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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, select elective surgical procedures, pharmaceuticals, oral surgery, transplants, and other services. The guidelines are:

CCA Medical Necessity Guidelines

Alzheimer Coaching

Cardiac Rehabilitation

CG-Drug 95 Belatacept (Nulojix)

Chiropractic Services

Chore Services

Day Services

Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility


Electronic Aids to Daily Living

Outpatient Part B COVID-19 Treatment

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

Hearing Aid

Homemaker Services

Hospital Beds

Hyaluronic Acid Injection for Knee Osteoarthritis

Hyperbaric Oxygen Therapy

Iron Infusion

Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

Mattress – HCPC Coded Pressure Reducing Support Surfaces

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

Pulmonary Rehabilitation

Radicava (Edaravone)

Radiofrequency Ablation for Lung Cancer

Recommendations for Intermittent Skilled Therapy in a SNF

Select Biologic Agents

Skilled Nursing Facility (SNF) Services Under Medicare Part A

Skin and Soft Tissue Substitutes

Sleep Studies

Stair Lift

Subacute level of Care in a Skilled Nursing Facility (SNF) under Medicare Part A

Wheelchair-Custom Fabricated Seat and Cushion

Wheelchair-Power Seating

Active Water Circulation Pump with Cold Compression Pad

Home Health Services

Home Oxygen Therapy

Non-Covered Benefit

Non-Emergent Transportation

Repairs and Modifications of Durable Medical Equipment (DME)