Clinical Criteria
CommunityCare uses clinical criteria to support consistent, evidence-based medical necessity determinations for services covered under our Commercial health plans.
When an applicable CommunityCare Medical Policy is available, the Medical Policy is used to evaluate the request. CommunityCare Medical Policies are maintained separately in our Medical Policy Library.
When an applicable CommunityCare Medical Policy is not available, CommunityCare uses nationally recognized clinical criteria based on current medical evidence, widely accepted clinical practice guidelines, and relevant clinical literature.
CommunityCare used InterQual® criteria for requests received before October 3, 2026, and uses MCG™ Care Guidelines for requests received on or after October 3, 2026.
Evolent Clinical Guidelines
CommunityCare partners with Evolent to administer utilization management for select services for our Commercial and Marketplace plans. Evolent clinical guidelines are used for services managed through this partnership.
Medical and Radiation Oncology
Advanced Cardiac Services
- Expanded Cardiac Guidelines
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Includes:
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Myocardial Perfusion Imaging (MPI)
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Multigated Acquisition Scan (MUGA)
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Stress Echocardiography
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Transthoracic Echocardiography (TTE)
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Transesophageal Echocardiography (TEE)
Advanced Imaging
Therapy Services
Interventional Pain Management
Musculoskeletal Surgery