Published Review Criteria Medical Policy (use of evidence-based guidelines)
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Defines the annual review and approval of the Published Review Criteria Medical Policy and the evidence-based guidelines (e.g., MCG, CMS, NCCN, EviCore) used for medical necessity decision-making for Network Health Plan lines of business (Commercial, Medicare, NH TPA).
Adoption of the MCG 30th edition when it becomes available (February 27, 2026).
Added NH TPA as a covered line of business.
Grammatical changes throughout the policy.
Authorized Guidelines and Coverage Rules
Authorized Evidence Sources
Covered when the following guideline sources are used for medical necessity determinations:
Policy authorizes use of these sources for utilization review; MCG 30th edition adoption requested upon availability (Feb 27, 2026).
Network Health medical policies do not supersede contract language or law. Contract language and state/federal laws take precedence over any medical policy; coverage determinations are made first by the member's specific Network Health coverage documents (for example, the Certificate of Coverage, Evidence of Coverage, or Summary Plan Description).
Medicare members follow applicable CMS coverage statements including National Coverage Determinations (NCD) and Local Coverage Determinations (LCD); refer to the CMS website for details. Because coverage terms can differ across plans and lines of business, services that are inconsistent with a member's coverage documents or applicable CMS rulings may be denied.
Provider Requirements and Prior Authorization
Use authorized evidence sources for prior authorization
Medical necessity and prior authorization determinations will reference the authorized evidence sources listed in this policy, including CMS (NCD/LCD/Billing & Coding/Manuals), MCG Guidelines (30th edition and specified modules), NCCN, EviCore clinical guidelines (for delegated programs), and CareContinuum clinical guidelines (for delegated programs).
- MCG 30th edition (Ambulatory, Inpatient & Surgical, Recovery, Home Care, Behavioral Health)
- CMS Medicare Coverage Center resources (NCDs, LCDs, Billing & Coding, Manuals)
- NCCN; EviCore clinical guidelines for delegated programs; CareContinuum clinical guidelines for delegated programs
Annual review completed; MCG 30th edition adoption requested
Annual review of the Published Review Criteria policy was completed and the Utilization Management Committee is asked to approve use of MCG 30th edition when available; the policy’s utilization guidance remains unchanged.
- Requests approval to adopt MCG 30th edition effective February 27, 2026
- Policy wording updates were limited to grammatical changes
Verify member-specific coverage documents and CMS rules
Before determining coverage or submitting authorization requests, consult the member’s specific Network Health coverage documents and applicable CMS coverage statements for Medicare members.
- Network Health coverage documents: Certificate of Coverage, Evidence of Coverage, Summary Plan Descriptions
- Medicare members: follow applicable CMS coverage statements (NCDs and LCDs) and refer to www.cms.gov
Denial risk if inconsistent with contract, state/federal law, or CMS determinations
Coverage decisions may be superseded by contract language or state/federal law; services inconsistent with a member’s Network Health coverage documents or applicable CMS determinations risk denial.
- Contract language and state/federal laws take precedence over medical policies
- Coverage differences across Network Health documents may trigger denials if services are inconsistent with those documents or CMS rulings
Key Terms
Policy Background
This policy documents the set of evidence‑based guideline sources the Utilization Management Committee authorizes for use in medical necessity and utilization review decisions. Authorized sources include CMS determinations (NCD/LCD/Billing & Coding/Manuals), MCG Guidelines (30th edition — Ambulatory, Inpatient & Surgical, Recovery, Home Care, Behavioral Health), NCCN, and vendor guidelines such as EviCore and CareContinuum for delegated programs.
The policy establishes that these Published Review Criteria are to be referenced when making prior authorization and other utilization management determinations to standardize review across Network Health lines of business (Commercial, Medicare, and NH TPA). The policy is updated periodically (reviewed annually), and operational approval has been requested for adoption of the MCG 30th edition when available.
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