Clinical Criteria
Clinical criteria are used to support consistent, evidence-based decisions regarding the diagnosis, management, and treatment of health care conditions.
Medicare Coverage Requirements
CommunityCare follows applicable Medicare coverage requirements, including federal statutes and regulations, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and general coverage and benefit conditions established in Original Medicare manuals and instructions and interpreted by the Centers for Medicare & Medicaid Services (CMS).
CommunityCare Clinical Criteria
When applicable coverage criteria are not fully established in Medicare statutes, regulations, NCDs, LCDs, or Original Medicare manuals and instructions, CommunityCare may use publicly accessible internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature.
CommunityCare uses an applicable CommunityCare Medical Policy when one is available. When an applicable CommunityCare medical policy is not available, CommunityCare may use nationally recognized clinical criteria.
CommunityCare currently uses InterQual® criteria and anticipates transitioning to MCG™ care guidelines on or after August 1, 2026.
The applicable Medicare coverage requirements described above take precedence over CommunityCare medical policies, nationally recognized clinical criteria, and other supporting clinical guidelines.
Criteria Administered by CommunityCare Partners
Certain benefits or utilization management services are administered by CommunityCare partners. These organizations apply applicable Medicare coverage requirements and, when Medicare coverage criteria are not fully established, may use the publicly accessible criteria identified below.
Dental Benefits
CommunityCare partners with Dominion to administer supplemental dental benefits for its Medicare Advantage plans.
Radiation Oncology and Medical Oncology
CommunityCare partners with Evolent to administer utilization management for radiation oncology and medical oncology services.
Diagnostic Cardiology
Evolent administers utilization management for certain diagnostic cardiology services, including:
- Myocardial perfusion imaging
- Mutligated acquisition scans
- Stress echocardiography
- Transthoracic echocardiography
- Transesophageal echocardiography
- Expanded Cardiac Guidelines
Advanced Imaging
Evolent administers utilization management for certain advanced imaging services, including:
- MRI and MRA
- CT, CTA, and CCTA
- PET imaging
- Advanced Imaging Guidelines
Physical Medicine Services
Evolent administers utilization management for certain physical medicine services, including:
- Physical therapy
- Occupational therapy
- Speech therapy
- Physical Medicine Clinical Guidelines
Interventional Pain Management
Evolent administers utilization management for certain interventional pain management services, including:
- Facet joint injections
- Epidural spinal injections
- Sacroiliac joint injections
- Facet neurolysis
- Interventional Pain Management Guidelines
Musculoskeletal Services
Evolent administers utilization management for certain musculoskeletal services, including:
- Lumbar spine surgery, including fusion and non-fusion procedures
- Cervical spine surgery, including fusion and non-fusion procedures
- Hip, knee, and shoulder surgery
- Musculoskeletal Surgery Guidelines
Senior Health Plan is an HMO plan and a D-SNP plan with a Medicare & Medicaid contract. Enrollment in Senior Health Plan depends on contract renewal.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact www.medicare.gov or 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. Medicare customer service representatives are available 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.
