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Clinical Determination Criteria and Medical Necessity
Medical Necessity
Medical Necessity means health care services or supplies that are consistent with accepted medical standards, appropriate for the patient’s condition, effective in diagnosing or treating an illness, injury, or disease, not primarily for convenience, and provided in the most cost-effective manner expected to achieve the same clinical outcome.
Clinical Determination Criteria
UM clinical staff use the following information, criteria, and hierarchy to make medical necessity determinations:
- CMS
- National Coverage Determination (NCD)
- Local Coverage Determination (LCD)
- LCDs outside of applicable Plan Service Area
- Medicare Benefit Policy Manuals, Transmittals and Publications
- AAH Medical Coverage Policies (AAH-MCP)
- Evidence Based Criteria
- MCG Care Guidelines
- Medicare Drug Compendia
- Other Approved Evidence Based Resources and Medical Literature
Find more information about clinical determination criteria by clicking the links below:
- National Coverage Determination (NCD) and Local Coverage Determination (LCD) Search (cms.gov)
- Medicare Internet-Only Manuals (IOMs)
Other Approved Evidence Based Resources and Medical Literature include:
Follow the instructions below to access the MCG Guidelines:
Step 1: Read the disclaimer and accept the terms and conditions.
Step 2: Complete the User Information Form.
Step 3: Complete the verification process to continue.
Step 4: Click on the arrow icon.
Step 5: Click on the guidelines you wish to view.
MCG Care Guidelines are protected by copyright and cannot be shared without permission. Members and prospective members can view applicable guidelines online but cannot print them.