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Guideline overview

³È×ÓÊÓƵapp performs delegated medical management functions on behalf of certain Medicare Advantage plans. These activities may include review of medical necessity and appropriate level of care for services covered under such plans. ³È×ÓÊÓƵapp determines medical necessity and appropriate level of care according to a hierarchy of criteria based on the applicable Medicare Advantage benefit plan package (Evidence of Coverage).

There are times when Medicare statutes, regulations, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) do not fully establish the coverage criteria for an item or service. This occurs when:

A.?Additional, unspecified criteria are needed to interpret or supplement general provisions to determine medical necessity consistently;

B.?NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications that are listed in the NCD or LCD; or

C.?There is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria.

In these cases, ³È×ÓÊÓƵapp may also use coverage criteria developed or licensed by a health plan or ³È×ÓÊÓƵapp to determine medical necessity and/or appropriate level of care.? ³È×ÓÊÓƵapp uses MCG Care Guidelines or InterQual criteria when needed to fully establish the coverage criteria for an item or service under review because the clinical benefits of using such additional criteria, as described in and supported by the evidence detailed within each guideline, are highly likely to outweigh any clinical harms which may result from delayed or decreased access to the item or service.

MCG Care Instructions

MCG care guidelines are the intellectual property of MCG Health and access is strictly controlled. Users are not able to distribute any MCG content without the permission of MCG. By following these instructions, you will have access to view MCG care guidelines online.

Step 1 Disclaimer: Select the ¡°MCG Care Guidelines¡± link to where you will land on MCG disclaimer page.

• You must check the ¡°Accept Terms and Conditions¡± box and select the ¡°Accept and Proceed¡± button to continue to the next page.

Step 2 User Information: Next you will be required to enter the following information:

• First Name
• Last Name
• Select the button the most closely aligns with your interest in MCG care guidelines.
• Select ¡°Next¡±

Step 3 Contact Information: MCG will ask for your preferred way of receiving a verification code. Select from

• Text message
• Email
• Telephone call
• Select ¡°Next¡±

Step 4 Access Code: Enter the code once received via your preferred method.

• Click on the ? desired product to be a shown a list of MCG care guidelines selected for the client¡¯s program.
• Click on the guidelines you wish to review. Copy/pasting, printing, or other methods of duplication are not allowed.
• Once finished Select ¡°Back to Guidelines¡± list or close your tab.

Please click on the links below to access the applicable ³È×ÓÊÓƵapp clinical guidelines:

MCG Care Guidelines

InterQual Care Guidelines

³È×ÓÊÓƵapp Health Solutions MSK