CurrentFidelis CarePolicy CP.FC.05

Medical Necessity Criteria

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Defines Fidelis Care's hierarchy of guidance and definitions used to make medical necessity determinations for all lines of business except Medicare; applies to providers and utilization reviewers evaluating coverage for member/enrollees.

Policy Summary

PayerFidelis Care

PolicyMedical Necessity Criteria

Policy CodePolicy CP.FC.05

Change TypeNo material change noted

Effective Date

Next Review Date

Key ActionApply the ordered hierarchy (federal/state law, plan-specific policies, Centene policies, MCG, then other sources) when making medical necessity decisions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A-FHierarchy sources

LOCUS/CALOCUSBehavioral health tools

All LOB except MedicareScope

MCG availableMCG availability

Never events listNever events referenced

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CurrentFidelis CarePolicy CP.FC.05

Medical Necessity Criteria

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Policy Summary

PayerFidelis Care

PolicyMedical Necessity Criteria

Policy CodePolicy CP.FC.05

Change TypeNo material change noted

Effective Date

Next Review Date

Key ActionApply the ordered hierarchy (federal/state law, plan-specific policies, Centene policies, MCG, then other sources) when making medical necessity decisions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A-FHierarchy sources

LOCUS/CALOCUSBehavioral health tools

All LOB except MedicareScope

MCG availableMCG availability

Never events listNever events referenced

Coverage and Medical Necessity Criteria

General medical necessity determination

Covered when ALL of the following are met

Hierarchy: Decision-makers must apply guidance in the following order: A. Federal law for federal programs (e.g., NCD, LCD) or state law when applicable; B. State law/guidelines (including behavioral health tools LOCUS/CALOCUS and LOCADTR for SUD); C. Plan-specific clinical policy (including plan-specific MCG custom content); D. Fidelis-adopted Centene clinical policy (including Centene MCG custom content); E. If no Plan- or Centene-specific policy exists, nationally recognized decision support tools such as MCG are used; F. If no guidance from A-E, the Health Plan Medical Director may consider peer-reviewed literature, professional standards, nationally recognized drug compendia, medical association publications, and expert/attending provider opinion.

Order and items drawn from chunk 2.

Standards for medical necessity: Services must be in accordance with generally accepted standards of medical practice, clinically appropriate in type, frequency, extent, site, and duration, considered effective for the patient's illness/injury/disease, and not primarily for convenience or more costly than an alternative expected to produce equivalent results.

Standards and appropriateness language from chunks 6 and 7.

Not covered: Experimental/Investigational: Services are considered experimental and/or investigational if any of the following apply: they are the subject of active and credible evaluation (e.g., clinical trials) to determine efficacy or therapeutic value; they lack final clearance/unrestricted market approval from applicable regulatory bodies (e.g., FDA) for the requested indication; or recent peer-reviewed studies do not conclude, or are inconclusive, that the service is safe and effective for the requested indication.

Definition of experimental/investigational from chunk 7.

Experimental/investigational services are excluded from medical necessity coverage when they meet the policy definition of experimental and/or investigational: the service is under active and credible evaluation (for example, clinical trials), lacks final governmental regulatory clearance or unrestricted market approval for the requested use, or the most recent peer‑reviewed studies are inconclusive or do not demonstrate that the service is safe and effective for the requested indication. Carve‑out inpatient days are also excluded — defined as non‑medically necessary inpatient hospital days that occur during an otherwise approved admission (for example, delays unrelated to the member's clinical condition such as equipment downtime, unavailable operating room time or specialist, social reasons, discharge logistics, or preventable quality‑of‑care issues).

Services that meet the policy definition of not medically necessary and not investigational are not covered. This includes services for which there are no peer‑reviewed studies in recent literature, no active credible evaluations underway, conclusive evidence showing ineffectiveness in the peer‑reviewed literature, no published studies demonstrating safety and efficacy for the requested use, or services that are contraindicated. Determinations must be based on the scientific quality of the supporting evidence and rationale from recognized sources.

References and Coding

References (not billing codes)mixed

N/A	No CPT/HCPCS/ICD-10/NDC codes are enumerated in this policy.

Provider Requirements and Operational Notes

Prior Authorization

Use ordered guidance for prior authorization

Fidelis Care makes medical necessity determinations on a case-by-case basis using an ordered hierarchy of guidance. Providers requesting prior authorization should expect decisions to follow this precedence: federal law/guidance (e.g., Medicare NCDs/LCDs), state law/guidance, plan-specific clinical policies, Fidelis-adopted Centene clinical policies, nationally recognized decision support tools (e.g., MCG) when no plan/Centene policy exists, and, if none of the above apply, peer-reviewed literature, professional standards, and nationally recognized compendia as considered by the Health Plan Medical Director.

Order of guidance used for prior authorization: A. Federal law/guidance; B. State law/guidance; C. Plan-specific clinical policy; D. Fidelis-adopted Centene clinical policy; E. Nationally recognized decision support tools (e.g., MCG); F. If A–E do not provide guidance, peer-reviewed literature, professional standards, compendia, and medical association publications are considered.

Denial Risk

Never events may trigger non-reimbursement

Policy Background

Fidelis Care clinical policies are developed with oversight from board‑certified physicians, are reviewed at least annually, and are intended to reflect current scientific research and clinical practice. When plan‑ or Centene‑specific guidance is not available, nationally recognized decision support tools (such as MCG) and other accepted clinical resources are used; behavioral health decisions reference tools such as LOCUS/CALOCUS and LOCADTR as applicable.

Definitions

Medically necessary / Medical necessity

DefinitionHealth care services that a physician, exercising prudent clinical judgment, would provide to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms.

Standards requiredServices must be: 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 alternative at least as likely to produce equivalent results.

Exclusions notedMedically necessary services may not include experimental/investigational technologies or carve-out inpatient days; see CP.MP.36 for experimental technologies guidance.

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

Experimental and/or investigational technologies

Policy Summary

PayerFidelis Care

PolicyMedical Necessity Criteria

Policy CodePolicy CP.FC.05

Change TypeNo material change noted

Effective Date

Next Review Date

Key ActionApply the ordered hierarchy (federal/state law, plan-specific policies, Centene policies, MCG, then other sources) when making medical necessity decisions.

SourceLink

On This Page

Services and events classified as 'never events', 'serious reportable events', or 'non-reimbursable serious hospital-acquired conditions' are often preventable and of significant concern. Depending on the member's benefit plan contract, services that result directly from such events may not be covered and/or may be non-reimbursable. Providers should be aware that claims tied to these events may be denied reimbursement.

Examples include (not exhaustive): intravascular air embolism with death/disability; hypoglycemia with death/disability; Stage 3 or 4 pressure ulcers after admission; electric shock causing death/disability; burns incurred within a facility; certain surgical site infections after specified procedures; death from self-inflicted injury occurring in specified timeframes around care; homicide while under care or supervision.
Coverage and reimbursement for services resulting from these events are subject to the member's benefit plan contract and may be denied.

Services (drugs, procedures, devices, supplies, and other health care services) currently under active and credible evaluation (e.g., clinical trials or research) to determine clinical efficacy, therapeutic value, or benefits beyond established alternatives.

Regulatory statusServices that do not have final clearance or unrestricted market approval from applicable governmental regulatory bodies (e.g., FDA) for the requested use are considered experimental/investigational.

Evidence standardWhen the most recent peer-reviewed scientific studies are inconclusive or do not conclude the Service is safe and effective for the requested condition, the Service is considered experimental/investigational.

Carve-out days (inpatient)

DefinitionNon-medically necessary inpatient hospital days that occur during an approved admission when the inpatient stay was prolonged unnecessarily.

Examples — service delaysA day when a member meets inpatient criteria and needs a service (e.g., imaging, surgery) but the service is not performed on the earliest possible date for reasons unrelated to the clinical condition (e.g., equipment downtime, unavailable OR time, specialist not available).

Examples — social or discharge delaysDays solely 'social' in nature (e.g., waiting for foster placement or discharge instructions) or days at the end of a stay when discharge criteria are met but the member is not discharged due to nonclinical factors (e.g., transportation, DME delivery, SNF placement delays).

Examples — quality/preventable issuesDays necessitated by or appearing to be caused by quality-of-care issues or largely preventable complications (e.g., wrong medication dose complications, central line–associated bloodstream infections, certain device-related infections).