Medical Necessity

“Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:

1. in accordance with generally accepted standards of medical practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease; and
3. not primarily for the convenience of the patient, physician, or other health care provider, and
4. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

Clinical Determination Criteria

UM clinical staff use the following information, criteria, and hierarchy to make medical necessity determinations:

1. Health Plan (Administrative – eligibility and plan benefits)
   1. Evidence of Coverage (EOC)
   2. The Plan Benefit Package (PBP)
2. UM Clinical System Software (Administrative – eligibility and plan benefits)
3. CMS
   1. National Coverage Determination (NCD)
   2. Local Coverage Determination (LCD)
   3. LCDs outside of applicable Plan Service Area
   4. Medicare Benefit Policy Manuals, Transmittals and Publications
4. AAH Medical Coverage Policies (AAH-MCP)
5. Evidence Based Criteria
   1. MCG Care Guidelines
   2. Medicare Drug Compendia
6. Other Approved Evidence Based Resources and Medical Literature

Find more information about clinical determination criteria by clicking the links below:

• National Coverage NCD Report Results (cms.gov)
• Local Coverage Final LCDs by Contractor Report Results (cms.gov)
• Local Coverage Articles by Contractor Report Results (cms.gov)
• Medicare Internet-Only Manuals (IOMs)

Other Approved Evidence Based Resources and Medical Literature include:

• MCG
• Dental

Care Guidelines are the protected intellectual property of MCG. Align Senior Care is not able to distribute them without the permission of MCG. MCG has provided a tool that allows our members and prospective members to view relevant MCG guidelines, however you will not be able to print them.

Follow the instructions below to access the MCG Guidelines: