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Medical Guidelines

These guidelines detail when certain medical services are considered medically necessary and are based on Original Medicare National Coverage Determinations (NCD's) & Local Coverage Determinations (LCD's) when available. The guidelines are reviewed and updated in response to changing CMS guidelines for medical coverage or change in scientific literature if applicable.

As a Medicare Advantage (MA) plan, we are required by Centers for Medicare & Medicaid Services (CMS) to provide, at a minimum, the same medical benefits to our members as Original Medicare. As an MA plan, we also cannot be less restrictive that Original Medicare, however, we are allowed to clarify or more fully explain coverage in our policies. If Original Medicare does not have an NCD or LCD applicable to the service under review, the MA plan can develop a guideline to define the plan's coverage. Each individual's unique, clinical circumstances may be considered in light of current CMS guidelines and scientific literature.

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