In addition to the documents we develop and maintain for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, the plan’s medical policy supersedes.
MCG care guidelines are licensed and utilized to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG guidelines licensed include:
- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic Care
- Behavioral Health Care
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).
Customizations to MCG Care Guidelines 23rd Edition
This document provides a summary of customizations to the MCG Care Guidelines 24th Edition (Publish date June 26, 2020).
Customizations to MCG Care Guidelines 24th Edition
AIM Specialty Health (AIM)
Our health plans may use guidelines developed by AIM Specialty Health (AIM) to perform utilization management services for some procedures and certain members. AIM guidelines that may be adopted for use include:
Clinical Appropriateness Guidelines for Radiology (adult and pediatric)
Clinical Appropriateness Guidelines for Sleep Disorder Management
Musculoskeletal Clinical Appropriateness Guidelines: spine surgery, joint surgery, and interventional pain management
Level of Care Guidelines for Musculoskeletal Surgery and Procedures
Preoperative Admission Guidelines for Musculoskeletal Surgery and Procedures
Cardiology Clinical Appropriateness Guidelines: advanced imaging of the heart, arterial ultrasound, percutaneous coronary intervention, and diagnostic coronary angiography
Radiation Oncology Clinical Appropriateness Guidelines: brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS)
AIM guidelines applicable to Plan programs are maintained by AIM Specialty Health. Updates to these guidelines can be found on their website.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the plan. Clinical criteria for drugs and biologics paid under the medical benefit for certain Medicare/Medicaid markets can be found on the IngenioRx website.
The pharmacy clinical criteria for injectable, infused or implanted prescription drugs and therapies covered under the medical benefit are available for certain