Medical Necessity Guidelines
Designed to facilitate consistent medical necessity determinations for coverage of select services and supplies.
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:
- 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
Alzheimer Coaching
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Cardiac Rehabilitation
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CG-Drug 95 Belatacept (Nulojix)
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Chiropractic Services
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Chore Services
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Day Services
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Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility
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Eculizumab
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Electronic Aids to Daily Living
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Outpatient Part B COVID-19 Treatment
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Excision of Excessive Skin & Subcutaneous Tissue
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Experimental and Investigational Services
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External Breast Prostheses
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FDG PET for Dementia and Neurodegenerative Diseases
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Gender Affirming Surgery and Related Procedures
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Genetic and Molecular Testing
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Hearing Aid
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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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Hyperbaric Oxygen Therapy
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Iron Infusion
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Lung Cancer Screening with Low Dose Computed Tomography (LDCT)
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Mattress – HCPC Coded Pressure Reducing Support Surfaces
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Medical Necessity
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Medicare Part B Step Therapy
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Medicare Part B Step Therapy Preferred Drug List
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Modified T-Cell Therapy
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Non-Preferred DME
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Osteogenesis Stimulators
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Personal Emergency Response System
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Pulmonary Rehabilitation
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Radicava (Edaravone)
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Radiofrequency Ablation for Lung Cancer
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Recommendations for Intermittent Skilled Therapy in a SNF
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Select Biologic Agents
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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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Sleep Studies
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Stair Lift
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Subacute level of Care in a Skilled Nursing Facility (SNF) under Medicare Part A
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Wheelchair-Custom Fabricated Seat and Cushion
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Wheelchair-Power Seating
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Active Water Circulation Pump with Cold Compression Pad
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Home Health Services
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Home Oxygen Therapy
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Non-Covered Benefit
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Non-Emergent Transportation
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Repairs and Modifications of Durable Medical Equipment (DME)
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