncology (Injectable – Proteasome Inhibitor) – Kyprolis
Oncology (Injectable – Topoisomerase Inhibitor) – Onivyde
Oncology (Injectable – Topoisomerase Inhibitor) – Topotecan Products
Oncology (Injectable – Vascular Endothelial Growth Factor Inhibitors) – Zaltrap
Oncology (Injectable – Antibody-Drug Conjugate – CD19) – Monjuvi
Oncology (Injectable – Antibody-Drug Conjugate – CD22)– Besponsa
Oncology (Injectable – T-Cell Immunotherapy – MAGE-A4) – Tecelra
Oncology (Injectable) – Adcetris
Oncology (Injectable) – Aliqopa
Oncology (Injectable) – Amtagvi
Oncology (Injectable) – Arsenic Trioxide
Oncology (Injectable) – Azedra
Oncology (Injectable) – Bendamustine Products
Oncology (Injectable) – Bevacizumab Products
Oncology (Injectable) – Bizengri
Oncology (Injectable) – Blenrep
Oncology (Injectable) – Blincyto
Oncology (Injectable) – Carmustine Products
Oncology (Injectable) – Cosela
Oncology (Injectable) – Cyramza
Oncology (Injectable) – Decitabine Products
Oncology (Injectable) – Elahere
Oncology (Injectable) – Elzonris
Oncology (Injectable) – Empliciti
Oncology (Injectable) – Fulvestrant
Oncology (Injectable) – Gonadotropin-Releasing Hormone Analogs
Oncology (Injectable) – Imdelltra
Oncology (Injectable) – Imlygic
Oncology (Injectable) – Kimmtrak
Oncology (Injectable) – Levoleucovorin Products
Oncology (Injectable) – Lymphir
Oncology (Injectable) – Margenza
Oncology (Injectable) – Mylotarg
Oncology (Injectable) – Nipent
Oncology (Injectable) – Padcev
Oncology (Injectable) – Pemetrexed Products
Oncology (Injectable) – Pluvicto
Oncology (Injectable) – Polivy
Oncology (Injectable) – Portrazza
Oncology (Injectable) – Poteligeo
Oncology (Injectable) – Pralatrexate Products
Oncology (Injectable) – Proleukin
Oncology (Injectable) – Provenge
Oncology (Injectable) – Temozolomide Intravenous
Oncology (Injectable) – Thiotepa Products
Oncology (Injectable) – Tivdak
Oncology (Injectable) – Vyloy
Oncology (Injectable) – Vyxeos
Oncology (Injectable) – Yondelis
Oncology (Injectable) – Ziihera
Oncology (Injectable) – Zynlonta
Oncology (Injectable) – Sylvant
Oncology (Intravesical) – Adstiladrin
Oncology (Intravesical) – Anktiva
Oncology (Intravesical) – Inlexzo
Oncology (Intravesical) – Valrubicin Products
Oncology (Intravesical) – Zusduri
Oncology (Other) – Jelmyto
Ophthalmology – Durysta
Ophthalmology – Gene Therapy – Luxturna
Ophthalmology – iDose TR
Ophthalmology – Izervay
Ophthalmology – Tepezza
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Aflibercept Products
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Beovu
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Ranibizumab Products
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Susvimo
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Vabysmo
Ophthalmology – Gene Therapy – Encelto
Ophthalmology – Syfovre
Papillomatosis – Gene Therapy – Papzimeos
Parkinson’s Disease – Onapgo
Parkinson’s Disease – Vyalev
Pompe Disease – Enzyme Replacement Therapy – Lumizyme
Pompe Disease – Enzyme Replacement Therapy – Nexviazyme
Pompe Disease – Enzyme Replacement Therapy – Pombiliti
Proprotein Convertase Subtilisin Kexin Type 9 Related Products – Leqvio
Psychiatry – Spravato
Psychiatry – Zulresso
Pulmonary Arterial Hypertension – Epoprostenol Products
Pulmonary Arterial Hypertension – Treprostinil Injection
Repository Corticotropin – Acthar Gel
Repository Corticotropin – Cortrophin Gel
Rituximab Intravenous Products
Scenesse
Sickle Cell Disease – Adakveo
Somatostatin Analogs – Lanreotide Products
Somatostatin Analogs – Lutathera
Somatostatin Analogs – Octreotide Long-Acting Products
Somatostatin Analogs – Signifor LAR
Spinal Muscular Atrophy – Gene Therapy – Zolgensma
Spinal Muscular Atrophy – Spinraza
Synagis
Testosterone (Injectable)
Thrombocytopenia – Nplate
Transplantation – Grafapex
Transplantation – Nulojix
Uplizna
Xiaflex
Provider Services is here to help
8 am – 5 pm Monday, Tuesday, Wednesday, and Friday
8:30 am – 5 pm Thursday
8:30 am – 5 pm Thursday