Clinical Criteria
CommunityCare uses clinical criteria to support consistent, evidence-based medical necessity determinations for services covered under our Medicare Advantage plans, including our Dual Eligible Special Needs Plan (D-SNP).
Medicare Coverage Requirements
CommunityCare follows applicable Medicare coverage requirements when making clinical determinations for Medicare Advantage members.
Medicare coverage requirements may include Medicare benefit requirements, federal statutes and regulations, CMS rulemaking, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and associated coverage articles, and applicable CMS manuals and other interpretive guidance. These Medicare requirements take precedence over CommunityCare or other non-CMS clinical criteria.
CommunityCare Clinical Criteria
When applicable Medicare coverage requirements are silent or do not fully establish the criteria needed to make a clinical determination, CommunityCare may use additional clinical criteria that are consistent with Medicare requirements.
When an applicable CommunityCare Medical Policy approved for Medicare Advantage use is available, the Medical Policy will be used to evaluate the request. CommunityCare Medical Policies are maintained separately in our Medical Policy Library.
When an applicable CommunityCare Medical Policy is not available, CommunityCare uses nationally recognized clinical criteria based on current medical evidence, widely accepted clinical practice guidelines, and relevant clinical literature.
CommunityCare used InterQual® criteria for requests received before October 3, 2026, and uses MCG™ Care Guidelines for requests received on or after October 3, 2026.
Evolent Clinical Guidelines
CommunityCare partners with Evolent to administer utilization management for select services for our Medicare plans. Evolent clinical guidelines are used for services managed through this partnership.
Medical and Radiation Oncology
Advanced Cardiac Services
- Expanded Cardiac Guidelines
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Includes:
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Myocardial Perfusion Imaging (MPI)
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Multigated Acquisition Scan (MUGA)
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Stress Echocardiography
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Transthoracic Echocardiography (TTE)
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Transesophageal Echocardiography (TEE)
Advanced Imaging
Therapy Services
Interventional Pain Management
Musculoskeletal Surgery
