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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:

CCA Medical Necessity Guidelines


Adult Day Health

Adult Foster Care

Air Conditioner

Alzheimer Coaching

Assisted Living Services

Cardiac Rehabilitation

CG-Drug 95 Belatacept (Nulojix)

Chiropractic Services

Chore Services

Community Support Programs

Community Support Programs for Chronically Homeless Individuals

Day Habilitation

Day Services


Electronic Aids to Daily Living

EUA Antibody Therapies for COVID-19

Excision of Excessive Skin & Subcutaneous Tissue

Experimental and Investigational Services

External Breast Prostheses

FDG PET for Dementia and Neurodegenerative Diseases

Gender Affirming Surgery and Related Procedures

Genetic and Molecular Testing

Grocery Delivery

Group Adult Foster Care

Hearing Aid

Home Based Wandering Response System

Home Delivered Meals

Home Health Aide

Homemaker Services

Hospital Beds

Hyaluronic Acid Injection for Knee Osteoarthritis

Hyperbaric Oxygen Therapy

Iron Infusion

Laundry Services (Delivery)

Medical Necessity

Medicare Part B Step Therapy

Medicare Part B Step Therapy Preferred Drug List

Modified T-Cell Therapy

Non-Preferred DME

Osteogenesis Stimulators

Personal Emergency Response System

Program of Assertive Community Treatment

Radicava (Edaravone)

Recommendations for Intermittent Skilled Therapy in a SNF

Recovery Coach

Recovery Support Navigator

Select Biologic Agents

Skilled Nursing

Skin Subtitutes (Epifix)

Sleep Studies

Stair Lift

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