Currentcare_continuumPolicy n00240

Published Review Criteria

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This policy governs Network Health/Network Health Insurance/Network Health Administrative Services (and NH TPA) Utilization Management use of nationally published clinical criteria to make medical necessity decisions for covered members.

Policy Summary

Payercare_continuum

PolicyPublished Review Criteria

Policy CodePolicy n00240

Change TypeNo material change

Effective Date

Last ReviewFeb 20, 2025

Next Review DateFeb 19, 2027

Key ActionSubmit prior authorization requests consistent with published criteria and local desk procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~12listed published guideline sources referenced

annualreview frequency

11revision number

appliesMedicare NCD/LCD alignment

Coverage Criteria and Application

Published Criteria Application

Covered when ALL of the following governance conditions are met:

Governance and application: Utilization Management decisions must use the listed published criteria and apply them in a manner responsive to individual patient needs and local delivery system characteristics.

Uses sources listed in Procedure Detail sections A–K and considers patient characteristics in L.

Plan coverage limitation: Coverage is determined by medical necessity and limited by the member's specific plan coverage; follow the member's coverage booklet limitations and exclusions.

See Certificate of Coverage/Evidence of Coverage and members' Coverage Booklet Limitations and Exclusions.

Medicare alignment: For Medicare Advantage members, Medicare National and Local Coverage Determinations (Wisconsin jurisdiction) and Medicare manuals are followed as applicable.

References CMS NCD Search, Medicare National Coverage Determinations Manual, and Medicare Internet-Only Manuals.

Policy Summary

Payercare_continuum

PolicyPublished Review Criteria

Policy CodePolicy n00240

Change TypeNo material change

Effective Date

Last ReviewFeb 20, 2025

Next Review DateFeb 19, 2027

Key ActionSubmit prior authorization requests consistent with published criteria and local desk procedures.

SourceLink

On This Page

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Currentcare_continuumPolicy n00240

Published Review Criteria

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Sign up for care_continuum Policy n00240 alerts

Get alerted when Policy n00240 changes without checking for updates manually.

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Policy Summary

Payercare_continuum

PolicyPublished Review Criteria

Policy CodePolicy n00240

Change TypeNo material change

Effective Date

Last ReviewFeb 20, 2025

Next Review DateFeb 19, 2027

Key ActionSubmit prior authorization requests consistent with published criteria and local desk procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~12listed published guideline sources referenced

annualreview frequency

11revision number

appliesMedicare NCD/LCD alignment

Coverage Criteria and Application

Published Criteria Application

Covered when ALL of the following governance conditions are met:

Uses sources listed in Procedure Detail sections A–K and considers patient characteristics in L.

Plan coverage limitation: Coverage is determined by medical necessity and limited by the member's specific plan coverage; follow the member's coverage booklet limitations and exclusions.

See Certificate of Coverage/Evidence of Coverage and members' Coverage Booklet Limitations and Exclusions.

Medicare alignment: For Medicare Advantage members, Medicare National and Local Coverage Determinations (Wisconsin jurisdiction) and Medicare manuals are followed as applicable.

References CMS NCD Search, Medicare National Coverage Determinations Manual, and Medicare Internet-Only Manuals.

Policy Summary

Payercare_continuum

PolicyPublished Review Criteria

Policy CodePolicy n00240

Change TypeNo material change

Effective Date

Last ReviewFeb 20, 2025

Next Review DateFeb 19, 2027

Key ActionSubmit prior authorization requests consistent with published criteria and local desk procedures.

SourceLink

On This Page

Provider Requirements and Operational Pathways

Prior Authorization

Use published criteria for prior authorization

Utilization Management decisions use nationally published, evidence‑based review criteria to evaluate medical necessity for services; providers must submit prior authorization requests consistent with those published criteria and local desk procedures for clinical criteria application.

Examples of referenced sources: MCG editions, NCCN, CMS NCDs/LCDs, EviCore and CCUM guidelines.
See the Desk Procedure “Clinical Criteria for Utilization Decisions” for instructions on applying criteria to requests.

Step Therapy

Follow delegated program pathways

When care is delegated to external guideline programs, follow that program's pathways and step‑therapy rules for medical necessity determinations and approvals for the delegated services.

EviCore is delegated for programs including advanced imaging, cardiac diagnostics, musculoskeletal procedures, spine, interventional pain, radiation therapy, medical oncology, molecular genetic studies, GI procedures, PT/OT, Part D oncology adjuncts, and vascular intervention.
CCUM (ESI Care Continuum) is delegated for medical drug reviews (excluding oncology drugs).

Documentation Required

Verify plan-specific coverage

Verify the member's specific plan coverage and eligibility by consulting the member's Certificate of Coverage, Evidence of Coverage, Summary Plan Description, or Individual and Family Policy before requesting authorization or delivering services.

Employer group/plan sponsor and government contract terms may vary; Medicare Advantage follows Medicare NCD/LCDs where applicable.

Denial Risk

Denial risk from lack of medical necessity or plan limits

Coverage is determined by medical necessity and limited by the member's specific health plan; failure to meet published criteria or plan limits may result in denial of the request or noncoverage.

Services not meeting medical necessity as determined by the published review criteria and plan coverage limitations are not covered.
Members' Coverage Booklet Limitations and Exclusions supersede published criteria where applicable.

Policy Background

The Utilization Management department applies nationally published, evidence-based review criteria when evaluating requests. Sources include, for example, MCG and NCCN guidance, Medicare National and Local Coverage Determinations and manuals, delegated-vendor guidelines such as EviCore and CCUM, and other listed clinical guideline sets. These published criteria are applied in a manner responsive to individual patient characteristics (e.g., age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment) and to local delivery system considerations.

Key Definitions

Published clinical criteria — examples

MCG (various care guidelines)MCG — Recovery Facility Care; Ambulatory Care; Home Care; Inpatient and Surgical Care; General Recovery; Behavioral Health (30th Edition listed)

NCCNNational Comprehensive Cancer Network (listed as a referenced published criterion)

CMS National Coverage Decisions / Local Coverage DeterminationsMedicare NCDs and WI jurisdiction Local Coverage Determinations via the Medicare Coverage NCD Search and the Medicare National Coverage Determinations Manual (Pub. 100-3)

Medicare Part B resourcesPart B Answer Book, Medicare and related CMS Program Transmittals/Program Memoranda referenced for coverage policy context

Other delegated guideline sourcesEviCore and CCUM are referenced elsewhere in the policy as examples of delegated guideline sets used for utilization management

Individual patient characteristics considered

AgePatient age is considered when applying published criteria and determining medical necessity

Comorbidities and complicationsExisting comorbid conditions and any complications are evaluated against published criteria to determine appropriateness of services

Progress of treatmentClinical progress and response to prior treatment are considered in applying criteria

Psychosocial situation and home environmentPsychosocial factors and the patient’s home environment are considered when interpreting and applying published criteria

Individualized considerationsCriteria must be applied responsively to individual patient needs and local delivery system characteristics