How to access internal coverage criteria used to make medical necessity determinations?

As part of the preauthorization requirement, we use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and the general conditions of coverage and benefits included in the Traditional Medicare laws in our region. In addition to the coverage and benefits, we evaluate that the requested item or service is considered reasonable and necessary for the diagnosis and treatment of your health conditions, using your medical history, functional status, clinical notes, and recommendations from your doctor. Medical necessity determinations are based on the specific individual circumstances of each individual.

When coverage criteria are not established by the applicable Medicare statutes, regulations, NCDs, or LCDs, CMS allows us to create internal policies using evidence-based medical sources. In addition to our internal policies, we may use other recognized supporting guidelines based on medical evidence, such as MCG criteria or nationally accepted guidelines from private and government agencies and professional organizations.

GlobalHealth makes all these criteria publicly available for anyone who wants to view them. Refer to information and links below:

CLINICAL GUIDELINES

• MCG Transparency

Our medical necessity, also known as clinical criteria, are reviewed and updated at least annually to ensure the reflect the latest developments in serving individuals with medical diagnosis.

GlobalHealth utilizes MCG as a source for Clinical Guidelines.

Click here to learn about clinical guidelines

• Behavioral Health

GlobalHealth utilizes Carelon for our Behavioral Health Utilization. To view their clinical coverage criteria, please click this link. https://www.carelonbehavioralhealth.com/providers/resources/clinical-practice-guidelines

• Part B Drugs

To view Part B Drugs Part B Prior Authorization Criteria, please click this link:
Part B Prior Authorization Criteria.

Last updated Date – 6/12/2024