RetiredCareSourcePolicy N/A

Administrative Policy Statement — Arkansas PASSE

Sets CareSource's administrative policy framework for medical necessity determinations and decision hierarchy for services under the Arkansas PASSE program; applies to CareSource reviewers and providers making coverage requests under this program.

Policy Summary

PayerCareSource

PolicyAdministrative Policy Statement — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change (archived)

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionDetermine medical necessity using the defined hierarchy: federal/state regulation, nationally-accepted guidelines, CareSource policy statements, then reviewer judgment supported by peer-reviewed evidence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+documented decision hierarchy elements

2 studies preferredpeer-reviewed evidence standard

01/01/2022policy effective date

06/30/2022policy archived date

Coverage Criteria and Decision Rules

Medical Necessity Decision Hierarchy

Medical necessity determinations are made using the following hierarchy (in order):

Hierarchy level 1: Federal regulation or state regulation including state waiver regulations when applicable.

Hierarchy level 2: Nationally-accepted evidence-based clinical guideline (MCG Health).

Hierarchy level 3: CareSource medical policy statements.

Hierarchy level 4: Professional judgment of the medical or behavioral health reviewer supported by peer-reviewed evidence and specialty guidance; evidence from two published studies preferred (<5 years) and required within <10 years for novel uses.

Policy Summary

PayerCareSource

PolicyAdministrative Policy Statement — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change (archived)

Effective DateJan 1, 2022

Next Review DateN/A

SourceLink

On This Page

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Evidence Currency & Coding Considerations

Evidence currency requirement — two published studies preferred <5 years; <10 years required

Preferred evidence standardEvidence from TWO published studies from major scientific or medical peer‑reviewed journals that are <5 years old is preferred.

Minimum evidence requirement for novel usesEvidence from TWO published studies is required to be <10 years old to support the proposed use for the specific medical condition.

Study source and qualityStudies should be from major scientific or medical peer‑reviewed journals and approved by a U.S. institutional review board (IRB) where applicable.

Context of useThese evidence currency requirements apply when professional judgment and peer‑reviewed evidence are used to determine medical necessity for novel uses.

Provider Responsibilities, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization and Medical Necessity Hierarchy

Prior authorization and medical necessity determinations follow a defined hierarchy. Reviewers will apply federal and state regulations first, then nationally accepted evidence-based clinical guidelines, CareSource medical policy statements, and finally professional clinical judgment informed by peer-reviewed literature and specialty guidance.

Hierarchy includes: federal/state regulations; nationally-accepted guidelines (e.g., MCG Health); CareSource medical policy statements; professional judgment supported by evidence
Determinations may reference specialty society guidelines, NIH/CDC/AHRQ/NCCN/SAMHSA resources, and external evidence reviews (e.g., UpToDate, Hayes)

Note

Providers must submit complete clinical documentation and any supporting evidence at the time of prior authorization request. Include relevant history, diagnostic test results, prior treatments, and rationale for the requested service to avoid delays or denials.

Attach recent peer-reviewed studies or clinical guidelines when applicable
Document prior conservative treatments or why they are not appropriate

Documentation Required

Documentation and Acceptable Evidence Sources

Reviewers may require documented support from professional judgment, clinical practice guidelines, and nationally accepted evidence sources. Two published studies (preferably <5 years, required <10 years) from peer-reviewed journals may be requested to support novel or non-routine services.

Clinical Practice Guidelines from recognized consortiums
National panels and consortiums (NIH, CDC, AHRQ, NCCN, SAMHSA)
External evidence reviews (UpToDate, Hayes) and specialty peer consultation

Denial Risk

Denial Risk for Non‑Medically Necessary or Experimental Services

Coverage may be denied when a service is not medically necessary or is considered experimental, inappropriate, or ineffective based on objective clinical evidence and the established hierarchy of guidance.

Denials may be issued if service is not supported by federal/state regulation, accepted guidelines, CareSource policy, or adequate peer-reviewed evidence
Experimental or investigational services lacking sufficient objective evidence may be non-covered

Policy Background

This administrative statement defines medically necessary as a service reasonably calculated to prevent, diagnose, correct, cure, or prevent worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and for which no equally effective, more conservative, or less costly alternative exists.

Medical necessity determinations follow a defined hierarchy of evidence and authority, drawing on federal and state regulation, nationally-accepted clinical guidelines (e.g., MCG Health), CareSource medical policy statements, and the professional judgment of reviewers supported by peer-reviewed evidence. For novel uses, the policy prefers evidence from two published studies within 5 years and requires evidence within 10 years when applicable.

Coverage may be denied when services fail to meet these standards, and reviewers will reference the plan contract (Evidence of Coverage) where conflicts exist.

Key Definitions

Medically Necessary / Medical Necessity — definition

DefinitionA service is medically necessary if reasonably calculated to prevent, diagnose, correct, cure, or prevent worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction.

Comparative requirementMedically necessary services are those for which there is no other equally effective, more conservative, or less costly course of treatment available or suitable for the beneficiary.

Decision authorityDeterminations may be made by the Medical Director for the PASSE Program or by the PASSE Program Quality Improvement Organization (QIO).

Denial risk for experimental or ineffective servicesCoverage may be denied if a service is not medically necessary or is generally regarded by the medical profession as experimental, inappropriate, or ineffective unless objective clinical evidence demonstrates circumstances making the service necessary.