Clinical Guidelines
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. Please complete the request form for next steps to access a guideline.
MCG GUIDELINE REQUEST FORM
- National Guidelines
GlobalHealth annually reviews and adopts clinical practice guidelines based on guidance from national organizations generally accepted as experts in their fields. These clinical practice guidelines are available here.
|
Condition |
Clinical Guidelines |
|
Diabetes |
American Diabetes Association. Standards of Medical Care in Diabetes. (2023) https://diabetes.org/newsroom/american-diabetes-association-2023 |
|
Immunization Schedules for Persons Aged 0 Through 18 Years |
Centers for Disease Control and Prevention https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html |
|
Immunization Schedule for Adults Aged 19 Years or Older |
Centers for Disease Control and Prevention (CDC) |
|
Opioid Guidelines |
Centers for Disease Control and Prevention (CDC) |
|
Depression |
Major Depressive Disorder. U.S. Department of Veterans Affairs and Department of Defense. Clinical Practice Guideline on the Management of Major Depressive Disorder (MDD). (2022) |
|
Urinary Incontinence |
Journal of Women’s Health |
|
Hypertension |
American College of Cardiology/American Heart Association/European Society of Cardiology/European Society of Hypertension Blood Pressure https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.054602 |
|
Heart Failure |
American Heart Association/American College of Cardiology/Heart Failure Society of America) |
|
Osteoporosis |
Bone Health and Osteoporosis Foundation (BHOF) (formerly NOF). The clinician’s guide to prevention and treatment of osteoporosis. (2022) https://www.bonehealthandosteoporosis.org/news/bone-health-and-osteoporosis |
|
Kidney Disease |
National Kidney Foundation https://www.kidney.org/professionals/guidelines/guidelines_commentaries |
|
Asthma |
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. (2023) |
|
Chronic Obstructive Pulmonary Disease |
Global Initiative for Chronic Obstructive Lung Disease. Gold Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. (2023) |
|
Preventive Care |
U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/webview/#!/#!/ |
- 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:
2024 Part B Prior Authorization Criteria.
Last updated Date – 3/15/2024