CurrentCommunity Health Plan WashingtonPolicy MC.CP.CPC.05

Medical Necessity Criteria

Defines the hierarchy, definitions, and decision-making framework Medicare-affiliated Centene plans will use to determine medical necessity for coverage decisions; applies to Medicare health plans affiliated with Centene and Centene Advanced Behavioral Health.

Policy Summary

PayerCommunity Health Plan Washington

PolicyMedical Necessity Criteria

Policy CodePolicy MC.CP.CPC.05

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen making medical necessity decisions, follow the defined hierarchy of sources (federal/CMS guidance first, then Centene policies/InterQual, decision support tools, and lastly published guidelines/literature) to determine coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A-FHierarchy sections

26+Never event examples

AnnualReview frequency

1-9Reference list

Coverage criteria and decision framework

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Medical necessity decision hierarchy

When making medical necessity decisions, use the following hierarchy (use earlier source if guidance exists):

Hierarchy Level A: Federal law and regulations, sub-regulatory guidance, National Coverage Determinations (NCD), Local Coverage Determinations (LCD), Local Coverage Articles (LCA), Medicare policy manuals and other CMS guidance. When these do not constitute full coverage criteria, sources D-F may be used.

Level A is the primary source; additional criteria are permitted when NCDs/LCDs lack full coverage criteria.

Hierarchy Level B: Centene clinical policy adopted by Medicare plans (including InterQual custom content), or ASAM criteria for SUD-related care.

Used when Level A does not fully establish coverage.

Hierarchy Level C: Nationally recognized decision support tools such as InterQual Clinical Decision Support Criteria.

Used when Levels A-B do not provide full criteria.

Hierarchy Level D: If no criteria from A-C, the Medical Director may consider current, widely-used treatment guidelines; peer-reviewed literature (large RCTs, prospective cohort studies, large systematic reviews/meta-analyses); professional standards of safety and effectiveness; nationally recognized drug compendia; and assessments from government-funded or independent entities (e.g., AHRQ, NICE).

Level D lists acceptable evidence types (guidelines, RCTs, cohort studies, systematic reviews, compendia, AHRQ/NICE).

Medical necessity definition

Services are considered medically necessary when ALL of the following are met:

Medical necessity definition: The service is in accordance with generally accepted standards of medical practice; clinically appropriate in type, frequency, extent, site, and duration; and considered effective for the patient's illness, injury, or disease; and it is not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service at least as likely to produce equivalent therapeutic or diagnostic results.

Medically necessary services may exclude experimental/investigational technologies or carve-out days.

This policy excludes experimental or investigational services and carve-out inpatient days from medically necessary coverage. Experimental/investigational services are those under active, credible evaluation (for example, clinical trials), lack final regulatory clearance for the requested indication, or for which recent peer‑reviewed studies are inconclusive about safety and effectiveness. Carve-out days are defined as non‑medically necessary inpatient hospital days that occur during an otherwise approved admission where the stay is prolonged unnecessarily (for example, delays due to equipment downtime, unavailable operating room time, or administrative/placement issues).

A service is considered not medically necessary and not investigational when the scientific evidence and evaluation do not support its safety or effectiveness for the requested use. Examples include when there are no recent peer‑reviewed studies describing the service, no active credible evaluations of a previously non‑covered service, conclusive peer‑reviewed evidence showing lack of effectiveness, absence of peer‑reviewed studies demonstrating safety and efficacy, or when the service is contraindicated.

What providers must do / authorization and denial requirements

Note

Use of hierarchy to determine medical necessity

Medicare-affiliated Centene plans will use a defined hierarchy of sources (federal law/regulation, Centene clinical policy/ASAM, nationally recognized decision support tools, then other guidance) to determine medical necessity on a case-by-case basis. If an authoritative source higher in the hierarchy provides guidance applicable to the request, that source must be followed rather than lower-level sources.

See CP.CPC.05 Medical Necessity Criteria for the medical necessity criteria hierarchy for lines of business other than Medicare.

Prior Authorization

Medical necessity requirement for authorization

Services must meet the Health Plan's definition of medically necessary to be authorized. Medically necessary means services that, exercising prudent clinical judgment, are provided to prevent, evaluate, diagnose, or treat an illness/injury and are: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in type, frequency, extent, site, and duration; and (3) not primarily for convenience and not more costly than an equivalent alternative. Experimental or investigational technologies are generally not considered medically necessary.

Documentation Required

Denial notification documentation

Denial notifications must not rely solely on this policy. Any adverse determination must cite the specific medical necessity criterion or source used to make the denial decision (for example, the applicable NCD/LCD, Centene clinical policy section, InterQual rule, or specialty guideline), and must document the clinical rationale tied to the member's presented facts.

Denial Risk

Denial decision requirements and authorized reviewers

Denials based on medical necessity must reference the specific criterion(s) used and identify the practitioner type who reviewed and authorized the denial. Only appropriate practitioners may make denial decisions for their respective domains (examples: physicians for medical/behavioral/pharmaceutical/dental/chiropractic/vision/physical therapy denials; doctoral-level clinical psychologists or certified addiction-medicine specialists for behavioral health denials; pharmacists for pharmaceutical denials; dentists for dental denials; chiropractors for chiropractic denials; physical therapists for physical therapy denials; APRNs for requests within their licensed scope).

Key definitions used in this policy

Medically necessary / medical necessity

DefinitionHealth care services that a health care provider, exercising prudent clinical judgment, would provide to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are in accordance with generally accepted standards of medical practice; clinically appropriate in type, frequency, extent, site, and duration; and not primarily for convenience or more costly than an alternative service at least as likely to produce equivalent results.

ApplicabilityApplies unless defined differently by the member/enrollee's Benefit Plan Contract or applicable provider agreement.

Clinical appropriateness criteriaServices must be consistent with accepted standards and clinically appropriate in type, frequency, extent, site, and duration.

Experimental and/or investigational technologies

DefinitionAny drugs, procedures, treatments, devices, supplies, and other health care services that are currently the subject of active and credible evaluation (e.g., clinical trials or research) to determine clinical efficacy, therapeutic value, or benefits beyond established alternatives; lack final clearance from regulatory bodies or unrestricted market approval for the requested indication; or whose most recent peer-reviewed studies are inconclusive or do not conclude the Service is safe and effective for the requested condition.

Examples of active evaluationClinical trials or research assessing clinical efficacy, therapeutic value, or benefits beyond established alternatives.

Regulatory statusConsidered experimental/investigational if there is no final clearance from governmental regulatory bodies (e.g., FDA) for the requested indication.

Carve-out days / never events

DefinitionNon-medically necessary inpatient hospital days occurring during an approved admission (i.e., an inpatient stay prolonged unnecessarily) and serious reportable events that may be non-reimbursable under the benefit contract.

Common carve-out day scenariosDays when a needed service is delayed for non-clinical reasons (e.g., equipment downtime, OR unavailability, specialist no-show), days solely for social reasons (e.g., awaiting foster placement), or days after discharge criteria are met but discharge delayed (e.g., transportation, DME delivery, SNF placement).

Quality-related carve-outs and never eventsDays of care necessitated by largely preventable quality issues (e.g., complications from wrong medication dose, central line–associated bloodstream infections, infections with resistant hospital flora) and serious reportable events such as stage 3–4 pressure ulcers, wrong-site surgery, retained foreign object, death/disability from air embolism, hypoglycemia, electric shock, burns, or certain surgical site infections — which may be non-covered or non-reimbursable per contract.

Policy purpose and scope

This policy provides definitions and a clear decision framework to determine whether a health care service is medically necessary. It defines medical necessity as services that a prudent provider would provide to prevent, evaluate, diagnose, or treat an illness or injury in accordance with generally accepted standards of medical practice, and that are clinically appropriate in type, frequency, extent, site, and duration. To make determinations, Medicare‑affiliated Centene plans follow a hierarchical approach to evidence: start with federal laws, CMS guidance, NCDs/LCDs (Level A), then plan clinical policies and ASAM criteria (Level B), nationally recognized decision support tools such as InterQual (Level C), and when those do not provide criteria, consider clinical guidelines, peer‑reviewed literature, compendia, and technology assessments (Level D). Decisions must meet the plan definition of medical necessity and be supported by the appropriate level of evidence.