Clinical Criteria

Clinical criteria are used to guide medical decisions regarding diagnosis, management and treatment in health care.

CommunityCare complies with coverage criteria in statutes, regulations, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and general coverage and benefit conditions in Original Medicare as interpreted by the Centers for Medicare and Medicaid Services.
Medicare Coverage Database Search

When coverage criteria are not fully established in Medicare statutes, regulations, NCDs or LCDs, CommunityCare utilizes coverage criteria based on current evidence in widely used treatment guidelines or clinical literature.
InterQual® Transparency

Supporting websites:
CommunityCare may use the following guidelines to support coverage determinations:
Clinical Reference Guidelines

CommunityCare has a partnership with Dominion to administer supplemental dental benefits for our Medicare Advantage plans. Dominion’s coverage policies can be accessed below.
Dominion Utilization Review Guidelines

CommunityCare has a partnership with Evolent to administer utilization management for Radiation and Medical Oncology for our Medicare Advantage and Commercial plans. Evolent’s coverage policies can be accessed below.
Evolent Policies

CommunityCare has a partnership with Evolent to administer utilization management for the following services for our Medicare Advantage and Commercial (employer groups and individual/family plans):

• Diagnostic Cardiology

  • Myocardial Perfusion Imaging (MPI)
  • Mutligated Acquisition Scan (MUGA)
  • Stress Echocardiography
  • Transthoracic Echocardiography (TTE)
  • Transesophageal Echocardiography (TEE)

• Advanced Imaging

  • MRI/MRA
  • CT/CTA/CCTA
  • Pet

• Physical Medicine Management Services

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

• Interventional Pain Management

  • Facet Joint Injections
  • Epidural Spinal Injections
  • Sacroiliac Joint Injections
  • Facet Neurolysis

• Musculoskeletal Management Services

  • Musculoskeletal Surgery - Lumbar Spine (Fusion and Non-fusion)
  • Musculoskeletal Surgery - Cervical Spine (Fusion and Non-fusion)
  • Musculoskeletal Surgery - Hip, Knee, & Shoulder

Evolent’s coverage policies can be accessed below.

• Advanced Imaging Guidelines
• Expanded Cardiac Guidelines
• Interventional Pain Management Guidelines
• Musculoskeletal Surgery Guidelines
• Physical Medicine Clinical Guidelines