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
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Adult Day Health
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Adult Foster Care
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Air Conditioner
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Assisted Living Services (Specialized Personal Assistance (SPA))
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Balloon Dilation of the Eustachian Tube
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Bed and Mattress Non-HCPCS Coded MNG 103
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Chimeric Antigen Receptor (CAR) T-Cell Therapy
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Chiropractic Services
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Chromosomal Microarray Analysis
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Chore Services
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Clinical Trials, Routine Patient Care Costs
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Community Crisis Stabilization (CCS)
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Community Support Programs and Specialized Community Support Programs (CSP)
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Companion Services
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Continuous Glucose Monitors (CGM)
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Day Habilitation and Day Habilitation Individualized Staffing Supports
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Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility
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Eating Disorder Acute Residential Treatment
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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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Gender Affirming Surgery and Related Procedures
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Genetic Testing BRCA-Related Breast and/or Ovarian Cancer Syndrome
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Genetic and Molecular Testing
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Grocery Shopping and Delivery Service
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Group Adult Foster Care
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Home Delivered Meals and Medically Tailored Meals
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Home Accessibility Adaptations
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Home Health Aide Services Non-Certified
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Home Health Services Certified: Senior Care Option and One Care
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Home Health Services – Medicare Advantage
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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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Leqembi (lecanemab-irmb)
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Manual Wheelchair Power Accessories
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Massage Therapy
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Maternal Cell-Free Fetal DNA Testing
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Medical Necessity
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Medicare Part B Step Therapy
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MyoPro Upper Limb Compensatory Device
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New-to-Market Part B Medications
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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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Oral Liquid Nutrition Supplements
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Out of Network Coverage
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Outpatient Medications: 2025 Part B Preferred Drug List
Part B Drugs Requiring Prior Authorization
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Peroral Endoscopic Myotomy (POEM)
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Personal Care Agency
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Personal Care Attendant
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Power Operated Vehicle
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Power Seat Lift Chairs
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Pressure Reducing Support Surfaces – Group 2 and Group 3
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Program of Assertive Community Treatment
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Pulmonary Artery Pressure Monitoring (CardioMEMS)
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Recommendations for Intermittent Skilled Therapy in a Nursing Facility (NF)
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Recovery Coach Services
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Recovery Support Navigator (RSN)
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Repairs and Modifications of Durable Medical Equipment (DME)
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Rhinoplasty and Septoplasty
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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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Subacute Level of Care in a Skilled Nursing Facility (SNF) Under Medicare Part A
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Supportive Day Program
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Supportive Home Care Aide
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