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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 Foster Care

Air Conditioner

Alzheimer Coaching

Cardiac Rehabilitation

CG-Drug 95 Belatacept (Nulojix)

Chiropractic Services

Community Support Programs

Community Support Programs for Chronically Homeless Individuals

Day Habilitation

Dehydrated Human Amniotic Membrane (Epifix)


Electric Tumor Treatment Field Therapy

EUA Antibody Therapies for COVID-19

Excision of Excessive Skin & Subcutaneous Tissue

Experimental and Investigational Services

FDG PET for Dementia and Neurodegenerative Diseases

Gender Affirming Surgery and Related Procedures

Genetic and Molecular Testing

Hearing Aid

Home Based Wandering Response System

Home Delivered Meals

Hyaluronic Acid Injection for Knee Osteoarthritis

Hyperbaric Oxygen Therapy

Iron Infusion

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

Select Biologic Agents

Skilled Nursing

Sleep Studies

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